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Studies Provide Practical Advice for Implementing Clinical Guidelines This article examines the practical impact of implementing clinical guidelines in regard to patient outcomes and health service costs, based upon two studies revolving around the use of new guidelines. Differences in outcomes suggested the need to take account of local factors when developing and implementing guidelines. While guidelines may change some ; physicians' behavior, they may not of themselves change patient outcomes. : bmj cgi content full 322 7297 0 f, for example, pregnancy!
Theovent theophylline ; Theo-X theophylline ; Thiethylperazine: Antiemetic. chem class: phenothiazine Tx: nausea vomiting Toxicology drug to drug interactions: anticholinergics will cause anticholinergic effect, beta agonists will cause effects of both drugs, narcotics will cause CNS depression, sedative hypnotics will cause CNS response for additional drug interaction information, consult with another text ; . Tilade nedocromil ; Thioridazine: Antipsychotic Neuroleptic. chem class: phenothiazine, piperidine Tx: depression, mania and hypomania, bipolar disorder, anxiety Toxicology drug to drug interactions: toxicity with epinephrine, anticholinergic effects with anticholinergics, hypotension with antihypertensives, effects of both drugs with beta agonists, CNS depression with alcohol, CNS depression with narcotics, CNS depression with sedative hypnotics for additional drug interaction information, consult with another text ; Thiothixene: Antipsychotic neuroleptic. chem class: Thioxanthene Tx: psychotic disorders, schizophrenia, acute agitation Toxicology drug to drug interactions: sedation CNS depression with alcohol, toxicity with epinephrine, anticholinergic effects with anticholinergics, hypotension with antihypertensive, effects of beta agonists, CNS depression with narcotics, CNS depression with sedative hypnotics for additional drug interaction information, consult with another text ; Thiuretic hydrochlorothiazide ; Thombran trazodone HCL ; Thorazine chlorpromazine ; Thyroglobulin: Hormone Tx: hypothyroidism, goiter Thyrolar levothyroxine + liothyronine ; Tiagabine: Anticonvulsant Tx: adjunct treatment for partial seizures Action: blocks the reuptake of gamma aminobutyric acid GABA ; - therefore more GABA is available to interact with GABA receptors Tiamate diltiazem ; Tiazac diltiazem ; Ticarcillin: Antibiotic Tx: septicemia, skin, bone, joint and lower respiratory infection, urinary tract infection UTI ; and endomitritis Ticlid ticlopidine ; Ticlopidine: Platelet aggregation inhibitor Toxicology drug to drug interactions: the risk of embolic thrombotic stroke, TIAs, intermittent claudication, subarachnoid hemorrhage, sickle-cell disease risk of bleeding with ASA or oral anticoagulants Tikosyn dofetilide ; Tiludronate: Bone reabsorption inhibitor, calcium regulator Tx: Paget's disease Timentin clavulanate + ticarcillin ; Timolide hydrochlorothiazide + timolol ; Timolol: Antihypertensive, anti-glaucoma. chem class: non-selective -adrenergic blocker Tx: mild to moderate hypertension, glaucoma action: aqueous humor in.
Table 3. Common drug-drug interactions DDIs ; and potential adverse drug reactions ADRs ; in the elderly Drug or drug class Digoxin Interacting drugs Loop thiazide diuretics Pgp inhibitors e.g. clarithromycin, quinidine, verapamil, amiodarone Beta-adrenoceptor antagonists ACE inhibitors Potassium sparing diuretics potassium supplements NSAIDs Oral anticoagulants CYP inhibitors e.g. amiodarone, cimetidine, clarithromycin, cotrimoxazole, fluconazole, metronidazole CYP inducers e.g. barbiturates, carbamazepine, rifampicin, St. John's wort Low dose acetylsalicylic acid, clopidogrel, NSAIDs Insulin oral antidiabetics sulfonylureas, glinides ; Beta-adrenoceptor antagonists Other antidiabetics or insulin CYP 2C8 9 inhibitors e.g. cotrimoxazole, gemfibrozil, fluconazole Tricyclic antidepressants a Antipsychotics Other anticholinergic drugs e.g. some antispasmodics, antiparkinson agents biperiden, amantadine ; , first generation histamine H1 receptor antagonists Other sedative drugs e.g. first generation histamine H1 receptor antagonists, antipsychotics with high affinity to histamine H1 receptors e.g. chlorpromazine, chlorprothixene, clozapine, quetiapine ; , maprotiline Mechanism.
The Cochrane Collaboration is an international organisation that aims to help people make wellinformed decisions about healthcare by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions. The Cochrane Incontinence Group is a Collaborative Review Group CRG ; of the Cochrane Collaboration. We undertake systematic reviews of randomised controlled trials on different interventions designed to prevent or treat incontinence and related conditions, or aid rehabilitation. The group is concentrating on interventions where incontinence is the primary problem. The problems covered include urinary and faecal incontinence, enuresis, day-time wetting in children, encopresis, postprostatectomy incontinence, use of urinary catheters including catheter-related urinary tract infections but not other infections ; , enterocutaneous and enterovesical fistulae, neurogenic incontinence and retention, interstitial cystitis, postoperative urinary retention and rectal or vaginal prolapse.
There also appears to be a very important benefit of pre-treatment with clopidogrel, with lower rates of peri-procedural cardiac events. In the randomized PCI-CURE substudy of CURE, a total of 2, 658 patients who had presented with unstable angina or non-ST elevation MI within the CURE trial subsequently underwent PCI.19 They had been randomly assigned to receive either clopidogrel or placebo. Treatment with clopidogrel prior to PCI was associated with a 30% reduction in the rate of cardiovascular death, MI or urgent target vessel revascularization 30 days post PCI, from 6.4% for placebo to 4.5% for clopidogrel p 0.03 ; . Figure 5 ; 19 The endpoint of cardiovascular death or MI was reduced from 4.4 to 2.9%, a 34% reduction p 0.04 ; . As had been seen with IIb IIIa inhibitors, 20 clopidogrel was associated with a pre-PCI reduction and
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There was no significant difference in the composite incidence of death, myocardial infarction, stroke, and stent thrombosis between the 2 groups , but the target lesion revascularization rate per patient was significantly lower in the cilostazol group than in the ticlopidine group 2 9% vs 3 7%, p 030 ; 9 months post-coronary stenting and
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Letters tient with GCA in Figure 1. Associated inflammatory signal changes could be clearly identified in the superficial cranial arteries without significant changes for different delays following contrast agent administration. This illustrates the robustness of T1-weighted imaging of the vessel wall with respect to the delay in the injection of the bolus. GCA usually affects the superficial cranial arteries. However, involvement of other vascular structures such as the vertebral arteries, the aorta and its branches, the coronary arteries, the mesenteric arteries, and the lower leg arteries also can occur. It is therefore advantageous to know the exact vascular involvement pattern of the individual patient. Combining high-resolution assessment of the cranial arteries with analysis of the involvement of the aortic wall as presented by Desai et al. [1] should be feasible without the need for additional contrast agent injections or an increase in dosage. In addition, the contrast agent may even be further utilized by combining such studies with first-pass MR angiography for assessment of vascular geometries and potential detection of stenoses associated with inflammatory diseases. T. A. Bley M. Markl Department of Diagnostic Radiology and Medical Physics University Hospital Freiburg, Germany O. Wieben Department of Medical Physics and Radiology University of Wisconsin Madison, WI and metrogel.
7. Akcay A, Kanbay M, Agca E, Sezer S, Ozdemir FN. Neutropenia due to clopidogrel in a patient with end-stage renal disease [letter]. Ann Pharmacother. 2004; 38: 1538-1539. Phillips EJ, Knowles SR, Shear NH. Serum sickness-like reaction associated with clopidogrel [letter]. Br J Clin Pharmacol. 2003; 56: 583. Wolf I, Mouallem M, Rath S, Farfel Z. Clopidogrel-induced systemic inflammatory response syndrome. Mayo Clin Proc. 2003; 78: 618620. Naranjo CA, Busto U, Sellers EM, et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther. 1981; 30: 239245. Cosmi B, Rubboli A, Castelvetri C, Milandri M. Ticlopidine versus oral anticoagulation for coronary stenting. Cochrane Database Syst Rev. 2001; 4: CD002133. 12. Mitka M. Results of CURE trial for acute coronary syndrome. JAMA. 2001; 285: 1828-1829. Harker LA, Boissel JP, Pilgrim AJ, Gent M, CAPRIE Steering Committee and Investigators. Comparative safety and tolerability of clopidogrel and aspirin: results from CAPRIE. Drug Saf. 1999; 21: 325-335. Knowles S, Shapiro L, Shear NH. Should celecoxib be contraindicated in patients who are allergic to sulfonamides? revisiting the meaning of `sulfa' allergy. Drug Saf. 2001; 24: 239-247.
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The data used in this study were supplied by the prescription pricing authority, the department of health and the office for national statistics.
Treatment of benign prostatic hyperplasia BPH ; has changed tremendously in the last 10 years. Transurethral resection of the prostate TURP ; has been the mainstay of therapy, accounting for 90% of BPH surgery.1 New treatment techniques and new medical therapies have created options where none existed before.2-5 and moduretic.
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As well as aspirin antiplatelet therapy in acute myocardial infarction. Of particular relevance to us is the risk of bleeding with these interventions. The investigators showed a non-significant difference between clopidogrel and placebo in both fatal non-cerebral and transfused non-fatal bleeds. But they were unable to give a further breakdown of the underlying cause of these events notably gastrointestinal bleeds ; . Furthermore, inclusion criteria for this trial were determined on a local basis, and although active bleeding was classified as high risk, there is no mention of past medical history of ulcer disease or the like. Evidence regarding the proposed combination of these agents is sparse at best. In the MATCH study, 2 aspirin and clopidogrel led to more bleeding than clopidogrel alone. In an aspirininduced gastrointestinal secondary prevention setting, Chan and colleagues3 showed that the combination of aspirin and a proton-pump inhibitor PPI ; was associated with a significantly lower incidence of bleeds than clopidogrel alone 07% vs 86%, p 0001 ; . Another study comparing both therapies individually with PPI cover revealed that both had a similar bleed profile.4 There are no established guidelines in this area, but PPIs have been tried and tested in the longer term and would seem to be the agents of choice.5 Obviously, this is a topic that requires further research. Pragmatically approaching the problem in a real-life setting, we would strongly advocate that our cardiology colleagues have a low threshold for prescription of such medications if there are concerns, especially acutely, but also later on. In gastrointestinal bleeding, prevention is clearly better than cure and
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One of the major problems in combating tuberculosis disease is that Mycobacterium tuberculosis is resistant to most therapeutic agents because it has an unusual bacterial cell wall with intrinsically low permeability 1 ; . Although acquired high-level drug resistance in mycobacteria in general is due to mutational alterations of the drug target, it has become clear that low-level drug resistance to a variety of different anti-infective agents is frequently found in clinically drug-resistant isolates with no alteration of the target. Nothing is presently known about the molecular mechanisms mediating this class of resistance, although it is likely that changes in drug transport are involved 2 ; . Multidrug efflux systems endow on bacterial cells the ability to limit the access of antimicrobial agents to their targets. Drug efflux appears to be one of the most widespread antibiotic resistance and
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1. Canadian Institute for Health Information CIHI ; . Canadian Coding Standards for ICD-10-CA CCI, 2004. Ottawa, Ontario, Canada. 2001. 2. Personal Communication with Grace Carter, PhD., Consultant with the RAND Corporation, Ottawa, Canada. February 19, 2004. 3. Canadian Institute for Health Information. Health Indicators 2004. Ottawa, Ontario, Canada. 2004. 4. Canadian Institute for Health Information. CMG Plx Directory 2003 For use with ICD-10-CA CCI ; . Ottawa, Ontario, Canada. 2003. 5. The National Center for Health Statistics NCHS ; . Draft ICD-10-CM Official Guidelines For Coding and Reporting for Acute Short-term and Long-term Hospital Inpatient and Physician Office and other Outpatient Encounters Introduction. Bethesda, MD, USA. June 2003. 6. World Health Organization. WHO Hospital Data Project--List of International Diagnosis Definitions. Geneva, Switzerland. June 2003. 7. Personal Communication with Participants at the 2003 Patient Classification System Europe PCS E ; Conference, Washington D.C., October 2003. 8. Canadian Institute for Health Information CIHI ; . Bulletin: April 1, 2004 Classifications Update. Ottawa, Ontario, Canada. April 2004 and
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Other indications apart from the use of glycoprotein iib iiia receptor antagonists in coronary angioplasty, the strongest indication for an alternative antiplatelet to aspirin is the use of ticlopidine in secondary stroke prevention.
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All generic medications are on the PRx formulary. Please use this quick reference list when you receive a prescription. To receive maximum prescription drug benefits, ask you doctor to prescribe a medication on the formulary. Remember, if a drug from the formulary is prescribed, your co-pay may be less than if a non-formulary drug a drug not on the complete formulary list ; is prescribe for you. To see the complete formulary visit under Services-or call toll free 877-468-5279. You must register and login to access the services. Drugs are listed alphabetically by brand name. KEY: generic medication lowest co-pay ; listed in all lower-case letters. Brand-name Medications middle co-pay ; listed with a leading capital letter * -brand versions of these drugs are nonformulary highest co-pay ; Acots Advair Aldara Alocril Alora Alphagan P Alupent * metapruterenol ; Amaryl Ambien Amoxil * amoxicillin ; Anapros, DS * naproxen sodium, DS ; Ansia * flurbiprofen ; Atrovent * ipatropium bromide ; Augmentin * amox clav ; Avandamet Avandia Avapro Azmacort Bactrin, DS * sulfamethoxazole trimethoprim ; Betagan * levobunolol ; Calan, SR * verapamil, SR ; Capoten * captopril ; Carafate * sucralfate ; Cardizem * diltiazem ; Cardura * doxazosin ; Ceclor, CD * cefaclor, ER ; Ceftin * cefuroxime ; Cefzil Celexa Celestine Cipro Climara estradiol ; Combipatch Corgard * nadolol ; Cosopt Coumadin warfarin ; Crolom * cromolyn ; Cytotec * misoprostal ; Dalmane * flurazepam ; Desyrel * trazodone ; Detrol, LA Diabeta * glyburide ; Diflucan Dilacor XR * diltiazem CR ; Diovan, HCT Dyazide * triamterene HCTZ ; Effexor, XR Estrace * estradiol ; Evista FemHRT Flonase Flovent Fosamax Glucophage * metformin ; Glucophage XR Glucotrol, XL glipizide ; Glucovance Glynase Prestab * glyburide micro ; Halcion * triazolam ; Humalog Humulin Hydrodiuril * hydrochlorothiazide ; Hytrin * terazosin ; Imdur * isosorbide mononitrate ; Imitrex Inderal * propranolol ; Inderal LA Indocin, SR * indomethacin, SR ; Intal Inh. Intal Soln. * cromolyn ; ISMO * isosorbide mononitrate ; Isoptin, SR * verapamil, SR ; Isordil * isosorbide dinitrate ; Keflex * cephalexin ; Lanoxin Lantus Lasix * furosemide ; Levaquin Lexapro Lipitor Lodine * etodolac ; Lop9d * gemfibrozil ; Lopressor * metoprolol ; Lortab * hydrocodone APAP ; Lotensin, HCT * benazepril HCTZ ; Lotrel Lozol * indapamide ; Lumigan Maxair Maxzide * triamterene HCTZ ; Miacalcin Micronase * glyburide ; Mirapex Monoket * isosorbide mononitrate ; Motrin * ibuprofen ; Nalfon * fenoprofen ; Naprosyn * naproxen ; Nasacort AQ Niaspan Nitro-Dur Nitrostat * nitroglycerin ; Nizoral * ketoconazole ; Norpramin * desipramine ; Norvasc Ocupress * carteolol ; Ogen * estropipate ; Omnicef Omnipen * ampicillin ; Ortho-Est * estropipate ; Orudis * ketoprofen ; Oruvail * ketoprofen ; Pamelor * nortriptyline ; Paxil CR Persantine * dipyridamole ; Plavix Precose Premarin Prempro, Premphase Prinivil * lisinopril ; Prinzide * lisinopril hctz.
Pharmaceutical manufacturer Pfizer New York ; has announced plans to move ahead with development of a novel compound that apparently makes drugs more effective. The company announced at year-end plans to exercise an option to acquire an exclusive worldwide license to nitric oxide-donating compounds developed by a French company, NicOx Sophia Antipolis ; . As part of the agreement, Pfizer has paid NicOx 2 million. NicOx creates patentable new compounds by taking an existing drug and grafting a nitric oxide-donating molecule. According to the company's Web site, nitric oxide plays a critical role in a number of biochemical processes in the human body, such as acting as a messenger molecule and regulating certain cellular processes. Pfizer and NicOx were jointly responsible for this research project, in which a number of nitric oxidedonating compounds were synthesized and submitted to an extensive series of preclinical tests. Several com, because lopid.
He choice of antibiotic is based on microbiological sensitivities. Patients with CF will generally be reviewed at threemonthly intervals, when they will have sputum samples taken. The sample will be tested against a range of antipseudomonal antibiotics for sensitivity. Therefore, when the patient needs antibiotic treatment, there will be a sputum sensitivity result available that is no more than three months old. On the basis of this result, two antibiotics to which the Ps aeruginosa is sensitive will be chosen. Where possible, an aminoglycoside will be used with a beta-lactam to take advantage of the synergy between the drugs. As patients are exposed to antibiotics on a repeated and regular basis, the Ps aeruginosa strains carried by each individual develop resistance to more antibiotics. As the patient grows older, antibiotic resistance becomes more of a problem, and it becomes more difficult to select two antibiotics to which the Ps aeruginosa is sensitive. The selection problem is compounded by drug allergies. CF patients are at risk of developing al and lopressor.
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The most suitable base case we believe is treatment with an lhrh agonist alone.
From the Department of Dermatology, University of Nevada School of Medicine, Las Vegas, Nevada Address correspondence to James Q. Del Rosso, DO, Las Vegas Skin and Cancer Clinics, 4488 S. Pecos Road, Las Vegas, NV 89121. E-mail address: doctorskin777 yahoo 2003 by Elsevier Science Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010.
CMDP knows it may be difficult to locate a health care provider outside of Arizona. Out-ofstate foster caregivers should use their family doctor and dentist when possible. However all providers are required to register with the Arizona Health Care Cost Containment System. The Provider Services staff is responsible for handling the registration of all health care providers including those out-of-state. Provider Services staff contacts the identified out-of-state providers. The staff explains health plan coverage and claim payments. Please contact the staff for assistance with out-of-state providers. The phone numbers are 602-3512245 or 1-800-201-1795, ext. 7042 and ext. 7081. Request For Member Addresses It is important that we have the current address of each member. We get the addresses from the agencies that enroll children with our health plan. To make sure we have the right address for each child in your home, please contact Member Services. CMDP welcomes calls from foster caregivers and members.
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Method: The medical records were examined for all patients who had been read coded for epilepsy or who were on a epileptic drug. The diagnosis was reviewed and also the appropriateness of treatment was examined. Data collected included patient ID, gender, age, date of diagnosis, drug treatment, the date of last review, date of last visit at surgery, date of last seizure.
A computer file that contained antibiotic utilization data for the month of January 1996. Clinical pharmacists collected data from patient medical records using a data collection tool designed to capture all.
13. Mehta SR, Eikelboom JW, Yusuf S. Long-term management of unstable angina and non-Q-wave myocardial infarction. Eur Heart J 2000; 2: 612. Bennett CL, Connors JM, Carwile JM, Moake JL, Bell WR, Tarantolo SR, McCarthy LJ, Sarode R, Hatfield AJ, Feldman MD, Davidson CJ, Tsai HM, Michalets EL. Thrombotic thrombocytopenic purpura associated with clopidogrel. N Engl J Med 2000; 342: 17737. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events CAPRIE ; . Lancet 1996; 348: 132939. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE, Theroux P. ACC AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines Committee on the Management of Patients with Unstable Angina ; . J Coll Cardiol 2000; 36: 9701062. Topol EJ. Cardiology in the 21st century. Eur Heart J 2000; 2: 1827. Theroux P. Antiplatelet drugs in the acute phase of myocardial infarction. Eur Heart J 1999; 1: 2933. Robertson GC. Management of intermediate coronary syndrome: role of conservative treatment, glycoprotein IIb IIIa receptor inhibitors, and direct interventions. J Cardiol 2000; 85: 216. Lincoff AM, Califf RM, Topol EJ. Platelet glycoprotein IIb IIIa receptor blockade in coronary artery disease. J Coll Cardiol 2000; 35: 110315. Teirstein PS. Early clinical results with the new oral glycoprotein IIb IIIa agents. J Cardiol 1999; 83: 125. Curtin R, Fitzgerald DJ. A cold start for oral glycoprotein IIb IIIa antagonists. Eur Heart J 2000; 21: 19923. BRAVO stopped Blockade of the glycoprotein IIb IIIa Receptor to Avoid Vascular Occlusion. Cardiosource , Trails News, December 13, 2000 24. Chew DP, Moliterno DJ. A critical appraisal of platelet glycoprotein IIb IIIa inhibition. J Coll Cardiol 2000; 36: 202835. Lincoff AM, Korngold S. An overview of platelet GP IIb IIIa receptor antagonists trials. Eur Heart J 1999; 1: 1826. Tcheng JE. Differences among the parenteral platelet glycoprotein IIb IIIa inhibitors and implications for treatment. J Cardiol 1999; 83: 711. Verheugt FWA. Hotline sessions at the 22nd European Congress of Cardiology. Eur Heart J 2000; 21: 19848. Fox KAA. Comparing trials of glycoprotein IIb IIIa receptor antagonists. Eur Heart J 1999; 1: 107. Turpie AGG. Anticoagulants in acute coronary syndrome. J Cardiol 1999; 84: 26. Cohen M. New therapies for unstable angina and non-Q-wave myocardial infarction: recent clinical trials. Heart J 1998; 135: 34352. Kontny F. Reactivation of the coagulation system: rationale for long-term antithrombotic treatment. J Cardiol 1997; 80: 5560. Fareed J. Heparins in the new millennium: will unfractioned heparin survive? Medscape Cardiology Treatment Updates 2000. 33. Fareed J, Jeske W, Hoppensteadt D, Clarizio R, Walenga JM. Low-molecularweight heparins: pharmacologic profile and product differentiation. J Cardiol 1998; 82: 310.
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Ticlopidine, aspirin, heparin, endothelial cell growth supplement and DAPI were from Sigma; antibodies and ELISA kits for measurement of VEGF and endostatin were from Chemicon; apoptosis ELISA kits were from Boehringer Mannheim; HUVECs and medium were from American Type Culture Collection; antiplatelet serum was from Cedarlane Laboratories; and all other supplies were from Fisher Scientific. Results.
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2. Specifications for Devices.--The devices used by the patient are highly portable usually pocket-sized ; and detect and convert the normal EKG signal so that it can be transmitted via ordinary telephone apparatus to a receiving station the receiving end, the signal is decoded and transcribed into a conventional EKG.There are numerous devices available which transmit EKG readings in this fashion.For purposes of Medicare coverage, however, the transmitting devices must meet at least the following criteria: a. They must be capable of transmitting EKG Leads, I, II, or III.
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