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Refusal of Care A competent patient’s indication that a rescuer may not provide care order viagra professional 100 mg free shipping. Refusal of care must be honored viagra professional 50mg line, even if the patient is seriously injured or ill or desperately needs assistance. If a witness is available, have the witness listen to, and document in writing, any refusal of care. Advance Directives Written instructions that describe a patient’s wishes regarding medical treatment or healthcare decisions. Guidance for advance directives, including any required identification and verification process, is documented in state, regional or local laws, statutes and/or protocols and must be followed. Battery The unlawful, harmful or offensive touching of a person without the person’s consent. You must continue care until someone with equal or more advanced training takes over. Confidentiality The principle that information learned while providing care to a patient is private and should not be shared with anyone except personnel directly associated with the patient’s medical care. Alcohol-based hand sanitizers allow you to clean your hands when soap and water are not readily available and your hands are not visibly soiled. As a healthcare professional, you also need to adhere to good health habits to prevent the spread of infection and disease transmission and be current with all required/suggested immunizations. And always make sure to review your employer-specific guidelines for standard precautions. Unfortunately, even with the best use of standard precautions, exposures do occur. When an exposure incident occurs, follow these steps: ŸŸ Clean the contaminated area thoroughly with soap and water. After the exposure: ŸŸ Report the incident to the appropriate person identified in your employer’s infection/ exposure control plan immediately. The American Red Cross Scientific Advisory Council is a panel of nationally recognized experts drawn from a wide variety of scientific, medical and academic disciplines. The American Red Cross is a not-for-profit organization that depends on volunteers and the generosity of the American public to perform its mission. The potential draw- groups were assembled at key international meetings (for those backs of making strong recommendations in the presence of low- Special Article committee members attending the conference). The entire guidelines process was groups: 1) those directly targeting severe sepsis; 2) those targeting conducted independent of any industry funding. A stand-alone general care of the critically ill patient and considered high priority in meeting was held for all subgroup heads, co- and vice-chairs, severe sepsis; and 3) pediatric considerations. Teleconferences and electronic-based Results: Key recommendations and suggestions, listed by cat- discussion among subgroups and among the entire committee egory, include: early quantitative resuscitation of the septic served as an integral part of the development. Complete author and committee disclosures are listed in Supplemental 12 University of Chicago Medical Center, Chicago, Illinois. This article is being simultaneously published in Critical Care Medicine 00 14 Friedrich Schiller University Jena, Jena, Germany. Participation and endorsement: The German Sepsis Society Pediatric and Neonatal Intensive Care, Infectious Diseases Society of and the Latin American Sepsis Institute. Rhodes consulted for Eli Lilly with monetary compensation paid to him- 2010); he has a pending patent for a bed backrest elevation monitor. Her institution such as data monitoring boards, statistical analysis from Orion, and for Eli receives grant support from the National Institutes of Health Research, Lilly; he is an author on manuscripts describing early goal-directed therapy, Health Technology Assessment Programme-United Kingdom (trial doc- and believes in the concept of minimally invasive hemodynamic monitoring. His nonfnancial disclosures include being the princi- pal investigator of a completed investigator-led multicenter randomized con- Dr. Gerlach has disclosed that he has no potential conficts of interest; raria for lectures including service on the speakers’ bureau from Biosyn he is an author of a review on the use of activated protein C in surgical Germany (less than €10,000) and Braun Melsungen (less than €10,000). He received royalties from Edwards Life Sciences for sales of central venous oxygen catheters (~$100,000). Kleinpell received monetary compensation for providing expert testimony $3,000), British Therapeutics (consultant on polyclonal antibody project (four depositions and one trial in the past year). Her institution receives $1,000), and Biotest A (consultant on immunoglobul project $2,000). Sevransky received grant support to his institution from Sirius Genom- for sepsis-induced tissue hypoperfusion. Deutschman has nonfnancial involvement as a coauthor of the Society intensive care unit organizational and structural factors, including proto- of Critical Care Medicine’s Glycemic Control guidelines. Machado reports unrestricted grant support paid to her institution for reminders to busy clinicians to consider certain therapies in patients with Surviving Sepsis Campaign implementation in Brazil (Eli Lilly do Brasil); sepsis or other life-threatening illness. His institution received grants rated ($1,000–$5,000), Novartis Corp (less than $1,000). He received honoraria, consulting fees, editorship, royalties, and paid to his institution and consulting income from Artisan Pharma/Asahi Data and Safety Monitoring Board membership fees paid to him from Bayer Kasei Pharma America Corp ($25,000–$50,000).

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From the send menu select “text” and a new page will be displayed which resembles an ordinary text document for printing discount 100mg viagra professional free shipping. This “send to text” option can also be used for single references and will omit all the graphics discount 50 mg viagra professional otc. To save the entire set of search results click the display pull-down menu to select the desired format and then select “send to file” from the send menu. To save specific citations click on the check-box to the left of each citation, including other pages in the retrieval process, and when finished making all of the desired selections, select “send to file. It can also be used to send e-mail alerts, apply filters, and other customization features. General searching in PubMed The general search page in PubMed is useful to find evidence that is not coming up on the Clinical Queries search, or when looking for multiple papers by a single author who has written extensively in a single area of interest. Begin by clicking on the PubMed symbol in the top left-hand corner of the screen to display the general search screen (Fig. Simply type the search terms in the query box and your search results will be displayed as before. The search can then be refined by clicking on the term to bring up the detailed display (Fig. Clicking “search PubMed” will execute the search, which will automatically explode the term unless restricted by selecting the “do not explode this term” box. This will probably result in retrieval of about one-quarter of the articles retrieved in the previous search. A simple way to do this is that once a relevant citation has been found, click on the author link to view the abstract and then go to the “display” box and open it as shown in Fig. Linking to “related articles” will find other relevant citations, but the selected limits are not applied to this retrieval. If there was a search limited 46 Essential Evidence-Based Medicine Fig. These can be selected by lim- iting the search to one study design type in PubMed under the limit feature for publication types in the pull-down menu. An appropriate methodological filter may help confine the retrieved studies to primary research. For example, if searching whether a screening intervention reduces mortality from colorectal cancer, confine the retrieved studies to con- trolled trials. The idea of methodological terms as filters may be extended to Searching the medical literature 47 multiple terms that attempt to identify particular study types. Field searching It is possible to shorten the search time by searching in a specific field. This works well if there is a recent article by a particular author renowned for work in the area of interest or if a relevant study in a particular journal in the library has recently been published on the same topic. To search for an article with “colorectal cancer” in the title using PubMed, select the title field in the limits option using the fields pull-down menu in the “Tag Term” default tag for the selected search term. As with truncation this turns off the automatic mapping and exploding features and will not get articles with the words “colorectal neoplasms” in the article title. The most commonly used field labels are abstract (ab), title (ti), source (so), journal (jn), and author (au). The difference between source and journal is that “source” is the abbreviated version of the journal title, while “journal” is the full journal title. In PubMed the journal or the author can be selected simply by using the journals database located on the left-hand side bar or by typing in the author’s last name and initials in the query box. Remember, when searching using “text words,” the program searches for those words in any of the available fields. For example, if “death” is one search term then articles where “death” is an author’s name as well as those in which it occurs in the title or abstract will be retrieved. Normally this isn’t a problem but once again could be a problem when using “wildcard” searches. The Cochrane Library The Cochrane Library owes it genesis to an astute British epidemiologist and doctor, Archie Cochrane, who is best known for his influential book Effectiveness and Efficiency: Random Reflections on Health Services, published in 1971. In the book, he suggested that because resources would always be limited they should be used to provide equitably those forms of health care which had been shown in properly designed evaluations to be effective. Cochrane’s simple propositions were soon widely recognized as seminally important – by lay people as well as by health professionals. In his 1971 book he wrote: “It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials. His suggestion that the methods used to prepare and maintain reviews of con- trolled trials in pregnancy and childbirth should be applied more widely was taken up by the Research and Development Programme, initiated to support the United Kingdom’s National Health Service. Funds were provided to establish a “Cochrane Centre,” to collaborate with others, in the United Kingdom and else- where, to facilitate systematic reviews of randomized controlled trials across all areas of health care.

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Since then diagnostics have become more sophisticated order viagra professional 50 mg online, and a revolution in information technology has made it possible for researchers to collect buy 50mg viagra professional amex, store and analyse ever-larger quantities of data that are relevant to patient care. On 1-2 June 2016, the European Commission held a second conference on personalised medicine, this time to discuss a broader policy perspective. Putting the patient at the center of healthcare will require innovation in the way medicines are developed and healthcare systems are structured to deliver care. Under this new paradigm, the patient ceases to be the subject of research or treatment and instead becomes an active partner. This will require a big adjustment amongst all participants in the healthcare system. But the potential rewards can be significant: better healthcare at more affordable prices. They will use their own funding rules and policy processes to contribute to the overall goals of the consortium. As highlighted by the Commissioner, the focus of this consortium will be to make Europe a global leader in personalised medicine, define the research challenges and develop the science and drive innovation. Ruxandra Draghia-Akli, Director of the Health Directorate, Directorate-General for Research and Innovation, gave an overview of the subject. While there are other ways to describe patient-centric healthcare, such as stratified medicine and precision medicine, the Commission has elected to use the term personalised medicine. According to this definition, personalised medicine “…refers to a medical model using characterisation of individuals’ phenotypes and genotypes (eg molecular profiling, medical imaging, lifestyle data) for tailoring the right therapeutic strategy for the right person at the right time, and/or to determine the predisposition to disease and/or to deliver timely and targeted prevention. The Commission was an early mover in the field, already in 2011 it looked at the role of the ‘omics’ disciplines in helping understand the causes of disease. Robert-Jan Smits, Director-General for Research and Innovation, said that personalised medicine goes beyond the scope of pharmaceuticals to include other industries. It promises to make healthcare smarter and proactive and it is in line with the Commission’s priorities of supporting cutting edge research, driving innovation and creating new markets and jobs. It will rely on the ability of participants to integrate data from multiple sources and use this information to improve health without affecting patient confidentiality. He noted that inequalities still exist within healthcare systems at a national level. Personalised medicine is an opportunity to look at new ways of delivering healthcare, assessing healthcare technologies and monitoring regulatory systems to make sure that they are keeping up with innovation. It is an approach to healthcare that presents an opportunity to bring people together to work on big issues of common interest. There are opportunities for industry to develop new business models based on the widespread use of digital technologies. Personalised medicine also goes hand-in-hand with the development of 2 The Council conclusions on personalised medicine for patients can be consulted on the web page: http://eur- lex. While the regulatory aspects of some of the new technologies are being addressed, there remains the issue of the cost of personalised medicine. Roberto Viola, Director-General for Communications Networks, Content and Technology, addressed the issue of data. For example, computing power needs to be increased, with the possibility of creating a European science cloud. The Directorate-General for Communications Networks, Content and Technology plays various roles in the personalised medicine initiative; considering activities in e-Health, Big data and High Performance Computing. The regulatory aspects are equally important: such as data flows, cybersecurity and data exchanges. Using breast cancer as an example, he said molecular analysis has shown that there is not one, but several types of the disease. Yet will these new treatments help a woman with cancer who also lives in a deprived area and may also be suffering from obesity and diabetes? Personalised medicine may be a way of closing the gap between clinical medicine and the other aspects of real life that affect human health. These differences can be captured in data, but patients must consent to provide this data. Another question is whether it will be possible to produce a better quality of care at a reduced cost. This will require a shift from a system that reacts to disease to one that seeks to prevent disease. Patient-reported outcome statistics will make it possible to establish which interventions are necessary and which are not. Anders Olauson, Honorary President of the European Patients’ Forum, ended the session with a call for patient empowerment. This entails giving patients access to information that will enable them to work with doctors in the management of their own healthcare. Personalised medicine puts the patient at the centre of healthcare decision-making.

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The number buy discount viagra professional 50 mg line, characteristics and technical specifications should depend on the population to be served cheap 50mg viagra professional overnight delivery, the availability of resources in the respective health care system, and the volume of procedures to be carried out in a given unit of time [2]. The very first issue the facility should consider is whether the type of equipment to be acquired is really needed and whether it will require additional staff to operate it. Radiation safety requirements The design of radiation emitting equipment and equipment to be used with radioactive materials, such as a gamma camera, should comply with national or international radiation protection and safety standards [3]. Compliance with manufacturer’s specifications Second hand equipment should maintain the original manufacturer’s specifications. If an original feature is no longer functional, but the equipment could still be used, this should be clearly indicated in the documentation provided by the donor/seller. Warranties Refurbished equipment should be sold with warranties, at least for one year of operation. It is important to establish exactly whether it includes parts (X ray tubes are very costly, for example) and when the warranty actually starts. Obsolescence Even in good operating conditions and meeting the manufacturer’s specifications, equipment should not be acquired if deemed to be obsolete; i. For example, a cobalt therapy unit with an adequate radioactive source is not obsolete, but a mammography unit with a tungsten target and an aluminum filter is, because the image quality that is produced is substandard. Acquiring obsolete equipment may have detrimental effects on the health care system. Availability of operation and service manuals No piece of equipment should be acquired without operation and service manuals. This may be difficult if the language of the original equipment owner was different from that of the intended recipient and the equipment is no longer being manufactured. Availability of accessories and replacement parts When acquiring second hand equipment, it is important to assess whether the original accessories come with the main unit. Examples of potential problems are wedges for cobalt therapy machines, image receptors for mammography units and collimators for gamma cameras. It is essential that replacement parts be available from the original manufacturer or a reputable distributor for the length of the intended use of the equipment. The recipient institution should investigate from the original manufacturer the length of time they can support the equipment and whether local distributors and/or third party maintenance organizations have spare parts and accessories in stock, for how long and at what cost. Equipment which uses some kind of software, especially if it is no longer manufactured, may have old software versions that may be out of date, or if nothing else, awkward to use. Before acquiring any equipment, the availability of software upgrades should be explored from the original manufacturer and budgeted for. Environmental (facility) conditions There are several types of environmental concerns that need to be addressed when installing a piece of equipment in a new facility built to house it. First, the facility needs to comply with local building codes regarding space, accessibility, floor loading capacity, electrical power (voltage, frequency, phase and heat dissipation), water volume, pressure and drainage, etc. If the equipment emits radiation, the structural shielding needs to be calculated and its adequacy tested — preferably before the unit is installed, but certainly before it is put into clinical use — taking into account patient, staff and public dose constraints [3]. If the second hand equipment to be acquired is to be placed in an already existing building, to comply with local regulations may be more difficult, as there may be structural limitations. Furthermore, if open radioactive sources, such as those used in nuclear medicine, are included, there should be a plan for disposal of the radioactive waste that will be generated. Most types of radiological equipment can only function well with a stable power supply. This is particularly true for old computed tomography scanners, which cannot function unless the room temperature is very low. The requirements for both temperature and humidity should be known before the equipment is acquired. Room modifications should be implemented and plans for daily monitoring of the temperature and the humidity established, before the equipment is put into clinical use. Sustainability considerations Prior to equipment acquisition, facilities should ensure, through appropriate budgeting, that there is adequate and properly trained staff for its operation and that the equipment can be maintained during its projected lifetime. If the equipment is technically complex, it may be less expensive to outsource maintenance services than to train local maintenance personnel. Discarding the equipment at the end of its life cycle should also be contemplated and disposal costs budgeted. Obtaining authorization from the regulatory authorities Facilities of countries with radiation protection legislation/regulations need to seek approval of the regulatory authority before acquiring radiological equipment. The authorization process may require registering the equipment or licensing the installation [3]. Most refurbishing companies will not sell any piece of equipment to a foreign country until such documentation is produced. Facilities which plan to introduce new practices will need to produce more documentation than facilities which only replace a unit and usually require permits from other governmental entities such as the ministry of health, which regulates medical practices. In facilities of countries which do not have any radiation safety legislation, it is the responsibility of the facility manager to ensure that the equipment and its use comply with international safety standards. The compliance should be documented in writing and be made available to the staff and to the patients and public, if required. Site preparation Good coordination should exist between equipment acquisition and site preparation.

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They may play a particularly significant role in drug cases because many drug defendants have significant histories of prior offending viagra professional 100 mg cheap. According to the Bureau of Justice Statistics generic viagra professional 100 mg fast delivery, for example, 66 percent of felony defendants arrested on drug offenses have prior convictions; 14 percent have 10 or more prior convictions (Cohen and Kyckelhahn 2010). Although there are no national data providing a breakdown of prior criminal records for drug offenders by race, the higher drug arrest rates for African Americans suggest they are more likely to have prior convictions. Frase (2009) found that criminal history was the single most important factor contributing to racial disparities in Minnesota—disparities that were substantially greater than at arrest and conviction. Black criminal history scores were higher than white within all major offense categories and were especially higher for drug offenders. Criminal history influences the exercise of prosecutorial and judicial discretion in ways that disproportionately burden blacks. Spohn and Spears (2001) found that black drug offenders with prior felony convictions in Miami had higher odds of incarceration than white drug offenders with the same criminal record. Crawford, Chirico, and Kleck (1998) found that “the combination of being Black and being charged with a drug offense substantially increases the odds of being sentenced as habitual” (p. Revisiting Crawford’s study a decade later, Crow and Johnson (2008) found that “race (and ethnicity) still matter for habitual-offender designations” (p. Black and Hispanic defendants are significantly more likely to be prosecuted as habitual offenders than white defendants, and the odds were greatest for black and Hispanic drug defendants (Crow and Johnson 2008, p. More research is needed to understand the effects of prior criminal records on drug offender sentencing. Black drug arrestees in New York are more likely than whites to have prior convictions, given that blacks are far more likely to be arrested on drug charges. Frase (2009) points out that the emphasis given to prior criminal records in sentencing is a policy choice and one that appears due for reconsideration. Although there is widespread support for imposing longer sentences on repeat offenders (Roberts 1997), there is scant evidence that habitual offender sentencing enhances public safety or reduces crime. Crow and Johnson (2008) conclude, “given the findings of over a decade of habitual-offender research that demonstrates racial and ethnic discrimination (unwarranted disparity), it may be time to reconsider the utility of habitual-offender statutes” (p. Rehavi and Starr (2012), make the same point, “the heavy weight placed on criminal history in [federal] sentencing law is also a subjective policy choice with racially disparate consequences. Legislators and the Sentencing Commission members who are concerned about incarceration rates among black men may wish to consider these distributional consequences when assessing the costs and benefits of these aspects of the sentencing scheme” (p. Drug laws typically prescribe higher sentences for sales and manufacturing than for possession. Defendants convicted of sale are more likely to go to prison than are those convicted of possession, and the sentences are typically longer (Cohen and Kyckelhahn 2010). Blacks are disproportionately likely to be arrested for sales offenses, so it is likely that harsher sentencing for sales contributes to the disparities in sentencing outcomes. Racial disparities in the incarceration of drug offenders also reflect legislative priorities. Because black Americans are more likely to be sentenced for federal crack offenses, they are disproportionately burdened by the higher crack sentences. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Sentencing Commission 2011, p. Race, Crime, and Punishment There are racial disparities at every stage of drug case processing in state and federal criminal justice systems. As the Seattle research illustrates, race influences perceptions of the danger posed by the different people who use and sell illicit drugs, the choice of drugs that warrant the most public concern, and the choice of neighborhoods in which to concentrate drug law enforcement resources. Yet race is a powerful lens that colors what we see and what we think about what we see. In the United States, images of crime, danger, drug offenders, and criminals are deeply racialized. Tonry (2011) and Provine (2007) summarize studies on the effects of racial attributions and stereotypes on people’s perceptions, attitudes, and beliefs and the ways race correlates with policy choices. Whites may no longer consciously believe in the inherent racial inferiority of blacks, but they nonetheless harbor unconscious racial biases (Rachlinski et al. In one typical study, police officers shown black and white photographs of male university students and employees thought more of the black than white faces looked criminal; the more stereotypically black the face was, the more likely the officers thought the person looked criminal (Eberhardt et al. Unconscious notions and attitudes are most likely to influence criminal justice decisions that have to be made in the face of uncertainty and inadequate information or in ambiguous or borderline cases. To recognize the influence of race on social psychology, unconscious cognitive habits, and “perceptual shorthand” (Hawkins 1981, p. Race helps explain the development and persistence of harsh drug laws and policies. White Americans tend to support harsher punishments more than do blacks, a predilection that has strong roots in racial hostilities, tensions, and resentments (Tonry 2011, p.

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