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- Clinical Associate Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Michigan
- Clinical Pharmacist, University of Michigan Health System, Ann Arbor, Michigan
Glybera is used to blood pressure medication grapefruit discount 40mg betapace treat an ultra-orphan8 indication arteria retinae generic 40mg betapace otc, lipoprotein lipase defciency heart attack news purchase betapace 40mg on-line, but much of the pipeline similarly aims to heart attack pain in arm discount betapace online master card cure disease, and will likely be priced highly. The challenges associated with the cost of ground-breaking curative treatments in the pipeline must be tackled proactively. Innovative approaches to funding will be a necessary pre-requisite of success when commercialising such valuable treatments. Drug delivery: calls for change Innovation in biologics is not limited to the therapies themselves. This has the material advantage of making biologics scalable for larger Innovation in biologics is populations, often taking treatment out of the hospital and into the home. However not limited to the therapies it is important to note that some novel delivery mechanisms were developed for the themselves. It can also functional necessity to target specifc parts of the body, and therefore enable treatment be seen in the routes where previously it was not possible. It requires health care professional presence to administer and treatment can take long periods of time. This is particularly burdening if treatment is required on a frequent basis over a long period of time and for large patient populations. This has the advantage of enabling patient self-administration and often cutting down on the delivery time. In the diabetes space subcutaneous injection devices are extremely discreet, but patients can still feel stigmatised when moving away from oral treatments. Patient compliance also becomes a hurdle when we take drug treatment out of the hospital and into the home. Patients incorrectly administering, inappropriately storing or forgetting treatment can have serious medical consequences. These drug launches have not been successful despite backing from major pharmaceutical players, even though they provide simpler administration with comparable efcacy. Their failure to disrupt the subcutaneous status quo tells us that removing the stigma/inconvenience from subcutaneous treatment may not be enough to succeed. In this current environment payers are not interested in spending more and switching to medicines with longer patent lives in order to treat patients that are already adequately served Inhaled insulins provide an important message for all novel biologic delivery mechanisms: clearly justifable real-world therapeutic improvements over convenience. Implanted biologics: Implanting a drug is an interesting concept which has seen use in small molecule hormonal control. Implants have the beneft of requiring extremely infrequent treatment, sometimes once a year. Their constant presence nullifes the threat of poor patient adherence whilst also providing a constant steady fow of medication, which may be clinically benefcial. If patients are consistently well controlled using only this medication, the infrequency of administration makes this less a treatment and practically likened to a cure. Oral biologics: this is the holy grail of biologic administration to make administration the same as a small molecule. The simplicity of using oral biologics would enable more convenient and compliant treatment. The hope is that it would enable access to more patients that would beneft from treatment, but are discouraged by injections. However, due to difculty of working against fundamental human digestive physiology; achieving stability, absorption and distribution of oral biologics is likely to be some way of. Several other biologic delivery mechanisms are in development, such as intranasal, microneedle patches and dissolving flms. These have more niche disease-specifc advantages, for example it has been shown that intranasal delivery of biologics have the potential of increasing bio-availability past the blood brain barrier Much of the work for innovative biologic delivery has been in the diabetes space. This is because diabetes is a primary care area with an extremely large and growing patient population that could see signifcant beneft and increased compliance of insulin treatment should it be made easier. In the 2012-16 period, the upfront value of a biologic product deal rose from ~$20Mn to $60Mn, tripling in four years. This is possible due to greater scientifc understanding of disease, advancement in scientifc techniques and their wider availability. Investment strategies are increasingly incorporating biologics into the pipeline with large pharma driving the trend. This competition, particularly between companies with deep pockets, is driving up deal values. There has been prolonged availability of capital at low interest rates, promoting deal making across all sectors the forecasted average value of a biologic deal in 2016 will be lower than 2015, a record year. The Valeant, Turing and Mylan pricing scandals attracted heavy criticism in late 2015 and 2016. If we look at deal growth in absolute terms, the bulk of biologic deal increase deal growth is in is coming from very early stage, discovery/ preclinical (392 more deals, 71% of deal Discovery/Pre-clinical growth). Demand for pipeline biologic therapies has increased but it will take several years before reactive supply will progress to the late stage. High valuation of biologic products is pushing players who are unwilling to invest heavily to look earlier in development for promising candidates. As a result of this experience, more players have comfort conducting early stage deals. The greater risk of early deal making has been balanced with the increased usage of contracted milestones within deals 15 Disruption and maturity: the next phase of biologics | These savings are channelled into the funding of new innovative drugs and expanding access to older ones. Many biologic blockbuster products now have biosimilars lined up to take market share. Those biologic makers facing loss of exclusivity on a current marketed product can be partially comforted by the prospect of funding availability for future launches. They will gain a lot of experience in the space of a few years: Regulators will be clarifying guidance for biosimilar manufacturers. Important decisions on stance for switching patients will be applied as a result Payers will be grappling with barriers to biosimilar uptake in order to fnd savings and increase leverage Physician and patient groups will express their views. These will form the backbone of public opinion on biosimilars, and can infuence agency guidance the biopharma industry, innovative and biosimilar players, will develop new strategies of competition. The level of discounting that a biosimilar business model can sustainably provide will be better understood the decisions and opinions developed during this transitionary period will set precedent moving forwards. As a result, keeping up to date with this rapidly changing space will be important for strategic decision making for the short and the long term. State of the biosimilar market Many of the top 20 biologics are already exposed to biosimilars competition. It would be expected for these high revenue products to be top priority targets for biosimilar makers, and that market entry would be rapid. Yet, as of November 2016, biosimilars have launched for only three of the seven (infiximab, insulin glargine, etanercept), with launches late by many months after patent expiry. Development costs are higher than for small molecules due to greater clinical trial requirements, requirement for larger and more sophisticated manufacturing facilities, promotional activity, and drawn out expensive patent litigation lawsuits. The skill set and investment required to develop and launch a biosimilar resembles those needed to launch a new biologic brand, rather than a generic small molecule. Finding biologic/biosimilar talent is a major hurdle for the many small generic companies who are interested in entering the space. Large biologic players have been tempted in to a biosimilar play due to their existing infrastructures. There are important synergies to be found in manufacturing, expertise in molecule development and regulatory approval. Uptake is slower and lower than for small molecule generics; this will improve but it is uncertain to what extent. The biosimilar space has become crowded relative to the investment required for entry. For biologics, the exact manufacturing processes used are infuential in the fnal structure and function of the drug. The complex structure of biologics and their high sensitivity to their manufacturing conditions is why the process can defne the structure. Biosimilar manufacturers will attempt to fnd alternative ways around these additional process patents. However, if this is taken too far they risk the drug no longer being truly biosimilar.
Holt and coworkers (1997) blood pressure headaches order generic betapace on line, how ever hypertension zyrtec cheapest generic betapace uk, reported that the insulin response to heart attack 36 order genuine betapace line consumption of carbohydrate foods is influenced by the level of the glucose response blood pressure and alcohol buy betapace online, but varies among individuals and with the amount of carbohydrate consumed. Adults with type 1 or type 2 diabetes have been shown to have similar glycemic responses to specific foods (Wolever et al. Individuals with lactose maldigestion have reduced glycemic responses to lactose-containing items (Maxwell et al. It is defined as the area under the curve for the increase in blood glucose after the ingestion of a set amount of carbohydrate in an individual food. Thus, glycemic load is an indicator of glucose response or insulin demand that is induced by total carbohydrate intake. This does not imply that it is the best or only system for classifying glycemic responses or other statistical associations. With progressive ripeness of foods, there is a decrease in starch and an increase in free sugar content. Although the glycemic response of diabetics is distinctly higher than that of healthy individuals, the relative response to different types of mixed meals is similar (Indar-Brown et al. For instance, coingestion of dietary fat and protein can some times have a significant influence on the glucose response of a carbohydrate containing food, with a reduction in the glucose response generally seen with increases in fat or protein content (Gulliford et al. For instance, it is important that the incremental area, rather than the absolute area, under the blood glucose curve be measured (Wolever and Jenkins, 1986). The breakdown of starch begins in the mouth where salivary amylase acts on the interior? The digestion of these linkages continues in the intestine where pancre atic amylase is released. The microvilli of the small intestine extend into an unstirred water layer phase of the intestinal lumen. When a limit dextrin, trisaccharide, or disaccharide enters the unstirred water layer, it is rapidly hydrolyzed by enzymes bound to the brush border membrane. These limit dextrins, produced from starch digestion, are degraded by glucoamylase, which removes glucose units from the nonreducing end to yield maltose and isomaltose. Maltose and isomaltose are degraded by intestinal brush border disaccharidases. Maltase, sucrase, and lactase digest sucrose and lactose to monosaccharides prior to absorption. Intestinal Absorption Monosaccharides first diffuse across to the enterocyte surface, followed by movement across the brush border membrane by one of two mecha nisms: active transport or facilitated diffusion. The intestine is one of two organs that vectorially transports hexoses across the cell into the bloodstream. The mature enterocytes capture the hexoses directly ingested from food or produced from the digestion of di and polysaccharides. The resultant gradient results in the cotransport of one molecule each of sodium and glucose. The driving force for glucose transport is the glucose gradient and the energy change that occurs when the unstirred water layer is replaced with glucose. In this type of transport, called facili tated diffusion, glucose is transported down its concentration gradient (from high to low). Absorbed sugars are transported throughout the body to cells as a source of energy. The concentration of glucose in the blood is highly regulated by the release of insulin. Most of the glucose-1-phosphate derived from galactose metabolism is converted to glycogen for storage. The glyceraldehyde can be con verted to glycolytic intermediary metabolites that serve as precursors for glycogen synthesis. Glyceraldehyde can also be used for triacylglycerol synthesis, provided that sufficient amounts of malonyl coenzyme A (CoA) (a precursor for fatty acid synthesis) are available. In muscle, glucose is metabolized anaerobically to lactate via the glycolytic pathway. Glucose can be synthesized via gluconeogenesis, a metabolic pathway that requires energy. Gluconeogenesis in the liver and renal cortex is inhibited via insulin following the consumption of carbohy drates and is activated during fasting, allowing the liver to continue to release glucose to maintain adequate blood glucose concentrations. Glycogen is present in the muscle for storage and utilization and in the liver for storage, export, and maintenance of blood glucose concentrations. Glycogenesis is activated in skeletal muscle by a rise in insulin concentration following the consumption of carbohydrate. In the liver, glycogenesis is activated directly by an increase in circulating glucose, fructose, galactose, or insulin concentration. Following glycogenolysis, glucose can be exported from the liver for maintenance of normal blood glucose concentrations and for use by other tissues. A limited amount of carbohydrate is converted to fat because de novo lipogenesis is generally quite minimal (Hellerstein, 1999; Parks and Hellerstein, 2000). This finding is true for those who are obese, indi cating that the vast majority of deposited fat is not derived from dietary carbohydrate when consumed at moderate levels. Based on the metabolic functions of insulin discussed above, the ingestion of carbohydrate produces an immediate increase in plasma insulin concentrations. This immediate rise in plasma insulin concentra tion minimizes the extent of hyperglycemia after a meal. The effects of insulin deficiency (elevated blood glucose concentration) are exemplified by type 1 diabetes. Individuals who have type 2 diabetes may or may not produce insulin and insulin-dependent muscle and adipose tissue cells may or may not respond to increased insulin concentrations (insulin resis tant); therefore, circulating glucose is not effectively taken up by these tissues and metabolized. Clinical Effects of Inadequate Intake the lower limit of dietary carbohydrate compatible with life appar ently is zero, provided that adequate amounts of protein and fat are con sumed. However, the amount of dietary carbohydrate that provides for optimal health in humans is unknown. There are traditional populations that ingested a high fat, high protein diet containing only a minimal amount of carbohydrate for extended periods of time (Masai), and in some cases for a lifetime after infancy (Alaska and Greenland Natives, Inuits, and Pampas indigenous people) (Du Bois, 1928; Heinbecker, 1928). Caucasians eating an essentially carbohydrate-free diet, resembling that of Greenland natives, for a year tolerated the diet quite well (Du Bois, 1928). However, a detailed modern comparison with populations ingesting the majority of food energy as carbohydrate has never been done. It has been shown that rats and chickens grow and mature success fully on a carbohydrate-free diet (Brito et al. It has also been shown that rats grow and thrive on a 70 percent protein, carbohydrate-free diet (Gannon et al. Azar and Bloom (1963) also reported that nitrogen balance in adults ingesting a carbohydrate-free diet required the ingestion of 100 to 150 g of protein daily. The ability of humans to starve for weeks after endogenous glycogen supplies are essentially exhausted is also indicative of the ability of humans to survive without an exogenous supply of glucose or monosaccharides convertible to glucose in the liver (fructose and galactose). However, adaptation to a fat and protein fuel requires considerable metabolic adjustments. The only cells that have an absolute requirement for glucose as an oxidizable fuel are those in the central nervous system. The central nervous system can adapt to a dietary fat-derived fuel, at least in part (Cahill, 1970; Sokoloff, 1973). Also, the glycolyzing cells can obtain their complete energy needs from the indirect oxidation of fatty acids through the lactate and alanine-glucose cycles. In the absence of dietary carbohydrate, de novo synthesis of glucose requires amino acids derived from the hydrolysis of endogenous or dietary protein or glycerol derived from fat. Therefore, the marginal amount of carbohydrate required in the diet in an energy-balanced state is condi tional and dependent upon the remaining composition of the diet. Never theless, there may be subtle and unrecognized, untoward effects of a very low carbohydrate diet that may only be apparent when populations not genetically or traditionally adapted to this diet adopt it. Of particular concern in a Western, urbanized society is the long-term consequences of a diet sufficiently low in carbohydrate such that it creates a chronically increased production of?
Psoriasis Patients Treated With Biologics and Methotrexate Have a Reduced Rate of Myocardial Infarction: A Collaborative Analysis Using International Cohorts blood pressure chart game purchase betapace 40 mg online. Psoriasis and Cardiovascular Comorbidities: Focusing on Severe Vascular Events arteria pudenda interna order betapace 40mg without a prescription, Cardiovascular Risk Factors and Implications for Treatment 5 htp and hypertension betapace 40mg visa. Impact of biologic therapies on risk of major adverse cardiovascular events in patients with psoriasis: systematic review and meta-analysis of randomized controlled trials prehypertension for years order 40 mg betapace with visa. Does biologic treatment of psoriasis lower the risk of cardiovascular events and mortality? Choosing First-Line Biologic Treatment for Moderate-to Severe Psoriasis: What Does the Evidence Say? Economic burden of psoriasis compared to the general population and stratified by disease severity. Safety, efficacy and drug survival of biologics and biosimilars for moderate-to-severe plaque psoriasis. Effect of Ixekizumab Treatment on Work Productivity for Patients With Moderate-to-Severe Plaque Psoriasis: Analysis of Results From 3 Randomized Phase 3 Clinical Trials. The effects of adalimumab treatment and psoriasis severity on self-reported work productivity and activity impairment for patients with moderate to severe psoriasis. Ixekizumab treatment leads to early resolution of bothersome symptoms versus ustekinumab. Impact of adalimumab treatment on health-related quality of life and other patient-reported outcomes: results from a 16-week randomized controlled trial in patients with moderate to severe plaque psoriasis. Infliximab treatment improves productivity among patients with moderate-to-severe psoriasis. Ustekinumab does not increase body mass index in patients with chronic plaque psoriasis: a prospective cohort study. Efficacy and safety of subcutaneous anti-tumor necrosis factor-alpha agents, etanercept and adalimumab, in elderly patients affected by psoriasis and psoriatic arthritis: an observational long-term study. Anti-tumour necrosis factor-alpha therapy increases body weight in patients with chronic plaque psoriasis: a retrospective cohort study. Effect of secukinumab on psoriasis symptoms and physical functioning compared with placebo and etanercept in subjects with moderate-to severe plaque psoriasis and concomitant psoriatic arthritis: A subanalysis from the phase 3 fixture study. Secukinumab improves patient-reported psoriasis symptoms of itching, pain, and scaling: Results of two phase 3, randomized, placebo-controlled clinical trials. Impact of ixekizumab treatment on skin-related personal relationship difficulties in moderate-to-severe psoriasis patients: 12-week results from two Phase 3 trials. Impact of ixekizumab treatment on depressive symptoms: An integrated analysis of three phase 3 clinical studies in patients with moderate-to-severe psoriasis. Efficacy of ixekizumab in moderate to severe psoriasis patients who have or have not received prior biologic therapies: An integrated analysis of 3 phase 3 studies. Ixekizumab in patients with psoriasis and psoriatic arthritis: Pooled analysis of three phase 3 studies in moderate-to-severe psoriasis. Efficacy and safety of brodalumab in subpopulations of patients with difficult-to-treat moderate-to-severe plaque psoriasis. Long-term clinical safety and efficacy of brodalumab in the treatment of Japanese patients with moderate-to severe plaque psoriasis. Ustekinumab improves overall skin response and healthrelated quality of life in a subset of moderate to severe psoriasis patients with psoriatic arthritis: Analysis of phoenix 1 and 2. Comparative effectiveness of commonly used systemic treatments or phototherapy for moderate to severe plaque psoriasis in the clinical practice setting. Comparison of long-term drug survival and safety of biologic agents in patients with psoriasis vulgaris. Comparative effectiveness of biological therapies on improvements in quality of life in patients with psoriasis. Efficacy of apremilast in the treatment of moderate to severe psoriasis: a randomised controlled trial. Apremilast, an oral phosphodiesterase 4 inhibitor, in the treatment of Japanese patients with moderate to severe plaque psoriasis: Efficacy, safety and tolerability results from a phase 2b randomized controlled trial. Apremilast for the Treatment of Moderate to Severe Plaque Psoriasis: A Critique of the Evidence. Evidence synthesis for decision making 3: heterogeneity- subgroups, meta-regression, bias, and bias-adjustment. Improvement in psoriasis symptoms and physical functioning with secukinumab compared with placebo and etanercept in subjects with moderate-to-severe plaque psoriasis and psoriatic arthritis: Results of a subanalysis from the phase 3 fixture study. Secukinumab sustains good efficacy and favourable safety in moderate to severe psoriasis patients up to 3 years of treatment: results from a double-blind extension study. Ustekinumab dosing, persistence, and discontinuation patterns in patients with moderate-to-severe plaque psoriasis. Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated. Risk of bias in 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the individual studies study or outcome level), and how this information is to be used in any data synthesis. Risk of bias across 15 Specify any assessment of risk of bias that may affect the cumulative evidence. Study characteristics 18 For each study, present characteristics for which data were extracted. Risk of bias within 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. Risk of bias across 22 Present results of any assessment of risk of bias across studies (see Item 15). Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. Updated Search Strategy of Medline 1996 to Present with Daily Update and Cochrane Central Register of Controlled Trials on the 2016 Review 1 Psoriasis/ 18421 2 psoria$. Search Strategy of Medline 1996 to Present with Daily Update and Cochrane Central Register of Controlled Trials on New Drugs 1 Psoriasis/ 18421 2 psoria$. Interventions of interest included all drugs of interest in our review (except risankizumab) in addition to conventional systemic treatments (acitretin, ciclosporin, fumaric acid esters, methotrexate), other small molecules (tofacitinib, ponesimod), and other biologics (alefacept, itolizumab). Two-thirds of the identified studies were placebo-controlled trials, 23% were head-to-head trials, and 10% were multi-armed trials (including both active comparator and placebo arms). This systematic review and network meta-analysis assessed the efficacy of brodalumab relative to other biologic therapies (adalimumab, etanercept, infliximab, ixekizumab, secukinumab, and ustekinumab) and apremilast for the treatment of moderate-to-severe chronic plaque psoriasis. Etanercept had significantly lower effectiveness compared to other biologics, and adalimumab and ustekinumab were not distinguished from each other. The other studies either did not conduct statistical tests or found non-statistically significant results. The authors identified the gap in the availability of direct evidence on effectiveness among agents. The authors proposed a network meta-analysis model adjusted for placebo response rate to control for measured and unmeasured patient and trial-level characteristics. Etanercept had statistically significant lower effectiveness than the other biologics, and the differences between the others were not statistically significant. The model assumed 80% of the population weighed less than 100 kg and were treated with 45 mg of ustekinumab, and the remaining patients received 90 mg of ustekinumab. In the base case, the manufacturer proposed a patient access scheme that discounted the cost of ustekinumab 90 mg to that of ustekinumab 45 mg. The manufacturer of etanercept modelled etanercept 25 mg and 50 mg over 12 and 96-week periods. Secukinumab Chronic plaque-type psoriasis for at least 6 Moderate to Severe quadruple-blinded 300 mg months Chronic Plaque-type Moderate-to-severe psoriasis at baseline Psoriasis/Novartis 3. Brodalumab N=3500 Incidence of November Long-Term Safety of observational Inclusion: malignancy 2031 Brodalumab cohort 2. Infliximab confirmed by dermatologist Receiving specific systemic drug for the first time 4. Ustekinumab Exclusion: Participating in a clinical trial at day of registration And other systemic treatments Spanish Registry of Prospective 1.
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These tests record nystagmus and eye movements to pulse pressure 17 purchase betapace in india diagnosis peripheral and central vestibular disorders prehypertension 120-139 over 80-89 cheap betapace uk. It involves the use of infrared goggles to blood pressure chart heart.org buy discount betapace line trace eye movements during visual stimulation and positional changes pulse pressure over 70 buy betapace overnight. W Wait times Time elapsed from when a Veteran requests an appointment for medical services and when the appointment is scheduled. Page 1-21 Audiology and Speech Pathology Design Guide November 2017 Workload the anticipated number of procedures that are processed through a department/service area. The total workload applied to departmental operational assumptions will determine overall room requirements by modality. Workplane An imaginary horizontal plane situated at the nominal working height in an interior space. Most illuminance and daylight factor measurements and calculations are made for points on this plane. Managers and other staff with no direct reports as well as part-time, seasonal, and job-sharing staff may qualify for a workstation. These environments work best when they have access to conference and small group meeting spaces. Service Structure/Organization General Audiology and Speech-Language Pathology are organizationally linked within Veterans Health Administration Patient Care Services. The Audiology and Speech-Language Pathology Service is dedicated to three major goals (U. Most commonly, the Chief of Audiology and Speech-Language Pathology reports as a Service Chief to the Chief of Staff, or as a Section Chief(s) to the Chief of Physical Medicine and Rehabilitation Service. Other administrative staff (such as, receptionist/check-in clerk) may be shared with adjacent specialty clinics. Providers may conduct administrative functions in a shared office or team work area. Often, patients seeking treatment in both services have multiple physical and cognitive disabilities. By comparison, the patient population for Speech-Language Pathology is approximately 50% inpatient and 50% outpatient. Advances in Telemedicine technologies have permitted remote treatment and diagnosis of patients for both services. Examination procedures have strict compliance guidelines requiring specialized space to meet test performance criteria (Dept. Auditory system disabilities, including hearing loss and tinnitus, are among the most common service-related disabilities. High incidences of traumatic brain injury and post-concussive symptoms reported over the last decade have resulted in increased rates of sensory and cognitive-communication complaints (Dept. Department of Veterans Affairs publications (for instance: (Vantage Point, 2015)). Rapidly emerging technologies, recognition of the benefits, Page 2-4 Audiology and Speech Pathology Design Guide November 2017 wider acceptance of the service model by both providers and patients, and the gradual erosion of barriers have contributed to the advancement of programs. Mobile health: Smartphone applications (apps) or other software is used for self management, independent of the practitioner. Readily available apps include those for hearing testing, auditory training, tinnitus management, and hearing aid counseling. This software is also being used to remotely adjust hearing aids (refer to Figure 4). For Speech Pathology services, speech and language therapy, and some swallow evaluations may be conducted via telehealth. These considerations are further discussed relative to teleaudiology and telehealth for Speech-Language Pathology in the functional and technical sections (2. Although the two services are organizationally joined, distinct differences exist with respect to functions, patient care, and support activities. Convenient access to the main or outpatient building entrance is preferred; however, if the department is located on a floor other than the entry level, proximity to vertical transportation is recommended. Although it is critical to maintain separation from busy and noisy areas, such as the main lobby or canteen, wayfinding to the department is a significant consideration due to the large number of outpatients, particularly for Audiology. Clear and intuitive wayfinding as well as convenient location are also important since patients and family members may have a variety of physical and cognitive disabilities, including balance disorders. Proximity to vertical transportation for access to departments that may be Page 2-7 Audiology and Speech Pathology Design Guide November 2017 on other floors of the facility for staff convenience and to facilitate efficient workflow is important. Providers treat patients at their bedside, and patients are sometimes transported to the department on beds/gurneys. In circumstances where space constraints or other limitations require service separation, Speech-Language Pathology may be located in another part of the facility, such as on another level proximate to inpatient services and/or an outpatient procedure area. If Speech-Language Pathology is separated, it must have all associated support and administrative functions collocated in order to function as an independent clinic. Provisions for connections to other patient care or support services via vertical transportation and good wayfinding are also important in such circumstances, particularly since Speech-Language Pathology is, in general, a smaller service in terms of both workload and footprint relative to Audiology. Note: the terms, ?Balance Testing? and ?Speech Lab? encompass several diagnostic/treatment functions within Audiology and Speech Pathology, respectively; they do not represent individual rooms described later in this Design Guide. Figure 7: Functional Relationships Service Proximity Figure 7 illustrates three alternative scenarios for the location of Audiology and Speech Pathology services; collocated services and functions are preferred. Since Audiology and Speech Pathology are specialty services, patient care functions are not readily accommodated in multi Page 2-10 Audiology and Speech Pathology Design Guide November 2017 function examination/treatment rooms; a dedicated clinic for the service shall be planned. If endoscopic swallow studies are performed, the process for handling scopes and functional relationship to Sterile Processing and other support spaces, such as Clean Supply and Soiled Utility/Holding Rooms, needs to be a consideration. Compensation and Pension (Comp & Pen) exams are performed in sound suites located within the outpatient Audiology Clinic, or in a separate Comp & Pen facility. In such circumstances, consideration for patient and staff flow and proximity between the two locations shall be evaluated during the facility planning phase. Access to a Canteen Service, coffee shop, or vending is important for patient, family, and staff convenience, but should not be adjacent. Audiometric exams for new patients average about 60 minutes, while those for established patients require between 30 to 45 minutes. Standard Support and Staff & Administrative Area functions, such as Clean Supply and Soiled Holding Rooms, Equipment Storage, Patient and Staff Toilet Rooms, Staff Lounge, Conference and Group Room(s), Reception/Waiting, and administrative offices may potentially be shared with Speech Pathology, based on local Page 2-12 Audiology and Speech Pathology Design Guide November 2017 operations and service size when the services are collocated. Figure 9: Functional Relationships Diagram: Audiology Key Spaces Page 2-13 Audiology and Speech Pathology Design Guide November 2017 Audiology Rehabilitation/Counseling Room the Audiology Rehabilitation/Counseling Room is a patient care space where Audiologists perform one-on-one auditory rehabilitation, device demonstrations, and counseling for assistive devices, including cochlear implants. Additional activities include quick fittings demonstrations of how to charge programmers, patient documentation, and other administrative work functions. Patient encounters are conducted one-on-one in the room, over the telephone, or via telehealth, and average 15 to 20 minutes (U. The Rehabilitation/Counseling Room is most closely associated with the Audiometric Examination Suites (?sound suites?) and Programming/Fitting rooms. While the tasks described above may be performed in the sound suite, it is beneficial for booth turnover/efficiency to conduct these activities in the Rehabilitation/Counseling Room. Locating the Rehabilitation/Counseling Rooms and Programming/Fitting Rooms along a perimeter/exterior wall with windows, if available, is beneficial for access to natural daylight outside of the sound suites; however, glare from windows must be controlled. Lighting control/adjustability should accommodate a variety of tasks and conditions. Sound attenuation to produce a quiet environment is an additional important consideration for this space. The layout of the Rehabilitation/Counseling Room supports consultation and demonstration activities, while maintaining safety considerations by locating the service provider close to the door (refer to Section 2. Provider Workstation: desk with sufficient surface area to accommodate paperwork functions, space for charging programmers, and standard desktop equipment, including a computer workstation with dual monitor setup for telehealth. The mounting and location of monitors on a flexible arm shall permit viewing by both the provider and patient. This need may be accommodated with a combination of mobile pedestal file and overhead ?flipper door? cabinets at the provider workstation. Mobile, adjustable height table for demonstrations, layout of hearing aids, and consultations positioned between the Audiologist and patient. Wire management is addressed via numerous outlet locations above and below the workstation and on all sides of the room.