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Sidney C. Smith, Jr., MD

Professor of Medicine
Division of Cardiology
University of North Carolina School of Medicine
Chapel Hill, North Carolina

Quality Assurance includes service and maintenance as required in conjunction with the use of controls and calibrators cholesterol ideal numbers generic caduet 5 mg on line. The combination of these methods provides the assurance of complete quality control and should be applied separately or in combination ratio van cholesterol order caduet 5mg without a prescription, in accordance with your laboratory and accreditation requirements cholesterol medication least side effects discount caduet 5mg overnight delivery. For additional information on doing and reviewing Daily Checks cholesterol plaque caduet 5 mg lowest price, refer to the Daily Checks chapter cholesterol in medium eggs buy caduet cheap online. Refer to Analyze Commercial Controls in the Quality Control chapter for more information running controls quest diagnostics cholesterol test cost purchase 5mg caduet free shipping. Rili-BAK (Guidelines of the Federal Chamber of Physicians), was first published in 1987 and amended in 1990 and 1993 covering clinical chemistry, immunochemistry and other tests, but not hematology. In 2003, the guidelines were extended to include hematology and were updated in 2008. Setup Refer to Daily Checks Configuration (Daily Checks > Auto Configuration > Configure Daily checks) in the Setup chapter for information on configuring Daily Checks. If you forget your password, contact your laboratory administrator to reset your password. A DxH 800 dialog box displays the following: Are you sure you want to start a Daily Checks procedure If there are any failures, you must Review Daily Checks in order to proceed with further analysis. Review Daily Checks the Daily Checks must pass or be reviewed in order to run specimens. From any tab on the Daily Checks screen, select the Review button on the Local Navigation bar to indicate that the Daily Checks results have been reviewed. Controls have known characteristics when run on a given system and are analyzed periodically in the same manner that patient specimens are analyzed. The results of analyzed controls are then compared to the known characteristics using statistical methods. The DxH 800 System allows you to use multiple quality control techniques that are outlined in this chapter. Beckman Coulter recommends that Quality Control checks be performed using patient or commercial controls by either cassette or single-tube presentation at intervals established by your lab. When using a commercial control, refer to the package insert to determine which method of presentation to use. For information on setting up Quality Controls and enabling the auto configuration of controls, refer to Quality Control (Menu > Setup > Quality Control) in the Setup chapter. If using a bar-code reader, ensure the bar code labels are clean and positioned correctly. If any of the problems mentioned in item 1 above existed, rerun the control; otherwise, proceed to the next step. Ensure the control material was not contaminated by running another vial or level of control. Ensure the control setup information (assigned values and expected ranges) matches those on the package insert. If they do not, change the control information to match the package insert, then rerun the control. If the control is still outside the expected ranges, call your Beckman Coulter Representative. If controls have not been reviewed, a dialog box displays a list of those controls that have not been reviewed. Component Description Delta Diff the difference between the calculated mean and the assigned target of the parameter within the specified filter. Target the assigned target of the parameter being used in your lab at the time of the control analysis. Limit the traditional expected limit of the parameter in use in your lab at the time of the control analysis. Exclude Allows you to exclude the results of that run from the control statistics calculations. Presentation Displays the method of presentation for each run in the control file. Thumbnail Levey-Jennings Graph the thumbnail graph on the Quality Control (Data View) screen displays the ten latest run points for the selected parameter (row). Options on the Local Navigation Bar on the Quality Control Screen Button Description Select Control Allows you to select a control file to view. View Graph (or View View Graph (on the Data View screen) -Allows you to view the control file Data) results graphically. View Data (on the Graph View screen) Allows you to view the control file results in table view. Delete Allows you to delete a selected run, all runs in the current filter, or all runs in the current control file. Systematic Random Allows you to review systematic, random errors and single measurement Review errors. Use the right and left arrows on the scroll bar under the expanded graph to view all of the data points. Up to 31 Thumbnail Levey-Jennings graphs display the latest run points for all parameters. Each graph displays up to 10 points and these points change to reflect the scrolling of the expanded graph. The points shown in the blue-shaded window of the expanded graph reflect those shown in the thumbnail graphs. The point cursor on the thumbnail graphs is synchronized with the selected run within the data grid and the point cursor in the expanded graph. If you select a thumbnail graph, that graph will be displayed as the expanded graph in the screen. Expanded Levey-Jennings Graph the expanded Levey-Jennings graph at the bottom of the Quality Control (Graph View) screen displays all of the results for a selected parameter in the control file. The blue-shaded window on the expanded graph, which contains up to 10 points and the point cursor, determines the points and cursor displayed in the thumbnail graphs. Point Cursor the point cursor is a blue vertical line on the graph that reflects the date selected in the Data View. The cursor can be moved left or right by either using the scroll bar or by selecting either the data points on the graph or the control run analysis Date/Times (column heading) in the Data View table. If the cursor moves to another point within the window, the window remains in place, and the cursor moves within the window. If the cursor moves to a point outside the window, the window shifts so that the new point displays in the window as the furthest right or left point (depending on where the new point is). The points displayed in the thumbnail graphs reflect those displayed in the window. These are the expected limits, in currently configured units, at the mean and +1 and +2 traditional expected limit and -1 and -2 traditional expected limit. For Body Fluid Level 1, only the upper section (values above 0) displays, since the control does not have a target +/ limit, but instead has an assigned upper limit. The name of the month displays above the tick representing the first day of a new month. Points Multiple runs for a single date display in chronological order, starting on the tick representing that day. For example, three points for the date 12/1 display as three points in order between 12/1 and 12/2. Points above or below the y-axis scale display as a red up-triangle or red down-triangle, respectively. Runs that are deleted from the control file will not be shown in the graph or data view. Results that have non-numeric values, whether in an Included or an Excluded run, are not plotted; however, a space on the x-axis displays where the result would have been if it had been a numeric value. View Logs You can view History logs for control files by selecting the View Log button on the Quality Control (Data View) screen or the Quality Control (Graph View) screen. Source Read-only field that displays the control source Type Read-only field that displays the control type. Report Status Read-only field that displays the report status for manually and automatically printed reports. System Message Read-only field that displays the additional information related to specific codes and flags. Data Grid Read-only grid that displays the result and flag data in up to 3 groups. If a type of analysis is disabled, then the corresponding dataplot does not display, and as a result, the tab does not display as well. Print Select this button to manually print the Quality Control Reports Additional Data Select this button to display the Additional Data window. Refer to the Viewing Additional Data section of this chapter for additional information. For component descriptions of this screen, refer to the Additional Data section of the Data Review chapter. If more than one lot triggered an error condition, the Select Control File to Review dialog box displays. If a batch has not been reviewed, Click to Review displays in this column for that batch. Point Cursor the point cursor is a blue vertical line on the graph that reflects the analysis date of the selected run in the date grid. The cursor can be moved left or right by either selecting another row in the grid or by selecting the data points on the screen. These are the assigned values in currently configured units at the Target and at (Target + Limit), (Target Limit), (Target +2x Limit), and (Target -2x Limit). The name of the month displays below the tick representing the first day of a new month. Points Multiple batch runs for a single date display in chronological order, starting on the tick representing the current day and ending before the tick representing the next day; for example, three for the date 12/1 display as three points in order between 12/1 and 12/2. If the current (batch in progress) is selected, the current will be deleted, otherwise, the last completed batch will be deleted. Each tab includes batch size, total batches, and calculated statistics data for each batch. The batches display in the order that they were run, with the newest results at the top. If the current batch has not completed, Current Batch will display in the Batch/Date Time column for that batch. If a batch has not yet been reviewed, Click to Review will display in the Reviewed By column. No Data Available will display in the Reviewed By column if there is no data for the current batch. In Progress displays in the Reviewed By column if there are some runs for the current batch, however there is no data displayed in the parameter columns. Mark as Reviewed 1 To mark a batch as reviewed, select the Click to Review link that displays in the Reviewed By column for that batch to display the Review Batches dialog box. If you attempt to review a batch that has already been reviewed, the following message displays: this batch has been reviewed and cannot be reviewed again. Thumbnail Levey-Jennings Graphs A separate thumbnail Levey-Jennings graph displays for each test in a group. The thumbnail graph shows all batch mean points for a maximum of 20 completed batches. Point Cursor the point cursor is a blue vertical line on the graph that reflects the batch position (row) of the selected batch in the list of batches. The cursor can be moved to the left or right by selecting another row in the grid. Points Points represent a batch mean value for a specific batch and are displayed in chronological order. Move your cursor or finger over the point to display the batch completion date and time. Body Fluids To reduce body fluid sample viscosity, use hyaluronidase to treat synovial fluids prior to analysis according to your laboratory standards. Ensure you leave space at the top of the tube between the sample and the stopper to facilitate automatic mixing. Specimen Preparation (Pre-dilute) You can use the Dispense Diluent function on the Single-tube Presentation dialog box to acquire diluent for use in your pre-dilute preparation. Place the labels so that they are in the viewable area of the tube through the cassette window, as shown in Figure 5. Do not place the label on the bottom 10 mm of the tube or the top 10 mm of the tube or skew the label more than 12 degrees. These areas are not viewable due to the curvature of the tube and the cassette window.

Multiple human studies have shown a high incidence of electrical seizure and electrical status epilepticus after what appeared to be successful treatment of convulsive seizure cholesterol ratio or total cheap caduet master card. In these cases cholesterol test after eating buy caduet online pills, the presence of electrical seizure is significantly and independently associated with higher mortality rates and loss of function definition of cholesterol and importance order caduet with paypal. Younger patients were at significant risk for electrical seizure and cats were at significant risk for electrical status epilepticus cholesterol medication affect kidneys purchase caduet 5 mg online. It was more common for electrical seizure or electrical status epilepticus patients to have had a seizure within 8 hours cholesterol of eggs order caduet 5 mg without prescription, history of cluster seizure good cholesterol foods list buy caduet 5 mg with visa, facial / ear twitching, and a structural brain problem, but none of these associations were statistically significant. Mortality rates were 41% in the electrical seizure / electrical status group and 21% in the non-electrical seizure group. Assessment of the prevalence and clinical features of cryptogenic epilepsy in dogs: 45 cases (2003-2011). When a client presents a recent onset seizure patient they are keenly interested in the diagnosis and prognosis along with best course of action. Some cases will be of unknown or genetic cause (idiopathic) and others will have a specific (structural) cause for the seizure. The diagnostic plan, prognosis and treatment plan can be very different between dogs with an unknown cause for their seizure and dogs with a structural problem (brain tumor, encephalitis, stroke, malformation). Considering the age of onset, breed, weight, historical and neurological exam findings are crucial in estimating the likelihood that there is a structural cause for the seizure. This talk will discuss the current terminology and rational for grouping seizure by their underlying cause and frequency and then discuss how to make the distinction between structural versus idiopathic epilepsy. Reactive Seizure Epilepsy generally means recurrent seizure, however in humans after just one seizure you can be considered epileptic if the seizure is associated with an enduring alteration of the brain that increases the likelihood of seizure. Reactive seizures occur when the brain is normal but reacting to an extra cranial toxic or metabolic insult. Idiopathic or primary epilepsy is diagnosed if no underlying cause can be determined other than a possible hereditary predisposition. Cryptogenic (probable symptomatic) epilepsy a heritable cause is not likely and an underlying pathologic change in the brain suspected but not proven. Genetic epilepsy can be diagnosed when the prevalence in a breed exceeds that of the general population. Making this distinction is important because certain breeds may have a particularly severe form of genetic epilepsy. For example in the Border Collie survival from seizure onset is 2 years with a 94% rate of cluster seizure and 53% rate of status epilepticus. Conversely genetic epilepsy in the Lagotto Ramagnolo starts at 6 weeks of age and resolves by 16 weeks of age. Structural epilepsy is diagnosed when there is a physical disruption of the brain from a malformation, infection, inflammation, stroke or brain tumor. Epilepsy of unknown cause is diagnosed when a cause for the seizure has not been determined. Classification by Seizure Frequency Progression of disease and a worse prognosis is often indicated when seizure becomes more frequent. A cluster seizure is noted there are 2 or more seizure within 24 hours and acute repetitive seizure is 2 or more seizure within 5-12 hours. In the dogs with structural epilepsy, 72% had a brain tumor with stroke and encephalitis being the next most common causes of seizure. At other end of spectrum, dogs younger than 6 months of age are very likely to have a genetic or seizure of unknown cause. Breed Genetic epilepsy and epilepsy of unknown cause is the most prevalent diagnosis in dogs between 6 months and 7 years of age. However, within this age group encephalitis in young dogs and prevalent in many small breeds (Pug, Chihuahua, Yorkshire terrier, Maltese, Westie, Dachshund, Minature poodle, Shih Tzu, others). Therefore in young, small breed dogs encephalitis should be highly suspected as the cause of seizure, especially when seizure are clustered, progressive over a few weeks to a few months or there are examination or behavioral changes. A recent study showed a statistically higher incidence of brain tumors in the breeds Golden Retriever, Boxers, French Bulldog, Rat Terrier and Boston Terriers. Therefore in these breeds and dogs > 15 kg, a recent onset seizure when 5 or older should raise a high suspicion for brain tumor. Behavior In dogs with seizure from structural brain disease the seizure can be the only symptom, however there are often subtle behavioral changes. When these behavioral changes are noted in a seizure patient then this should raise suspicion for a structural brain problem. These include inappropriate defecation, inappropriate urination, not greeting the owners, restless at night, sleeping more in the day, irritability, not playing, and aggression. Lesions in this area can cause patients to circle towards the side of the lesion and have contralateral menace and postural deficits. Since strength and gait are generated from the brainstem, a focal forebrain lesion would not be expected to cause weakness or ataxia. If a patient has a unilateral menace deficit with normal pupillary light responses and normal palpebral response then a contralateral forebrain mass lesion should be suspected. Similarly if the gait is normal but there is a unilateral postural deficit (paw flip test, tactile placing, hopping) then a contralateral forebrain lesion should be suspected. Lastly, while in the exam room if a patient circles to only one side then a forebrain lesion is very likely and will be located on the side towards which they are circling. In a recent study of dogs and cats where only neck pain was noted almost 10% had only a focal brain tumor. The presence of neck pain in a seizure patient should suggest there is a structural cause of the seizure. However an abnormal exam is not always noted and about 30% of patients with a mass lesion will have a normal neurological exam. Conclusion Your client expects a sense of the diagnosis, treatment plan and prognosis when they present with a pet with recent onset seizure. Postmortem evaluation of 435 cases of intracranial neoplasia in dogs and relationship with breed, age and body weight. There are several important questions that a veterinarian must ask during every seizure evaluation. Two, is there an underlying genetic, structural or metabolic cause that can be diagnosed and treated more specifically than just treating the symptom of seizure. Treatment Challenges About 30% of epileptic dogs will be refractory or drug resistant. Furthermore, in the Border Collie the average life expectancy after the first seizure is 2 years with cluster seizure and status epilepticus being significant risk factors for euthanasia. Secondly, there is very good experimental and some clinical evidence in people to suggest that having a seizure sets-up or facilitates connections in the brain that reduce the seizure threshold. In other words, every seizure can make it a little easier to have another seizure. We know that about 1/3 of veterinary patients with primary epilepsy are difficult to control and delayed treatment may allow a particular patient to be in this category. Thirdly, a recent study surveying owners of dogs with seizure revealed, not surprisingly, that the most acceptable seizure frequency was not once per month, but no seizure. Another study of dogs on bromide or/and phenobarbital found owners reasonably satisfied with seizures less often than every 3 months. Owners have come to the veterinarian not to be told seizures are harmless and that 1 seizure per a month is acceptable, but to have the seizure disorder treated with the goal being no more seizure. Lastly, the balance between side-effect, risk of organ failure, ease of administration and cost vs. These medications have been shown to be effective as add-on medications and clinical experience in human and veterinary patients suggest they are effective for monotherapy as well. However, when Levetiracetam was studied as an add-on to phenobarbital and bromide in a placebo controlled, randomized, crossover design, a significant reduction in seizure frequency was not observed but the quality of life was thought better on Levetiracetam relative to placebo. For the 3 trials evaluated, the average reduction in seizures during placebo administration relative to baseline was 26%. The authors concluded their findings were important because open label studies in dogs that aim to assess efficacy of antiepileptic drugs might inadvertently overstate their results and that there is a need for more placebo-controlled trials in veterinary medicine. There were statistically fewer cluster seizure in the study group and the authors concluded Levetiracetam pulse therapy for cluster seizure is probably effective. Bromide is avoided for pulse therapy due to side effects and long elimination half-life. Therefore while therapy can be initiated after a seizure, it can potentially be administered before a seizure, as many owners think they can predict when a seizure will occur. Subcutaneous Levetiracetam 60 mg/kg will reach therapeutic concentrations in 15 minutes or less and last for 7 hours and currently authors at home therapy of choice. The same dose, undiluted can be given as intravenous bolus to rapidly achieve useful serum concentrations without causing any sedation. Diazepam solution at 2 mg/kg per rectum is also advised, however an intranasal injection of 0. Rectal valium suppository formulations have unfavorable absorption and are not recommended for emergency treatment of seizure. Another important consideration is that phenobarbital will increase metabolism of both Levetiracetam and Zonisamide such that the serum concentrations maybe 50% lower than expected. Comparison of phenobarbital with bromide as a first-choice antiepileptic drug for treatment of epilepsy in dogs. Pregabalin as an adjunct to phenobarbital, potassium bromide, or a combination of phenobarbital and potassium bromide for treatment of dogs with suspected idiopathic epilepsy. Pancreatitis associated with potassium bromide/phenobarbital combination therapy in epileptic dogs. Improving seizure control in dogs with refractory epilepsy using gabapentin as an adjunctive agent. Epilepsy in Border Collie: clinical manifesations, outcome, and mode of inheritace. Double-masked, placebo-controlled study of intravenous levetiracetam for the treatment of status epilepticus and acute repetitive seizures in dogs. Serum triglyceride concentration in dogs with epilepsy treated with phenobarbital or with phenobarbital and bromide. Apparent acute idiosyncratic hepatic necrosis associated with zonisamide administration in a dog. Effects of long-term phenobarbital treatment on the thyroid and adrenal axis and adrenal function tests in dogs. Evaluation of levetiracetam as adjunctive treatment for refractory canine epilepsy: a randomized, placebo-controlled, crossover trial. Clinical signs, risk factors, and outcomes associated with bromide toxicosis (bromism) in dogs with idiopathic epilepsy. Treatment of partial seizures and seizure-like activity with felbamate in six dogs. Possible drug-induced hepatopathy in a dog receiving zonisamide monotherapy for treatment of cryptogenic epilepsy. Assessment of the prevalence and clinical features of cryptogenic epilepsy in dogs: 45 cases (2003-2011) J Am Vet Med Assoc. Prospective study of zonisamide therapy for refractory idiopathic epilepsy in dogs. Bromide toxicosis (bromism) in a dog treated with potassium bromide for refractory seizures. Clinical signs of dysfunction include side-stepping as though drunk, abnormal head or eye position and spontaneous eye movement. Examination of the patient will allow an assessment of whether the dysfunction is from the nerve and therefore peripheral to the brain or from the brainstem or central. This distinction is critical because central diseases are often life-threatening unless identified and treated, whereas peripheral disease often improves on its own or with minor intervention. Vestibular Anatomy and Function Movement of endolymph over the hair cells of the receptors of the inner ear (semicircular canal, saccule, and utriculus) provides input to the vestibular nerve. The cell bodies for the vestibular nerve are located in 4 paired nuclei located within the brainstem nestled around the fourth ventricle and choroid plexus. The receptor apparatus the detects acceleration, deceleration as well as the static position of the head. The generation of physiological nystagmus by moving the head left and right is called the vestibulo-ocular reflex. This reflex relies on structures deep within the brainstem and when abnormal and not related to drug therapy, there is an indication of severe brainstem dysfunction. Besides the receptors of the inner ear there are visual and proprioceptive inputs into the vestibular system. Blindfolding a vestibular patient and then lifting them off the floor often increase the sense of poor balance. Peripheral Vestibular Disease Peripheral vestibular disease has a fairly consistent clinical presentation. A useful tool to think about central disease is that dogs whose clinical signs do not look like they peripheral likely have central disease. Peripheral Vestibular Disease Peripheral vestibular disease typically has a sudden onset and can be associated with vomiting at its onset. Patients have rotary or horizontal nystagmus at a rate of 60 beats per minute or greater and a head tilt of about 20 degrees from midline. The nystagmus can change from rotary to horizontal but its fast phase should remain opposite the direction of the head tilt. Persistent weakness and postural deficit are not noted and after a few hours of acclimating these dogs are bright and responsive and able to ambulate.

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The fistula opening will likely require surgical intervention or pouching depending on the maturation of the fistula cholesterol test cost cheap caduet master card. If such symptoms are observed cholesterol lowering foods order 5 mg caduet with mastercard, immediately discontinue therapy cholesterol pathway caduet 5mg fast delivery, take appropriate measures to control the bleeding cholesterol levels chart australia order 5 mg caduet otc, and contact the treating clinician cholesterol lowering diet ppt 5 mg caduet with amex. Universal precautions should be observed whenever working with potentially contaminated parts or equipment cholesterol test ranges cheap 5mg caduet with visa. Patient size and weight should be taken into account when prescribing this device. Disconnect the device from the dressing prior to entering an area where this equipment will be used. If the patient must be disconnected from the device, protect the tube ends by inserting the tethered caps of the Quick-Click Connector immediately before turning off the device. When possible, move the device out of the X-ray or scanner range, check that it is functioning correctly following the procedure. Measures may include use of sterile gowns and eye protection with severely contaminated wounds. Ensure the abdomen and its contents are adequately visualized, controlled and protected throughout application of dressing. Preventing adhesions or obstructions that may otherwise form during open abdominal wound management is a critical parameter in achieving timely primary fascial closure and reducing the chance of fistula formation. The volume and appearance of the fluid in both the canister and tubing should be checked and recorded frequently while the patient receiving therapy. Because of the risk of further damage to the periwound area, foam should never overlap onto intact skin without first protecting the skin with additional Transparent Film or a hydrocolloid dressing. Foam should never be placed in contact with exposed bowel, arteries, veins, organs or nerves. Negative Pressure Wound Therapy Clinical Guidelines 41 Section 6 Pre-shaped Foam application Size the foam to the desired proportions by tearing along the pre-scored perforations. Do not allow foam to contact intact skin without use of an appropriate barrier such as Transparent Film or a hydrocolloid. It may be necessary to stack multiple pieces of foam depending on the wound profile. If multiple pieces of foam are required, count and record how many pieces are used to ensure all pieces are removed upon bandage changes. Ensure the foam is sized to fit loosely in the wound defect and does not go below the level of the abdominal wall. Transparent Film application Holding the Transparent Film, expose one side of the adhesive backing by removing a single panel and apply it to the foam. Apply film to the foam removing adhesive panels as well as the carrier film to seal. The film should extend at least 5cm beyond the wound margin to facilitate a good seal. Avoid stretching or pulling the film to minimize tension or trauma to the periwound skin. Remove the adhesive panel from the Soft Port dressing and align the port opening over the hole in the Transparent Film. Smooth the dressing down while removing the stabilization frame from the Soft Port dressing. Initiation of therapy Ensure the canister is installed correctly and connect the in-line Bacterial Overflow Guard to the device. To prevent airflow into the device ensure the guard tubing is fully inserted past the 4th ridge into the device vacuum port. Connect the Soft Port to the canister tubing by pushing the Quick-Click Connectors together. Negative Pressure Wound Therapy Clinical Guidelines 45 Section 7 Undermining and/or tunneling Undermining Undermining is a lateral tissue defect or pocket under the edges of the wound. Tunneling or sinus tracts A tunnel or sinus tract is a narrow opening in the wound bed that extends into adjacent tissue. Generally, lower pressure setting are utilized (60-80mmHg) for skin grafts and over skin substitutes. Negative Pressure Wound Therapy Clinical Guidelines 49 Section 7 Wrap the opposing Transparent Film around the limb. Remove the other top stabilization panel #3 from either the side or central split. If required use additional Transparent Film to ensure the dressing edges are adequately sealed. Remove dressing if any signs of discomfort are experienced and seek alternative treatment regime. It is intended for fixation of drainage tubing and is a useful accessory to help improve seals, especially in challenging anatomical areas or with challenging wound and skin conditions. Depending on the wound output and conditions, it is possible to overwhelm the dressing if enough fluid comes in contact. Ensure that the Gel Patch completely surrounds the tubing to create a seal and remove the backing. Apply Transparent Film over the foam or gauze interface and the Gel Patch to create a seal and finish the dressing. Continue to apply Gel Strips around wound margins ensuring that the strips overlap to create a good seal. Negative Pressure Wound Therapy Clinical Guidelines 53 Section 8 Creating a seal in challenging areas of the foot Cut the Gel Patch into strips in a direction with backing removal ends accessible. Creating a seal around external fixation pins Cut Gel Patch into strips and to a length that will cover the pin circumference. Pinch the film at the Gel Patch/pin interface to create a seal and finish the dressing. All drains are silicone and include a radiopaque strip for visualization under X-ray. Exudate is managed by the dressing through a combination of absorption and evaporation of moisture through the outer film. The kit is intended to be used for a maximum of 7 days on low exuding wounds and 6 days on moderately exuding wounds. Therapy duration of the kit may be less than indicated if clinical practice or other factors such as wound type, wound size, rate or volume of exudate, orientation of the dressing or environmental conditions, result in more frequent dressing changes. Certain patients are at high risk of bleeding complications which, if uncontrolled, could potentially be fatal. If sudden or increased bleeding is observed, immediately discontinue therapy, leave dressing in place, take appropriate measures to stop bleeding and seek immediate medical assistance. Patients suffering from difficult hemostasis or who are receiving anticoagulant therapy have an increased risk of bleeding. During therapy, avoid using hemostatic products that, if disrupted, may increase the risk of bleeding. In the event that defibrillation is required, disconnect the pump from the dressing prior to defibrillation. Remove the dressing if it is positioned in a location that will interfere with defibrillation. Regular monitoring of the wound should be maintained to check for signs of infection. If deemed clinically appropriate, care should be taken that the application of a circumferential dressing does not compromise circulation. The pump should be carried so that it is accessible and the patient/healthcare professional can check the status routinely. Inappropriate use or repeated application of fixation strips may otherwise result in skin stripping. If reddening or sensitization occurs discontinue use and contact the treating healthcare professional. The use of negative pressure presents a risk of tissue ingrowth into foam when this is used as a wound filler. Ensure the end of the tubing attached to the dressing is facing down so that water does not enter the top of the tube. The port should be positioned uppermost on intact skin and not extend over the wound so that the risk of fluid collecting around the port and potentially blocking the negative pressure is minimized. Use of any part of this system on more than one patient may result in cross contamination that may lead to infection. The potential for electromagnetic interference in all environments cannot be eliminated. Excessive bleeding is a serious risk associated with the application of suction to wounds which may result in death or serious injury. Careful patient selection, in view of the above stated contraindications, warnings and precautions is essential. Carefully monitor the wound and dressing for any evidence of a change in the blood loss status of the patient. Notify the healthcare professional of any sudden or abrupt changes in the volume or the color of exudate. Dressings should be changed in line with standard wound management guidelines, typically every 3-4 days. More frequent dressing changes may be required depending on the level of exudate, condition of the dressing, wound type/size, orientation of the dressing, environmental considerations or other patient considerations;. If the dressing appears ready for changing (see acceptable to be left in place diagrams A-C), press the orange button and disconnect the dressing from the pump. Apply another dressing, connect to the pump and press the orange button to reinitiate the therapy. When used on a moderately exuding wound, the size of the wound should generally be no more than 25% of the dressing pad area. Negative Pressure Wound Therapy Clinical Guidelines 61 Section 9 Instructions for use Application 1. Remove any excess hair to ensure close approximation of the dressing to the wound. Using a clean technique, peel off the central release handle and place the dressing centrally over the wound to reduce the chance of wound fluid coming into contact with the port. Remove the other two handles and smooth the dressing around the wound to prevent creasing. Depending on the size of the wound, the pump should take up to 30 seconds to establish negative pressure wound therapy. If after 30 seconds the system has not established negative pressure wound therapy, the amber air leak light will illuminate. In awkward areas, it may be useful to apply the strips to help achieve a seal prior to switching on the pump. Place each strip so that it overlaps the dressing border by approximately 1cm (2/5in. Please note that if at any time the fixation strips are removed, the dressing should also be replaced. General use Showering and bathing Light showering is permissible; however, the pump should be disconnected (see Precautions) and placed in a safe location where it will not get wet. Cleaning Adherence to clinical directives concerning hygiene is of prime importance. The pump may be wiped clean with a damp cloth using soapy water or a weak disinfectant solution. This includes generalized questions from the dressing techniques to troubleshooting an alarm situation.

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Newer systems include the use of dual stage inflators which basically means that just because an airbag has deployed it does not mean that there cannot be a second deployment cholesterol zly i dobry discount 5 mg caduet with amex. However our members should always treat the area around the airbag as if they have not deployed cholesterol levels 30 year old male discount caduet 5 mg line. These devices are either mechanically or electrically activated using a spring mechanism or a pyrotechnic device to deploy is the cholesterol in eggs really bad for you purchase cheapest caduet. The mechanically activated pretensioner will remain live even after the battery is disconnected cholesterol what foods are high caduet 5 mg overnight delivery. Accidental deployment during extrication can cause serious injury to both rescuers and occupants alike cholesterol free desserts order genuine caduet line. Plastic tends to crumple or shatter instead of bending making it hard to find a purchase point for leverage cholesterol medication for weight loss purchase caduet with visa. Conventional methods used in the past will not work on these newer types of glass. The body panels are attached to the frame to provide an outer surface many times consisting of plastic or a composite material. This presents a risk to members operating when deployment accidentally occurs during the rescue operation. Reinforcement for the mounting of seatbelts, pretensioner systems and airbag inflators as well as the advances in construction presents more of a challenge during cutting operations. Exposing the posts rails and pillars prior to cutting will allow members to see where these components are located so that they can be avoided. Under the hood, in the wheel well, under seats or in the trunk are some of the areas they may be found. First arriving officers must immediately notify the dispatcher when a person is pinned in the vehicle. There are so many variables at an accident with people trapped that no one procedure will work in all cases. Protect victim with materials such as a blanket or sheet before disentanglement procedures start. Members working inside of vehicle shall be cognizant when operating tools close to victim. The least amount of movement of the victim will result in the fewest secondary injuries. This will allow flexibility to operate on both sides of vehicle without having to reposition. The spreaders and cutters are the tools of choice and should be used to compliment each other at an operation. While one member is operating the spreaders, have other member holding cutters prepared to assist when needed. Always be in control of the tool and never position any part of your body between the tool and the vehicle. Firefighters shall gain access to the victim so that critical trauma assessment can be made and treatment initiated/augmented. Be prepared to allow ladder company members inside vehicle for disentanglement evaluation, if not already on scene. Inside team will ensure car is in park, windows are opened, seats are moved back and seatbelts removed before shutting down ignition. Placing step chocks, shutting down the engine, engaging the parking brake, putting the transmission into park and disconnecting the battery are all part of the stabilization process. Before disconnecting the battery, open power windows and adjust power seats to assist with extrication. Ropes, chains, hooks, and Halligans, in addition to step chocks and wedges, can all be used for this purpose. Place chocks just behind front wheels and in front of rear wheels, step side down. A wedge may be required to fill the gap between the step chock and the rocker panel (Figures 1 and 2). Though this is not always necessary it will afford the best possible stabilization. Keep in mind that once this is done you will be unable to reposition the step chocks when necessary. When deflating tires use vise grips or pliers to remove the valve stems (Figure 3). Because of the potential for vehicle movement, no member should enter a vehicle until properly stabilized. A good initial choice for entry into these vehicles could be the front or rear window. Whatever method is chosen, the victim must be protected from any flying debris, and the window opened or the glass removed. While attacking the Nader pin/ staple first has been successful in the past, the hinge side may be an improved approach with new car construction. Crush the wheel well section of the fender in between the spreader arms creating a purchase point between fender and door (Figure 8). Insert tips of spreaders perpendicular to purchase point, pushing fender forward exposing hinges (Figure 9). Figure 13 Figure 14 Note: Door may break free from Nader pin / staple when forcing it open. Place the adz end of the Halligan tool in the seam between the front fender and door in the vicinity of the top hinge. Apply a vertical up and down motion creating a gap in the seam exposing the top hinge. When room permits, place one arm of the spreaders in the vehicle between the victim and the door and keep the other arm outside of the vehicle. The outer arm should fall over the outside door handle or close to it, with the tips about midway down the door. Close the tool on the door, forcing the outer edge of the door to roll out exposing the Nader pin/staple. When necessary close the spreaders on the door using them for leverage (Figure 17). When a hinge has a spring it must be removed prior to cutting using a Halligan or Officers tool. Place the adz end of the Halligan tool in the seam between the door and the post just above the midway point of the door (Figure 18). Apply a vertical up and down motion, creating a gap in the seam exposing the Nader Pin/staple (Figures 19 and 20). With the spreaders in the closed position, place the tips at a level just above the Nader pin/staple. Inch your way into position by opening and closing the spreaders to avoid tearing or shredding the door. Using the vertical push to establish a purchase point may force the door from the Nader pin/staple. On newer type vehicles (lightweight construction), the possibility exists of the door splitting, losing the integrity of the door. Insert tips of the spreaders into the window opening close to the B post (Figure 21). When the above does not force the door use the cutters to cut the Nader pin/staple. The first step in removing the roof of a car is to decide which method of removal to employ. When cutting the A and D Posts, cut a portion of the windshield and rear window to allow access to cut the glass, if necessary. Cut all posts on one side before passing the tool to cut the posts on the opposite side of the vehicle. This will prevent dragging the cut windshield over victims in vehicle (Figure 32). When cutting the A Post, cut a portion of the windshield to allow access to cut the glass, if necessary. Before cutting the roof posts, be sure the support of the roof in not needed to force the doors. Today using cutters and spreaders which are already in operation will usually suffice. A metal hook should be positioned between the cutters and the rocker panel to prevent the tool from moving in towards the passenger compartment (Figure 38). To do this a second step chock should be placed under the rocker panel below the A post (Figure 46). A wooden wedge should also be placed in the gap that has been formed at the relief cut on the bottom portion of the A post (Figure 47). Exercise care when retracting the ram so the displaced dash does not come down on the victim. To avoid potential problems, seat displacement procedures should only be used for short distances. Make certain the extending end is not placed on the fixed base of the seat track or on the cushion portion of the seat. Make certain the spreader tip is not placed on the fixed base of the seat track or on the cushion portion of the seat. Tempered glass is being replaced on side and rear windows by laminated glass or rigid plastics due to it being highly resistant to breaking. This new type of glass presents a formidable barrier in gaining access to the occupants inside of the vehicle. As a rule, only the glass necessary to be removed for a certain procedure should be removed. Eyes and hands should be properly protected any time glass removal procedures are being used. Fabric blankets are not a good choice as they tend to keep pieces of glass in the fabric which could cause injury later to a victim or rescuer. Also, when they are contaminated with bodily fluids, they must be placed out of service. Before using the windshield saw, make sure that the blade is installed correctly (the teeth facing the handle of the tool). When using an axe, take firm but not full strokes and strike the windshield with the corner of the axe blade. A cut windshield should always be supported to prevent it from falling in on a victim. When using the halligan, insert the adz end between door frame (Figure 53) and glass exerting downward pressure (Figure 54). When the roof is crushed, access and extrication can be achieved by cutting the roof posts and hinging the roof down. The above methods of gaining access to the passenger compartment can only be attempted after the vehicle is firmly stabilized. When a door spring is present it must be removed prior to cutting using a Halligan or Officers tool (Figure 59). The operator(s) and any member working in close proximity to the operator(s) must wear eye protection. Do not place any portion of the body within this zone when opening or closing the jaws. This can even be the case in some side impact collisions due to smart systems that will only deploy/activate due to a persons weight. These systems that have not deployed will still remain live and could possibly activate once the rescuers weight is sensed. Removing the interior trim inside of a vehicle might help in determining the locations of these devices. On the low pressure hose, align the slot with the pin before you connect or disconnect the coupling. These couplings are provided with seals and rings compatible with hydraulic fluid. Because there is a ball check, they can be disconnected under pressure, but caution must be exercised since some fluid may spray out. If a member gets hydraulic fluid in their eyes, the member should flush their eyes with clean water for at least 20 minutes and immediately seek medical attention. Ice, cold water and surf rescues although uncommon, can be among our most difficult and dangerous responses. Preplanning, proper equipment and training will ensure the safest outcome in these types of incidents. These units have been trained in the proper use of this equipment as well as safe standard operating procedures. Any attempts at underwater operations will cause the rescuer to immediately surface, possibly trapping the rescuer under an ice shelf, under a pier, or inside a submerged automobile. A member with lifeguard experience or a trained scuba diver should be considered for this assignment. This member may not feel comfortable in the water and you may have someone with more training for that duty. All members must use extreme caution and good judgment with any ice or water rescue.

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One distinction in specific intelligences noted in adulthood cholesterol free foods chart order caduet 5 mg with mastercard, is between fluid intelligence cholesterol good buy 5 mg caduet with mastercard, which refers to the capacity to learn new ways of solving problems and performing activities quickly and abstractly cholesterol levels germany buy genuine caduet on-line, and crystallized intelligence quest diagnostics cholesterol test cost purchase caduet overnight delivery, which refers to the accumulated knowledge of the world we have acquired throughout our lives (Salthouse cholesterol to hdl ratio purchase caduet 5mg on-line, 2004) cholesterol test tips order caduet without prescription. These intelligences are distinct, and crystallized intelligence increases with age, while fluid intelligence tends to decrease with age (Horn, Donaldson, & Engstrom, 1981; Salthouse, 2004). Research demonstrates that older adults have more crystallized intelligence as reflected in semantic knowledge, vocabulary, and language. As a result, adults generally outperform younger people on measures of history, geography, and even on crossword puzzles, where this information is useful (Salthouse, 2004). It is this superior knowledge, combined with a slower and more complete processing style, along with a more sophisticated understanding of the workings Figure 8. The differential changes in crystallized versus fluid intelligence help explain why older adults do not necessarily show poorer performance on tasks that also require experience. A young chess player may think more quickly, for instance, but a more experienced chess player has more knowledge to draw on. Seattle Longitudinal Study: the Seattle Longitudinal Study has tracked the cognitive abilities of adults since 1956. Every seven years the current participants are evaluated, and new individuals are also added. Approximately 6000 people have participated thus far, and 26 people from the original group are still in the study today. Current results demonstrate that middle-aged adults perform better on four out of six cognitive tasks than those same individuals did when they were young adults. However, numerical computation and perceptual speed decline in middle and late adulthood (see Figure 8. According to Phillips (2011) researchers tested pilots age 40 to 69 as they performed on flight simulators. Older pilots took longer to learn to use the simulators but performed better than younger pilots at avoiding collisions. When in a state of flow, the individual is able to block outside distractions and the mind is fully open to producing. Additionally, the person is achieving great joy or intellectual satisfaction from the activity and accomplishing a goal. Further, when in a state of flow, the individual is not concerned with extrinsic rewards. Csikszentmihalyi (1996) used his theory of flow to research how some people exhibit high levels of creativity as he believed that a state of flow is an important factor to creativity (Kaufman & Gregoire, 2016). Other characteristics of creative people identified by Csikszentmihalyi (1996) include curiosity and drive, a value for intellectual endeavors, and an ability to lose our sense of self and feel a part of something greater. In addition, he believed that the tortured creative person was a myth and that creative people were very happy with their lives. According to Nakamura and Csikszentmihalyi (2002) people describe flow as the height of enjoyment. Tacit knowledge is knowledge that is pragmatic or practical and learned through experience rather than explicitly taught, and it also increases with age (Hedlund, Antonakis, & Sternberg, 2002). It does not involve academic knowledge, rather it involves being able to use skills and to problem-solve in practical ways. Tacit knowledge can be understood in the workplace and used by blue collar workers, such as carpenters, chefs, and hair dressers. In fact, the rate of enrollment for older Americans entering college, often part-time or in the evenings, is rising faster than traditionally aged students. Students over age 35, accounted for 17% of all college and graduate students in 2009, and are expected to comprise 19% of that total by 2020 (Holland, 2014). In some cases, older students are developing Source skills and expertise in order to launch a second career, or to take their career in a new direction. Whether they enroll in school to sharpen particular skills, to retool and reenter the workplace, or to pursue interests that have previously 331 been neglected, older students tend to approach the learning process differently than younger college students (Knowles, Holton, & Swanson, 1998). The mechanics of cognition, such as working memory and speed of processing, gradually decline with age. However, they can be easily compensated for through the use of higher order cognitive skills, such as forming strategies to enhance memory or summarizing and comparing ideas rather than relying on rote memorization (Lachman, 2004). Although older students may take a bit longer to learn material, they are less likely to forget it quickly. Older adults have the hardest time learning material that is meaningless or unfamiliar. Older adults are more task-oriented learners and want to organize their activity around problem-solving. Results indicated that older students were more independent, inquisitive, and motivated intrinsically compared to younger students. Additionally, older women processed information at a deeper learning level and expressed more satisfaction with their education. To address the educational needs of those over 50, the American Association of Community Colleges (2016) developed the Plus 50 Initiative that assists community college in creating or expanding programs that focus on workforce training and new careers for the plus-50 population. Since 2008 the program has provided grants for programs to 138 community colleges affecting over 37, 000 students. The participating colleges offer workforce training programs that prepare 50 plus adults for careers in such fields as early childhood educators, certified nursing assistants, substance abuse counselors, adult basic education instructors, and human resources specialists. These training programs are especially beneficial as 80% of people over the age of 50 say they will retire later in life than their parents or continue to work in retirement, including in a new field. Gaining Expertise: the Novice and the Expert Expertise refers to specialized skills and knowledge that pertain to a particular topic or activity. In contrast, a novice is someone who has limited experiences with a particular task. Expert thought is often characterized as intuitive, automatic, strategic, and flexible. Novice cooks may slavishly follow the recipe step by step, while chefs may glance at recipes for ideas and then follow their own procedure. Their reactions appear instinctive over time, and this is because expertise allows us to process 332 information faster and more effectively (Crawford & Channon, 2002). This is because they are able to discount misleading symptoms and other distractors and hone in on the most likely problem the patient is experiencing (Norman, 2005). Consider how your note taking skills may have changed after being in school over a number of years. Chances are you do not write down everything the instructor says, but the more central ideas. You may have even come up with your own short forms for commonly mentioned words in a course, allowing you to take down notes faster and more efficiently than someone who may be a novice academic note taker. The only way for experts to grow in their knowledge is to take on more challenging, rather than routine tasks. It is a long-process resulting from experience and practice (Ericsson, Feltovich, & Prietula, 2006). Middle-aged adults, with their store of knowledge and experience, are likely to find that when faced with a problem they have likely faced something similar before. This allows them to ignore the irrelevant and focus on the important aspects of the issue. Expertise is one reason why many people often reach the top of their career in middle adulthood. However, expertise cannot fully make-up for all losses in general cognitive functioning as we age. The superior performance of older adults in comparison to younger novices appears to be task specific (Charness & Krampe, 2006). As we age, we also need to be more deliberate in our practice of skills in order to maintain them. Charness and Krampe (2006) in their review of the literature on aging and expertise, also note that the rate of return for our effort diminishes as we age. In other words, increasing practice does not recoup the same advances in older adults as similar efforts do at younger ages. The civilian, non-institutionalized workforce; the population of those aged 16 and older, who are employed has steadily declined since it reached its peak in the late 1990s, when 67% of the civilian workforce population was employed. Those new entrants to the labor force, adults age 16 to 24, are the only population of adults that will shrink in size over the next few years by nearly half a percent, while those age 55 and up will grow by 2. In 2002, baby boomers were between the ages of 38 to 56, the prime employment group. In 2012, the youngest baby boomers were 48 and the oldest had just retired (age 66). These changes might explain some of the steady decline in work participation as this large population cohort ages out of the workforce. For both genders and for most age groups the rate of participation in the labor force has declined from 2002 to 2012, and it is projected to decline further by 2022. The exception is among the older middle-age groups (the baby boomers), and especially for women 55 and older. In 2012, 76% of Hispanic males, compared with 71% of White, 72% of Asian, and 64% of Black men ages 16 or older were employed. Among women, Black women were more likely to be participating in the workforce (58%) compared with almost 57% of Hispanic and Asian, and 55% of White females. Climate in the Workplace for Middle-aged Adults: A number of studies have found that job satisfaction tends to peak in middle adulthood (Besen, Matz-Costa, Brown, Smyer, & Pitt Catsouphers, 2013; Easterlin, 2006). This satisfaction stems from not only higher wages, but often greater involvement in decisions that affect the workplace as they move from worker to supervisor or manager. Job satisfaction is also influenced by being able to do the job well, and after years of experience at a job many people are more effective and productive. Another reason for this peak in job satisfaction is that at midlife many adults lower their expectations and goals (Tangri, Thomas, & Mednick, 2003). Middle-aged employees may realize they have reached the highest they are likely to in their career. This satisfaction at work translates into lower absenteeism, greater productivity, and less job hopping in comparison to younger adults (Easterlin, 2006). This may explain why females employed at large corporations are twice as likely to quit their jobs as are men (Barreto, Ryan, & Schmitt, 2009). Another problem older workers may encounter is job burnout, defined as unsuccessfully managed work place stress (World Health Organization, 2019). Russia 1978 United Kingdom 1674 Not all employees are covered United States 1790 under overtime pay laws (U. This is important when you Hours considered that the 40-hour work week is a myth for most Americans. The average work week for many is almost a full day longer (47 hours), with 39% working 50 or more hours per week (Saad, 2014). Fifty-five percent of adults reported some problems in the workplace, such as fewer hours, pay-cuts, having to switch to part-time, etc. While young adults took the biggest hit in terms of levels of unemployment, middle-aged adults also saw their overall financial resources suffer as their retirement nest eggs disappeared and house values shrank, while foreclosures increased (Pew Research Center, 2010b). Not surprisingly this age group reported that the recession hit them worse than did other age groups, especially those age 50-64. Middle aged adults who find themselves unemployed are likely to remain unemployed longer than those in early 335 adulthood (U. In the eyes of employers, it may be more cost effective to hire a young adult, despite their limited experience, as they would be starting out at lower levels of the pay scale. In addition, hiring someone who is 25 and has many years of work ahead of them versus someone who is 55 and will likely retire in 10 years may also be part of the decision to hire a younger worker (Lachman, 2004). American workers are also competing with global markets and changes in technology. Those who are able to keep up with all these changes or are willing to uproot and move around the country or even the world have a better chance of finding work. The decision to move may be easier for people who are younger and have fewer obligations to others. Leisure As most developed nations restrict the number of hours an employer can demand that an employee work per week, and require employers to offer paid vacation time, what do middle aged adults do with their time off from work and duties, referred to as leisure Around the world the most common leisure activity in both early and middle adulthood is watching television (Marketing Charts Staff, 2014). The leisure gap 336 between mothers and fathers is slightly smaller, about 3 hours a week, than among those without children under age 18 (Drake, 2013). Those age 35-44 spend less time on leisure activities than any other age group, 15 or older (U. This is not surprising as this age group are more likely to be parents and still working up the ladder of their career, so they may feel they have less time for leisure. As you read earlier, there are no laws in many job sectors guaranteeing paid vacation time in the United States (see Figure 8. Ray, Sanes and Schmitt (2013) report that several other nations also provide additional time off for young and older workers and for shift workers. In the United States, those in higher paying jobs and jobs covered by a union contract are more likely to have paid vacation time and holidays (Ray & Schmitt, 2007). A total of 658 million vacation days, or an average of 2 vacation days per worker was lost in 2015.

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