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A gene is an ordered sequence of nucleotides located in a particular position (locus) on a particular chromosome that encodes a specific functional product (the gene product generic 200mg viagra extra dosage with mastercard, i cheap viagra extra dosage generic. It includes regions involved in regulation of expression and regions that code for a specific functional product cheap viagra extra dosage online amex. Gene cassette: A cassette is a mobile element, but it does not code for genes involved in its own mobility. Its movements depend upon the integrase, which interacts with the recombination sites, the attl site located in the 5-conserved segment and the attc located at the 3-end of each cassette to excise an integrate cassette. Gene cloning: Isolation of a desired gene from one organism and its incorporation into a suitable vector for the production of large amounts of the gene. Gene pool: the total of all genes in a population of a particular species Gene probe: A strand of nucleic acid that can be labelled and hybridized to a complementary molecule from a mixture of other nucleic acids. Gene therapy: Introduction of healthy genetic material to replace, augment or influence genes that do not function properly. In some cases the material can be injected with what is known as a genetic vaccination. In other cases, the material is introduced through bio-engineered viruses that carry the therapeutic gene to the cell. Globules known as liposomes can also be used to carry therapeutic genes to specific cells. Genome: All the genetic material in the chromosomes of a particular organism; its size is generally given as its total number of base pairs. Genus (plural: genera): The taxon between family and species, and used to form the first element of the scientific name (binomial). Glycosidase: Enzyme that hydrolyzes bonds in carbohydrates, glycoproteins and glycolipids. Gram stain: Differential stain that divides bacteria into two groups, Gram-positive and Gram-negative, based on the ability to retain crystal violet when decolourized with an organic solvent such as ethanol. The cell wall of Gram-positive bacteria consists chiefly of peptidoglycan and lacks the outer membrane of Gram-negative cells. Growth factor: Organic compound necessary for growth as it is an essential cell component or precursor of such components and cannot be synthesized by the organism itself. Growth: In microbiology, an increase in both cell number and cellular constituents. Growth promoters: antimicrobials used in low concentrations to stimulate an animals growth, resulting in increased daily live weight gain and feed conversion efficiency. Hapten: A substance not inducing antibody formation but able to combine with a specific antibody. Hazard: A biological, chemical or physical agent with the potential to cause an adverse health effect. These cells are involved in the production of bactericidal peptides, in phagocytosis as well as in the encapsulation reaction. Haemocytes have the ability to internalize foreign material by a process called phagocytosis. They sense the foreign material, migrate towards it (chemotaxis), attach to the material (adherence) and internalize it by extending pseudopods and pulling the material into the haemocyte where it will reside surrounded by host cell membrane forming a phagocytic vacuole. Humic acid: Dark-coloured organic material extracted from soil by various reagents (e. Humic substances: Series of relatively high-molecular-weight, brown-to-black substances formed by secondary synthesis reactions. Hydrogen bond: Chemical bond between a hydrogen atom of one molecule and two unshared electrons of another molecule. Immunity: The ability of a human or animal body to resist infection by micro- organisms or their harmful products, such as toxins. Infectious disease: Any of many diseases or illnesses (caused by micro-organisms) that can be transmitted from person to person or from organism to organism, produced when the micro-organisms multiply faster than the immune system can destroy them. Integron: Genetic unit that includes genes of a site-specific recombination system capable of capturing and mobilizing genes contained in mobile elements called gene cassettes. Ions: Atoms, groups of atoms, or compounds that are electrically charged as a result of the loss of electrons (cations) or the gain of electrons (anions). In vitro: Literally in glass; it describes whatever happens in a test tube or other receptacle, as opposed to in vivo. Another approach employing liposomes, called chimeraplasty, involves the insertion of manufactured nucleic acid molecules (chimeraplasts) instead of entire genes to correct disease-causing gene mutations. Microbial biomass: Total mass of micro-organisms alive in a given volume or mass of soil. Microbial population: Total number of living micro-organisms in a given volume or mass of soil. Microenvironment: Immediate physical and chemical surroundings of a micro-organism. Mineralization: Conversion of an element from an organic form to an inorganic state as a result of microbial decomposition. Morbidity: A diseased condition or state; the incidence of a disease or of all diseases in a population. Mortality: The mortality rate; the proportion of deaths to population or to a specific part of the population. Mutant: Organism, population, gene or chromosome that differs from the corresponding wild type by one or more base pairs. Mutation: The term which De Vries introduced into biological literature for an abrupt change of phenotype which is inherited. Types of mutations include point mutations, deletions, insertions and changes in number and structure of chromosomes. Non target organisms: Organisms at which treatment is not aimed but which contact the product and may be affected by it. Peptidoglycan: Rigid layer of cell walls of bacteria, a thin sheet composed of N- acetylglucosamine, N-acetylmuramic acid, and a few amino acids. The term coined by Johannsen (1909) for the appearance (Greek phainein, to appear) of an organism with respect to a particular character or group of characters (physical, biochemical and physiologic), as a result of the interaction of its genotype and its environment. A Conjugative plasmid is a self-transmissible plasmid; a plasmid that encodes all the functions needed for its own intercellular transmission by conjugation. Polysaccharide: Long chain of monosaccharides (sugars) linked by glycosidic bonds. Protein: A large molecule composed of one or more chains of amino acids in a specific order; the order is determined by the base sequence of nucleotides in the gene coding for the protein. Proteins are required for the structure, function and regulation of the bodys cells, tissues and organs, and each protein has unique functions. Pseudomonad: Member of the genus Pseudomonas, a large group of Gram-negative, obligately respiratory (never fermentative) bacteria. Recombination: Process by which genetic elements in two separate genomes are brought together in one unit.

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As we have seen generic viagra extra dosage 150mg free shipping, the best results are achieved when we address health and vocational needs in a co-ordinated and holistic way order 150 mg viagra extra dosage mastercard. Improving integration of services and support between clinicians order viagra extra dosage 130mg overnight delivery, vocational specialists, employers, back to work support and individuals represents a positive approach to helping people remain in or return to work. Better working with and between all Symptoms of depression and their effects on employment 48 stakeholders be they government, voluntary sector or employers should be fundamental to policy in this area. The ability to provide integrated, in-parallel support for health and for employment was seen as vitally important by the experts. We need to provide individuals with well-rounded, personalised treatment and support which reflects their life goals. However, often we see government health and employment services not working together, nor even in some cases sharing information and knowledge, likely negatively affecting their understanding or knowledge of an individuals needs. Experts we spoke to highlighted specific examples including poor engagement between Jobcentre and clinicians, especially where someone is being assessed under the Work Capability Assessment, and the need to integrate employment support into health services at primary (i. This might be accomplished by: o Issuing joint commissioning guidance to encourage and support the pooling of resources to achieve shared local outcomes; or, o Revising and aligning applicable outcomes frameworks to ensure that mental health and employment is a priority for all local stakeholders. In particular, it is important to ensure that someone who is assessed as fit for work has access to appropriate health support to help them to return to work. Some experts spoke of energetic third sector providers in their local areas who are leading the way in developing evidence-based employment support services for people with mental health conditions. Enhancing employer knowledge about the needs of their employees is beneficial in terms of addressing stigma and the many implications that it has for workplace culture, as well as to improve their ability to make workplace adjustments which better support employees with depression to remain in work. Although the Fit Note provides a means for clinicians to communicate patient needs with employers, current practice is often not effective in conveying sufficient information to support a sustained return to work for people with depression. It is suggested that an employee-owned record of health and work, to complement and extend the Fit Note, could be developed for piloting. This would facilitate collection of information from all the above stakeholders; it would be possible to update it on an ongoing basis and to share it between stakeholders, with employees empowered to take a lead. It is recommended that: A template for an employee-owned health at work record is developed, to provide employees with a personalised and authoritative record on how their Symptoms of depression and their effects on employment 50 condition affects their work. This would highlight ongoing symptoms, what employers need to be aware of and what an employer can do to help them to stay in work. Promoting the concept of employment as a health outcome Recognition of employment as an outcome of clinical care has been slowly increasing but we need to keep this on the agenda and spread the message further. Getting work on the agenda during primary care consultations might be a way of improving understanding about work and developing treatment plans which reflect this. This was raised in the Chief Medical Officers report, where it was recommended that: employment status should be a routine and frequently updated part of all patients medical records. This will provide the baseline data for employment status to be an outcome of all medical specialties, including primary care (Davies, 2014). To this end, we recommend that: The Health and Social Care Information Centre, working with the Royal College of General Practitioners and other Royal Colleges, should review the existing taxonomy for the routine collection of employment data to ensure that it is usable and can be coded across all care settings. This is a change in process and the recommended activities need to be part of a comprehensive push to change the knowledge and culture of primary healthcare professionals regarding the role of employment for many people with mental health conditions. We need to continue the good work we have started and explore new ways in which we might make these changes. Further it is recommended that: An assessment is undertaken of the impact of measuring employment for those in secondary mental healthcare services in the Clinical Commissioning Group Outcome Indicator Sets. Should the outcome be positive we should consider expanding this to include people with any mental health condition, not just those in secondary care. Enhancing understanding and recognition of the symptoms of depression As highlighted in the Chief Medical Officers report, in many cases depression goes unrecognised by individuals themselves, by their clinicians or by their employers meaning many people dont receive any treatment or intervention for their condition. In order to improve employment outcomes for people with depression we need to get better at recognising symptoms of the illness so we can provide the best support. Even where depression is diagnosed, some symptoms, including cognitive symptoms such as difficulty concentrating, may be missed. Any ongoing symptoms of depression missed in treatment (particularly if access to treatment is limited) can provide an ongoing barrier to work. This need is perhaps as acute in the health environment as it is in the workplace and in employment support services. The workplace provides an important location for health and work interventions and often plays a vital role in the recognition of health conditions as well as their management. Managers need to be better equipped to support employees with mental health conditions, including in terms of preventing symptoms to escalate. It is recommended that: Mental health awareness and management training is provided to managers to enhance their understanding of employee needs. Training needs to be of a high quality, and evidence-based where possible techniques such as psycho-education may be useful. As suggested in the recent report of the Taskforce on Mental Health in Society (2015), this might be incentivised through inclusion in professional management standards and employer accreditation schemes. We would also concur with recommendations of both Mind (2014) and the Taskforce on Mental Health in Society (2015) that: Frontline staff in the Jobcentre and Work Programme providers receive training and upskilling to improve their understanding mental health conditions (including depression), helping them to better understand the needs of their clients and provide more appropriate support. It requires proactivity from the individual who may have already waited weeks or months to be contacted by the service only then to be unable to engage due to poor health, be branded as a did not attend and sent to the back of the queue. It was suggested that lessons on how to reach out to people with depression might be learnt from Assertive Outreach programmes, currently used for people with a severe and enduring mental illness, and a low-level approach might be considered. This could include health or social support staff (public or third sector) following up with people who have failed to engage with psychological therapy to identify the issues and provide support. Symptoms of depression and their effects on employment 53 It is recommended that: A form of low-level Assertive Outreach is developed and trialled to identify whether it can be used to improve engagement of patients with depression in treatment, in particular psychological therapy. For those who have had or are expected to have four weeks of sickness absence due to their depression, Fit for Work will be an option. The service will need to be monitored to see how well it is reaching people with depression and how successful it is with supporting their long-term return to work. Fit for Work assessors will also need to recognise ongoing symptoms associated with depression, which might remain a long time after remission of other symptoms and continue to cause problems at work, possibly affecting the long term sustainability of the return to work. The assessors will also need to recognise the difficulties many people with depression experience in engaging with treatment. Mitigation of the risks to the sustainability of return to work and the risks of relapse need to be addressed in return to work plans. It is recommended that: Guidance is provided to Fit for Work assessors to ensure they are aware of the likelihood of people with depression experiencing ongoing symptoms; these symptoms may be harder to spot but can have a substantial effect on return to work. In some cases there will be a need for more substantial, long term treatment of depression to ensure complete remission of symptoms. Improving access to job retention support Preventing people from losing their job in the first place is often seen as easier than finding a new job. More attention must be given to improving job retention for people with depression. External support for job retention was seen as limited especially access to specific locally-appropriate, retention-related information (e. It is recommended that: Commissioning guidance is developed that considers the distinct requirements of both return to work support and retention support for people Symptoms of depression and their effects on employment 54 with depression. A lack of specialist employment and occupational health knowledge and expertise within the health trusts was noted by the experts, in particular advocacy-related support for employees with health conditions.

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Analysis of 468 epileptics seen in neurology clinics of Addis Ababa showed highest incidence in males aged 11-20 years generic viagra extra dosage 120 mg fast delivery. The commonest type of seizure was found to be grand mal seizure accounting for 60% of all cases viagra extra dosage 120 mg line. Etiology of seizure or risk factors: The causes of epilepsy/seizure are vary greatly in different age groups and across different regions of the world Idiopathic or cryptogenic: in which the cause is unknown buy generic viagra extra dosage 200mg on-line, accounts for the majority. Partial Seizures: these are seizures, which arise from localized region of the brain. This seizure activity may spread over one side of the body (Jacksonian march) to involve larger body part. The patient is unable to respond appropriately to visual or verbal commands during the seizure, and has impaired recollection or awareness of ictal phase. These are usually tonic-clonic type and difficult to differentiate from primary generalized tonic-clonic seizure. Generalized seizures There are seizure disorders which arise from both cerebral hemispheres simultaneously, with without any detectable focal onset. After 10 20 seconds the tonic phase evolves to clonic phase characterized by bilateral jerking clonic movement involving the whole body. Patients gradually regain consciousness over minutes to hours, and during this transition there is typically a period of postictal confusion, headache, muscle ache and fatigue that can last for many hours. Complications Status epilepticus Accidents Hypoxic brain damage Mental retardation and impairment of intellectual function Sudden death Psychosocial (Social stigma). Diagnostic approach/Evaluation Patients history and physical examination can aid in the determination of whether or not a seizure or some other transient event was responsible for the patients symptoms History should include: - History of the event Presence of any prodromal symptoms Description of seizure by reliable observer 527 Internal Medicine Post ictal symptoms Urinary incontinence, myalgia and tongue bite or oral lacerations are clues to the proper diagnosis. Differential Diagnosis for Seizure Syncope Psychogenic seizure (hysteric conversion) Transient Ischemic attack Migraine 528 Internal Medicine Management: Goal of therapy: Complete control of seizure Prevent development of complications and socioeconomic consequences. Avoidance of precipitating factor Maintain normal sleep schedule Avoid taking excess alcohol Reduce stresses using, physical Exercise, meditation or counseling 3. General principles: An attempt is usually made to prevent subsequent seizure using a single agent, in order to limit side effects. The addition of a second drug is associated with worsening of adverse effects; hence care should be taken, before one decides to add a second drug to the original regimen. Phenytoin: is the usual prescribed as a second line drug in resource limited settings like ours mainly because of its availability and cost. It is often given for the treatment of partial seizure Dosage: a low initial dosage with gradual increase is advised. Side effects Aplastic anemia Dizziness drowsiness 531 Internal Medicine Skin rash Transient diplopia When to stop antiepileptic drugs? The more severe and long lasting a patients active epilepsy before remission, the greater the risk of relapse. When to refer patients to a neurologist or tertiary level hospital Failure to respond to treatment Recurrence of previously controlled seizure Change in clinical pattern of seizure Appearance of previously absent symptoms/sign Development of side effects of a drug 4. Surgical interventions include Temporal lobe resection Corpus callosum sectioning Status epilepticus A condition characterized by continuous or repetitive discrete seizure with impairment of consciousness during interictal period, which lasts for more than 30 minutes. Patients may have mild clonic movement of only the fingers, or fine, rapid movement of the eyes. Complications of Status epilepticus: Aspiration Hypoxia Metabolic acidosis Hypotension Hyperthermia Rhabdomyolysis and associated myoglobinuria Multiple physical injures including vertebral bone fracture Irreversible neuronal injury Management 1. Parkinsons Diseases and other movement disorders Learning objectives: at the end of this lesson the student will be able to: 1. Parkinsonism: Definition: Parkinsonism is a clinical syndrome characterized by:- Bradykineisa: slowness and paucity of movement Tremor: This occurs at rest Rigidity Snuffling gate and Flexed posture Etiologies: 1. These degenerative changes are believed to be due to accumulation of the presynaptic protein -synuclien. Bradykinesia/akinesia: It is the most disabling feature which interferes with all aspects of daily living. Patients have trouble in walking, rising from seated position, turning over in bed, dressing etc. Brief regular interruption of resistance during passive movement may give rise tocogwheels rigidity. Pharmacotherapy of motor symptoms: Therapy to control motor symptoms should be initiated as soon as the patients symptoms begin to interfere with the quality of life. This drug has minimal effect on symptoms when used as monotherapy or as an adjuvant to Carbidopa/levodopa. Advanced Therapy c) Levodopa/Carbidopa Formulation (Sinemet, Atamet) Levodopa: is converted to dopamine by presynaptic neuron and therefore increase the amount of neurotransmitter available to the post synaptic dopamine receptor. Some of the neuroprotecitve treatment trails arte Non steroidal anti-inflammatory agents Estrogens replacement therapy in post menopausal women Selegilline therapy delays the need for levodopa therapy by 9 -12 months in newly diagnosed patients. Studies demonstrated that patients who remain on Selegilline for 7 yrs experienced slower motor decline. Therapy of non motor symptoms Insomnia due to nocturnal akinesia : treated with night time supplemental dose of Carbidopa /levodopa Depression : Responds to anti depressants like Amitriptyline Psychotic patients: first remove anticholinergics and amantadine if the patient is taking. If still the patient has psychotic symptoms and signs, start antipsychotics with minimal extrapyramidal side effects. Surgical therapy Pallidotomy, and thelamothomy; may be a therapeutic option for refractory Parkinsons diseases Neurotransplantation: Transplantation of fetal substantia nigra tissue or cells. Other movement disorders Hyperkinetic disorders: these are disorders associated with increased movement. Tremor a) Benign essential tremor is characterized by posture related 5-9 Hz oscillation of hands and forearms that impairs performance of fine motor tasks. Myoclonus Definition: a brief, lightning-like contraction of a muscle or group of muscles. Alzheimers) Slow virus infections (Creuzfeldt-Jakob disease, subactue sclerosing panencephalitis) Severe closed head trauma Hypoxic-ischemic brain injury Signs and symptoms: Myoclonus may occur normally as a person falls asleep (nocturnal myoclonus). Treatment Education of patients and their family Drugs: Clonidine, Haloperidol 543 Internal Medicine 3. Chorea and Athetosis Definition: Chorea: is brief, purposeless involuntary movements of the distal extremities and face, which may merge imperceptibly into purposeful or semi purposeful acts that mask the involuntary motion. Chorea gravidarum It is choreiform movement occurring during pregnancy, often in patients with a history of rheumatic fever. Hemiballismus It is violent, continuous proximal limb flinging movements confined to one side of the body, usually affecting the arm more than the leg. Huntingtons Disease Definition: also called Huntingtons chorea, chronic progressive chorea or hereditary chorea. It is an autosomal dominant disorder characterized by choreiform movements and progressive intellectual deterioration, usually beginning in middle age. Disorder is always progressive; patients ultimately lose physical and mental abilities to care for themselves. Rarely, dystonic movements spread to an adjacent region (segmental dystonia), and even more rarely, the process generalizes. Peripheral neuropathy Definition: A general term indicating peripheral nerve disorder of any cause. The type of symptoms and signs : Sensory, Motor, Autonomic, Or any combination 2.

Followed by In hospitals indications where antibiotics are commonly cephalosporins viagra extra dosage 200 mg otc, macrolides and quinolones with proportion and prescribed inappropriately include: surgical prophylaxis volume of use varying considerably between countries buy viagra extra dosage master card. These principles ensure that providers only prescribe antibiotics for Reduce antibiotic consumption and costs without increasing non-self-limiting bacterial infections purchase generic viagra extra dosage canada. Antimicrobial stewardship mortality or infection-related re-admissions programs create processes that promote prescribing that aligns Pertinent studies that demonstrate how stewardship with the above defnition. Additionally, the stewardship program programs can optimise healthcare costs takes responsibility for tracking and reporting prescribing and resistance trends over time. Centers for Disease Control and Prevention have that a stewardship program may ensure timely and appropriate established core elements necessary for developing a successful antibiotic initiation. These core elements are as direct prescribers toward appropriate antibiotics for specifc follows: disease states. These clinical pathways can either be built into Leadership Commitment: Dedicating necessary human, the medical record software at the time of prescribing, or can be fnancial and information technology resources. Experience with successful programs stewardship programs may minimise risk for adverse events show that a physician leader is efective by implementing interventions for timely review or renal dose adjustment. Timely de-escalation (being part of the review of Drug Expertise: Appointing a single pharmacist leader antibiotic prescriptions) will minimize patient exposure to broad responsible for working to improve antibiotic use. Balancing measures in particular are needed to detect unintended negative consequences of these interventions are fundamental to ensure that antibiotic stewardship programs are safe. Healthcare systems, clinicians and patients should be confdent of the results and value of the interventions. Every organisation will have barriers that will need to be overcome to get a stewardship programme up and running. Clarify the organisational structure and accountability of your centres current stewardship activities. Explore and document your centers motivation to improve antimicrobial stewardship in terms of its leadership and dedication to the cause (measured in human and fnancial capital). Depending on the maturity of the national action plan, a ground up approach can also be employed by assessing this workforce and public engagement at the programme level. The correct test must be performed in the understood and is therefore a best guess to cover the most correct context. Current diagnostic tests have a turn around time and lead to the wrong diagnosis and/or treatment. Clinicians usually cannot or do not want to wait is the use of urine dipsticks (used for the diagnosis of urinary until results are back before ofering treatment. Test values rise in the presence of an receive an inappropriate antibiotic for the infection they have. Improvements to diagnostic tests are required to reduce turn around times and, ideally, make each antibiotic prescription an These tests can be used to diferentiate between bacterial and informed prescription. Laboratory accreditation and other quality assurance activities make sure that results are ft for purpose. The introduction of laboratory automation and updated working practices can make results available sooner. This is most relevant to the characteristics of the time-concentration curve and properties of antimicrobials that dictate their killing action. An example of where the antimicrobial the Measurement for Improvement Toolkit from the Australian stewardship group lies within the organisational structure in a Commission on Safety and Quality in Health Care. Suggested outcome measures include: Formulary restriction with re-authorisation of named anti-infectives Audit of compliance with guidelines. The proposed audience must be Antimicrobial order forms considered; what works in one setting may not work in another. There are many models but all use key principles of having Will, Ideas and Execution. Educational strategies for antimicrobial stewardship can be Clinical microbiology: theory, laboratory tests and their passive or active. They are not meant to be a Competences should be developed using an evidence-based comprehensive list. A strategic solution to stabilize or reduce microbial resistance is implementing Antimicrobial Stewardship Programs in healthcare settings. Despite the social and political challenges, regulating over-the-counter sales has proven efective in curbing self-medication with antibiotics. Misinterpretation of urine dipsticks can lead to overprescribing of antibiotics for urinary tract infections. The strategy must examine on the rate of antimicrobial prescribing and also the choices of antimicrobials prescribed, with a focus on local or national prescribing guidelines. The strategy must also examine the interpretation of urinary dipsticks and urinary catheter care. Infection Prevention and Control policies and procedures must adhere to national standards to prevent the spread of infection or outbreaks. The strategy should be feasible, using readily accessible data to benchmark antimicrobial resistance and prescribing data against local or national data. Usually, a single frst-generation cephalosporin for operations not expected to encounter anaerobes or a single second-generation cephalosporin with anaerobic operations based on local susceptibility patterns is sufcient. It has to be administered 60 minutes prior to surgery or for antimicrobials like Vancomycin it should be administered 120 minutes. It is especially important because redosing of the antimicrobial depends on a pharmacokinetic parameter named biological half-life. The biological half-life of a substance is the time it takes for a substance to lose half of its pharmacologic, activity. Intra operative redosing is recommended only for procedures that exceed two half-lives of the antimicrobial used for surgical prophylaxis. Invasive Medically important fungi capable of causing invasive fungal mould infection is proven if hyphae are seen in a histological or infection can be broadly split into three categories; yeasts (e. Treatment decisions therefore depend on: Antifungal resistance is well recognized and has been associated Host factors with antifungal exposure. A to be important in mitigating further emergence of antifungal good starting point is to create or review guidelines and clinical resistance. The availability and turn-around-time of diagnostics should be considered within this process. Priority should be placed on ensuring that consistent approaches to management are adopted across community and front of house hospital settings (emergency department/paediatric assessment unit). Inconsistent prescribing practices impact on future health seeking behaviour and antibiotic expectations. Online clinical portals containing guidelines enable clinicians to access and use recommendations at the point of care.