By M. Ugo. Idaho State University.

Patients are Our medical profession needs to consider how we can in fact much more than that best clopidogrel 75mg. Goals that funding agencies cheap 75 mg clopidogrel visa, patient safety organizations clopidogrel 75 mg with mastercard, over- should be set, performance should be monitored, and sight groups, and the media can play to assist in the overall progress expected. The authors in this supplement to The American these parties, based on our current—albeit incomplete and untested— understanding of diagnostic error (Table 1). Statement of Author Disclosure: Please see the Author Disclosures section at the end of this article. Healthcare leaders need to expand their concept of prove both the specificity and sensitivity of cancer detection 4 patient safety to include responsibility for diagnostic errors, more than an independent reading by a second radiologist. These resources have substantial poten- aspects of diagnostic error can to some extent be mitigated 5 tial to improve clinical decision making, and their impact by interventions at the system level. Leaders of healthcare will increase as they become more accessible, more sophis- organizations should consider these steps to help reduce ticated, and better integrated into the everyday process of diagnostic error. System-related Suggestions Have Appropriate Clinical Expertise Available When Ensure That Diagnostic Tests Are Done on a Timely It’s Needed. Don’t allow front-line clinicians to read and Basis and That Results Are Communicated to Providers interpret x-rays. Encourage inter- “Morbidity and Mortality (M & M) Rounds on the Web” personal communication among staff via telephone, e-mail, sponsored by the Agency for Healthcare Research and and instant messaging. Establish pathways for physicians who to communicate information verbally and electronically saw the patient earlier to learn that the diagnosis has across all sites of care. Ensure medical prevent, detect, and mollify many system-based as well as records are consistently available and reviewed. Strive to cognitive factors that detract from timely and accurate di- make diagnostic services available on weekend/night/holi- agnosis. Minimize distractions and production pressures help reduce the likelihood of error. For patients to act so that staff have enough time to think about what they are effectively in this capacity, however, requires that physi- doing. Minimize errors related to sleep deprivation by at- cians orient them appropriately and reformulate, to some tention to work hour limits, and allowing staff naps if extent, certain aspects of the traditional relationship be- needed. Two new roles for patients to help reduce the chances for diagnostic error are proposed below. Take advantage of sugges- tions from the human-factors literature on how to improve Be Watchdogs for Cognitive Errors the detection of abnormal results. For example, graphic Traditionally, physicians share their initial impressions with displays that show trends make it more likely that clinicians a new patient, but only to a limited extent. Sometimes the will detect abnormalities compared with single reports or tab- suspected diagnosis isn’t explicitly mentioned, and the pa- ulated lists; use of these tools could allow more timely appre- tient is simply told what tests to have done or what treat- ciation of such matters as falling hematocrits or progressively ment will be used. Computer-aided per- checking for cognitive errors if they were given more in- ception might help reduce diagnostic errors (e. Controlled tri- its probability, and instructions on what to expect if this is als have shown that use of a computer algorithm can im- correct. They should be told what to watch for in the Graber A Safer Future: Measures for Timely Accurate Medical Diagnosis S45 Table 1 Recommendations to reduce diagnostic errors in medicine: stakeholders and their roles Direct and Major Role Physicians ● Improve clinical reasoning skills and metacognition ● Practice reflectively and insist on feedback to improve calibration ● Use your team and consultants, but avoid groupthink ● Encourage second opinions ● Avoid system flaws that contribute to error ● Involve the patient and insist on follow-up ● Specialize ● Take advantage of decison-support resources Healthcare organizations ● Promote a culture of safety ● Address common system flaws that enable mistakes —Lost tests —Unavailable experts —Communication barriers —Weak coordination of care ● Provide cognitive aids and decision support resources ● Encourage consultation and second opinions ● Develop ways to allow effective and timely feedback Patients ● Be good historians, accurate record keepers, and good storytellers ● Ask what to expect and how to report deviations ● Ensure receipt of results of all important tests Indirect and Supplemental Role Oversight organizations ● Establish expectations for organizations to promote accurate and timely diagnosis ● Encourage organizations to promote and enhance —Feedback —Availability of expertise —Fail-safe communication of test results Medical media ● Ensure an adequate balance of articles and editorials directed at diagnostic error ● Promote a culture of safety and open discussion of errors and programs that aim to reduce error Funding agencies ● Ensure research portfolio is balanced to include studies on understanding and reducing diagnostic error Patient safety organizations ● Focus attention on diagnostic error ● Bring together stakeholders interested to reduce errors ● Ensure balanced attention to the issue in conferences and media releases Lay media ● Desensationalize medical errors ● Promote an atmosphere that allows dialogue and understanding ● Help educate patients on how to avoid diagnostic error upcoming days, weeks, and months, and when and how to nated, and all medical records would be available and ac- convey any discrepancies to the provider. Until then, the patient can play a valuable role in If there is no clear diagnosis, this too should be con- combating errors related to latent flaws in our healthcare veyed. Patients can and should function as confidence and certainty, but an honest disclosure of uncer- back-ups in this regard. They should always be given their tainty and the probabilistic nature of diagnosis is probably a test results, progress notes, discharge summaries, and lists better approach in the long run. In the absence of reliable and would be more comfortable asking questions such as “What comprehensive care coordination, there is no better person else could this be? Healthcare organizations by ne- health services research protocols to better understand these cessity pay attention to Joint Commission expectations; errors and how to address them. In the proper order of these expectations should be expanded to include the many things, our knowledge of diagnostic error will increase other organizational factors that have an impact on diagnos- enough to suggest solutions, and patient safety leaders and tic error, such as encouraging feedback pathways and en- leading healthcare organizations will begin to outline goals suring the consistent availability of appropriate expertise. A measure of progress will be the extent to ther the cause of accurate and timely diagnosis by drawing which both physicians and patients come to understand the attention to this issue and ensuring that diagnostic error key roles they each can play to reduce diagnostic error rates. For the good of all those who are affected by diagnostic The media also must acknowledge a responsibility to pro- errors, these processes must start now. If there is anything to be learned from how aviation has improved the safety of air travel, it is the lesson of contin- Acknowledgements uous learning, not only from disasters but also from simple observation of near misses. The media could substantially This work was supported in part from a grant from the aid this effort in medicine by emphasizing the role of learn- National Patient Safety Foundation. Berner, EdD, for review of the manuscript and to Grace Thus far, funding agencies have underemphasized diag- Garey and Mary Lou Glazer for their assistance.

Thecentralpulmonaryarteriesare matically in recent decades but appears to have peaked usually prominent and may be ‘pruned’ peripherally cheap clopidogrel 75mg mastercard. Itisdebatablewhethertheyarecarcinogenic buy clopidogrel 75mg otc, Pattern of disease Causative agents but their use has now been banned in new buildings Pulmonary fibrosis Mineral dusts such as coal discount 75 mg clopidogrel, silicon in the United Kingdom. They persist in the lung for alveolitis allergic response many years and are very fibrogenic and carcinogenic. Acute bronchitis, Irritant gases such as sulphur pulmonary dioxide, chlorine, ammonia, oedema oxides of nitrogen Bronchial carcinoma Asbestos, polycyclic hydrocarbons, Macroscopy/microscopy radon in mines r Asbestos bodies: These are long thin asbestos fibres in the lung parenchyma coated with haemosiderin and Aetiology/pathophysiology protein to form brown filaments with a beaded or Asbestos is made up of various silicates. Theyaretheresultofmacrophages, rally as a fibre, and has been widely used for its insulative which surround and attempt to engulf the fibres, but properties. It was used in sheets in buildings, sprayed on fail to clear them leading to fibroblast proliferation pipes as lagging, in shipbuilding and for boiler insula- and fibrosis. However, it is easily inhaled and the fibres induce r Pleural plaques are well-circumscribed elevated afibrogenic reaction in the lung. The risk of developing plaques of white hyaline fibrous tissue arranged sym- pathology from asbestos is dependent on the duration metrically on the parietal pleura over the ribs and di- and intensity of exposure, and the type of asbestos (see aphragm. Fibres are long (up to 2 cm) and are fibrotic changes in the interstitium, obliteration of Table3. Pleuritic Pleural effusion and knobbly Median survival 2 years 30–35 years from or dull chest wall pleural thickenings with after diagnosis exposure. Not pain reduction in volume in the related to affected area, possibly with smoking other signs of asbestos exposure Asbestos-related Risk related to level As for bronchial Evidence of asbestos exposure As for bronchial carcinoma of the of exposure and carcinoma may be seen together with carcinoma bronchus smoking features of the carcinoma Chapter 3: Occupational lung disease 133 alveoli and then thickened, cystic spaces (honeycomb Pathophysiology lung). Two different syndromes result from inhalation: r Malignant mesothelioma: Thoracoscopic or open r Simple pneumoconiosis in which there is deposition lung biopsy may be needed to make the diagnosis. There are peribronchiolar Macroscopically the lesion is thick, may be encapsu- depositsintheupperpartsofthelung,oftenassociated lated, with interlobar fissures. Local invasion antinuclearfactorandthedamageisthoughttobedue is extensive, 50% metastasise. Patients with carcinoma, which is usually adenocarcinoma or squa- progressive massive fibrosis suffer from considerable ef- mous cell carcinoma. Management r All patients with known asbestos exposure should be Macroscopy/microscopy advised to stop smoking. Routine surveillance with r Simplepneumoconiosisischaracterisedbyaccumula- repeated sputum cytology and chest X-ray does not tion of dust in macrophages at the centre of the acinus, appear to lead to earlier diagnosis. Pleural plaques and asbestos bodies require no treat- r In progressive massive fibrosis there are nodules of ment. Radiotherapy is in- material, containing little collagen and abundant effective and chemotherapy regimens are under eval- carbon, which frequently cavitates and liquefies. Patients with bilateral diffuse pleural thickening, as- ii Dense collagenous tissue and macrophages heavily bestosis and (in those with an occupational history or pigmented by carbon, seen where there is a high other evidence of asbestos exposure) mesothelioma or silica content in the coal dust. Coal worker’s pneumoconiosis Definition Complications Pathology resulting from inhalation of coal dust and its Simple pneumoconiosis is divided into three stages by associated impurities. Stage 1 does not progress, 7% of patients with stage 2 and 30% of Prevalence patients with stage 3 will go on to develop progressive Twoper 1000 coal workers. Aetiology The disease is caused by dust particles approximately Investigations 2–5 µmindiameter that are retained in the small airways The diagnosis is made by chest X-ray in those who have and alveoli of the lung. Simple pneumoconiosis Stage 1 Small round opacities are present Investigations but few in number Chest X-ray in the early stages shows reticular/nodular Stage 2 Small round opacities numerous shadowing. Withprogressionthereareradiologicalsigns but normal lung visible of massive fibrosis (destruction and lesions in the upper Stage 3 Small round opacities, normal zones), and thin streaks of calcification around the hilar lung totally obscured Progressive massive Round fibrotic masses, several cm nodes (‘eggshell calcification’). Definition Arare lung pathology resulting from the inhalation of silica dust (quartz). Respiratory oncology Aetiology This condition is mainly seen in workers in slate mines Bronchial carcinoma and granite quarries, metal foundries, stone masonry and tunnelling. Definition A malignant tumour of the bronchial (most common) Pathophysiology or rarely alveolar epithelium. The pathogenesis is thought to be a toxic effect on macrophages, which stimulate cytokine generation, pre- Incidence cipitating fibrogenesis. Short heavy doses produce acute Bronchialcarcinomaisthemostcommonmalignancyof silicosiswithpulmonaryoedemaandalveolarexudation. Microscopy The nodules in silicosis are made up of collagen and Geography contain silica particles which can be identified using po- Follows patterns of smoking, independent of this it is larised light. Complications Aetiology The development of tuberculosis is a common compli- Around 80–90% of cases occur in smokers (see Table cation of silicosis (silicotuberculosis). Afew show a mixed pattern: 70% of all tumours arise in relation to the main bronchus (central or hilar) and r It takesanex-smokerof ≤20perday13yearstoreturn 30% arise in the peripheral airways or alveoli. Pipe smokers 1 Squamous cell carcinoma: Usually located centrally have about 40% the risk of cigarette smokers.

The miscellaneous losses from both boys and girls are assumed to be the same since data from girls were limited order clopidogrel 75mg without prescription. Individual maintenance protein require- ments were estimated by first regressing nitrogen balance on nitrogen intake for the individuals studied at several different intake levels clopidogrel 75 mg with amex, and then using these individual regression equations to interpolate the intakes that would be expected to produce zero nitrogen balance (adjusting for 6 generic 75mg clopidogrel fast delivery. Table 10-8 contains seven studies that permit estimation of individual requirements and three studies that were used to estimate pooled requirements. As shown in the table, the average individual maintenance requirement was estimated as the median of the individual nitrogen requirements (108 mg/kg/d). For each study, an estimate was calculated as the median of the individual studies or the study pooled nitrogen requirement for those studies without individual data, and was 110 mg/kg/d. Since data for girls were sparse and could not be separated from that for boys, the protein maintenance requirement for both boys and girls is set at the same level. In addition, the maintenance protein requirement was not adjusted for age, as the requirement per kg of body weight for children 8 years of age and above appeared to be simi- lar to that of younger children ranging in age from 9 months to 5 years (Table 10-8). Supporting this decision are the data of Widdowson and Dickerson (1964), which demonstrated that around 4 years of age, body protein concentration reaches the adult value of 18 to 19 percent of body weight. Estimates of rates of protein deposition for infants from 9 months through 3 years of age (Butte et al. To obtain protein deposition rates since the data in young children were longitudinal (Butte et al. The gradients at specific ages in the range 4 through 17 years were determined by differentiation of the regression equation. Hence, the gradients at specific ages in the age range 4 through 18 years were determined by differentiation of the regression equation, whereas for ages 9 months through 2 years, the growth rates given by Butte and coworkers (2000) were employed. The variation in requirements is based on both the variation in maintenance needs and the variation in the rate of protein deposition (protein for growth). Median requirement for ages 14 through 18 years = 656 mg protein/kg/d (105 mg N/kg/d [Table 10-12] × 6. A coefficient of variation for growth of 43 percent was determined in a study of whole body potassium-40 content in children (Butte et al. The mean of the nitrogen intake for nitrogen equilibrium (thus measur- ing maintenance requirement only) is derived from all of the individual estimates for children and is 110 mg nitrogen/kg/d or 688 mg protein/kg/d (110 × 6. This is multiplied by the mean protein deposition (Table 10-9) for boys and for girls for each age group. While the nitrogen balance method for estimation of protein requirements has serious shortcomings (see “Nitrogen Balance Method”), this method remains the primary approach for determining the protein requirement in adults, in large part because there is no validated or accepted alternative. Nitrogen Balance Studies Over the last 40 years, a number of analyses of available data on adult nitrogen balance studies have been utilized to estimate adult protein require- ments; some reports are listed in Table 10-10. This was considered important so that estimates of individual require- ments could be interpolated. In addition, 9 studies of individuals fed a single level of nitrogen intake or that only provided group data for multiple levels of intake (n = 174 individuals) were used to assess the fit of the analyses conducted (Rand et al. The studies used were classified on the basis of age of the adults (young: 19 through 52 years of age; old: 53 years of age and older); protein source (animal [animal sources provided > 90 percent of the total protein], vegetable [vegetable sources provided > 90 percent of the total protein], or mixed), as well as gender and climatic origin (temperate or tropical area), and corrected for skin and miscellaneous losses when not included in the nitrogen balance data (Rand et al. Estimates of endogenous loss from some of the various analyses of protein requirements are included in Table 10-11. However, as discussed in earlier sections, the effi- ciency of utilization of dietary protein declines as nitrogen equilibrium is reached. With additional data it is possible to estimate requirements using regression analysis. Linear regression of nitrogen balance on nitrogen intake was utilized to estimate the nitrogen intake that would produce zero nitrogen balance in the most recent carefully done analysis available (Rand et al. In adults, it is generally presumed that the protein requirement is achieved when an individual is in zero nitrogen balance. To some extent, this assumption poses problems that may lead to under- estimates of the true protein requirement (see “Nitrogen Balance Method”). In this range there is no indication, either visually or statistically, for the utilization of an interpolation scheme other than linear (Rand et al. It was also recognized that while the use of more complex models would improve the standard error of fit, these models did not statistically improve the fits, in large part because of the small number of data points (3 to 6) for each individual (Rand et al. Estimation of the Median Requirement Utilizing the recent analysis of nitrogen balance data (Rand et al. Because of the non-normality of the individual data, nonparametric tests were used (Mann-Whitney and Kruskal-Wallis) to compare requirements between the age, gender, diet, and climate subgroups (Table 10-13). Where nonsignifi- cant differences were found, Analysis of Variance was used for power cal- culations to roughly estimate the differences that could have been found with the data and variability.

The Humean philosopher purchase clopidogrel 75 mg with visa, Antony Flew cheap clopidogrel 75 mg with amex, noted that: All persons and organisations campaigning against smok- ing have a compelling reason to establish that environmen- tal tobacco smoke is harmful buy clopidogrel 75mg amex, and the more extensive and substantial the harm the better. For this is precisely the 134 Lifestylism covery which they need in order to undermine principal 229 libertarian opposition. Luik observed that cor- rupted science has three major characteristics: First, corrupt science is science that moves not from hypothesis and data to conclusion but from mandated or acceptable conclusion to selected data to reach the man- dated or acceptable conclusion. Second, corrupt science is science that misrepresents not just reality, but its own process in arriving at its conclusions. Rather than acknowledging the selectivity of its process and the official necessity of demon- strating the right conclusion, and rather than admitting the complexity of the issue and the limits of its evidence, it invests both its process and its conclusions with a mantle of indubitability. Third, and perhaps most importantly, whereas normal science deals with dissent on the basis of the quality of its evidence and argument and considers ad hominem argument as inappropriate in science, corrupt sci- ence seeks to create formidable institutional barriers to dis- sent through excluding dissenters from the process of review and contriving to silence dissent not by challenging its qual- 230 ity but by questioning its character and motivation. If it is to command academic respect it is crucial that this new epidemiology develops rigor- ous canons of scientific inference and applies scientific criti- cism remorselessly and unselectively even when the results do not please the investigators. The 20th century has already had enough of regimes which tolerate, even encourage, bad or fraudulent science in the name of the good of the nation or society. But not many school leavers have heard of Mill since providers of compulsory state education are careful not to allow his essay On Liberty to fall into the hands of their charges. Until the 18th century, the place of man in the universe and the rules of right conduct were defined by the Church. Right conduct, common decency and even good manners were to be replaced by lifestylism. Lifestyle experts came mainly from the disciplines of epidemiology and statistics. Those on the receiving end were never asked whether their idea of happiness had any resemblance to a correct lifestyle as set down in government publications. As de Jouvenel put it, The handling of public affairs gets entrusted to a class which stands in physical need of certitudes and takes dubi- ous truths to its bosom with the same fanaticism as did in other times the Hussites and Anabaptists. Like Leninism, healthism, with its wonderful promises, attracts dedicated altruists and otherwise intelligent people. Some of them may even acknowledge that people may get hurt in the process, but as Marxist-Leninist activists used to say, when you are clearing a wood, splinters fly around. The glorious visions of Health for All, or of the Smoke-free Planet by the Year 2000 can only be criticised by irresponsible lack- eys on the payroll of industries which thrive on making people sick, or by moral idiots. Their power is, in practice, uncontested because of the legitimacy they have spuriously borrowed from medicine and science and their concerned beneficence. A benign form of paternalism or a puri- tanical zeal to establish behavioral conformity? While the medical profession is not renowned for an exemplary puritanical lifestyle, the control of the lifestyle of others enhances their power. The power of the medical profession is jealously guarded and is vested in their moral, charismatic and scientific authority. The moral authority of doctors has rarely been questioned as doctors are on the side of the angels; they fight evil, suffering and death. The study of human behaviour is not a science in that it discovers no universal laws. It constructs moral stories, meaningful only for a particular society, time and place. This is not to imply that human behaviour is not an important and intriguing subject, but not everything interesting is a science. In medi- cine, blinks correspond to the objective signs of disease, but the concept of disease is in part a wink-construct, and the purpose of medicine is to give blinks meaning. More recently, the urge to normalise has been extended to the behaviour of healthy people, as part of the new policy of health promotion and disease prevention. According to one, the Senior Minister of State for Education announced a new government strategy to combat obesity among schoolchildren - they were to be given marks for their weight in their report books, so that their parents when checking on their academic progress 4 would also see their grade for health and fitness. The Straits Times quoted a cardiologist who called for a tax rebate for those who joined health clubs or purchased sports equip- 5 ment, such as treadmills or exercycles. Health propaganda is disseminated in English, Mandarin, Tamil, and Malay in order to reach as many Singaporeans as possible. Even chew- ing gum is banned in Singapore, though according to the Singapore Ministry of Health, only those who chew in places 6 of food consumption are to be prosecuted. This argument is difficult to refute if those who have power to coerce others to change their ways also have a monopoly of defining what is foolish, stupid or irresponsible. I love banquettes of quail eggs with hollandaise sauce, and clambakes with lobsters and crepes filled with cream. And if I am abbreviating my stay on this earth for an hour or so, I say only that I have no desire to be a Methuselah, a hundred or more years old and still alive, 7 grace be to something that plugs into an electric outlet. Health education should provide useful, factual infor- mation to enhance rational decision-making, that is, reasoned choice. One of the possible outcomes of such a decision is to ignore the health warning and to accept the risk. As Wikler pointed out, Health education may call for actual or deliberate misinfor- mation: directives may imply or even state that the scien- tific evidence in favour of a given health practice is unequivocal even when it is not.

Marks from Supplementary Professional 1 and previous marks from Semester Examination must be more than 50% order 75 mg clopidogrel with mastercard. A student who fails the Supplementary Professional I Examination will leave the Doctor of Medicine Programme cheap clopidogrel 75mg. Excellent candidates are called for a viva-voce to determine the eligibility to pass with distinction discount clopidogrel 75 mg on-line. Students must complete and show satisfactory progress in all modules / postings assigned in each year of study. Year 3 Module Examinations The details of module examination and allocation for Year 3 consist of Continuous Assessment and End-of-Module Examination. Year 4 Module Examinations The details of module examination and allocation for Year 4 consist of Continuos Assessment and End-of-Module Examination. Year 5 Module Examinations The details of module examination and allocation for Year 5 consist of Continuos Assessment and End-of-Module Examination. Within theory and clinical components, the students are not required to pass individual paper/cases, instead they are added up. Candidates will be called for a viva-voce to determine the eligibility to pass with distinction. Special awards The awards falls into the following categories : (a) Special Award for Leadership (3 recipients) Awarded to final year students who have exhibited prominent leadership qualities and have achieved, satisfactory academic performance throughout the course of study. E Moreira Memorial Award, is given by the Malaysian Medical Association on for the best individual student. Elective Award The Awards fall into 2 categories : (a) The best elective group according to the criteria of the Elective Committee for the Phase 2 Medical Doctor Course Elective Programme. Departmental Award Awarded to the best students as decided by the respective departments. Deans Certificate Award Awarded in two categories to final year students on the medical course. One is awarded to the student who achieves Grade A with Distinction, and the other to the student who achieves Grade A. Inpatient Services Ophtalmology, Orthopaedics, Otorhinolaryngology, Psychiatry, Surgery, Paediatrics Newborn, Paediatrics Surgery, Paediatrics Medical, Medical, Obstetric & Gynaecology, Dental and Neuroscience, Reconstructive, Cardiothorasic. The 2-storey block consists of :- Level 1 (i) Reception counter (ii) Meeting room (iii) Briefing rooms (iv) Tutorial rooms 66 (v) Students’on-call room (vi) Students’ Resource Centre/ Quarantine room (vii) Prayer rooms (viii) Dinning area & pantry (ix) Main office Level 2 (i) 108 bed examination wards (ii) Children play area (iii) Examiner rooms (iv) Secretariat rooms (v) Document examination rooms (vi) Communication room with one-way mirror (vii) Dark-rooms for ophtalmology examination (viii) Rest examiners’ room (ix) Work station (x) Medical doctors’ counter (xi) Nurses’ counter (xii) Student counter (xiii) Resource block (xiv) Resuscitation room (xv) Students’ waiting area (xvi) Patients’ waiting area (xvii) Prayer rooms (xviii) Equipment examination room 1. The library was officially operational in February 1980 at the Main Campus in Penang. A large number of the collection and staff were transferred from the Penang Campus to the University’s branch in Kubang Kerian in 1982 and was temporarily located at level 8 of the Hospital building. In November 1985, the collection and staff were subsequently shifted to its permanent building which houses the current Library. In 1990, the remaining collections as well as staff of the Medical Library were completely moved from the main campus to Kubang Kerian. The Kubang Kerian Campus was appropriately renamed as the Health Campus in 2001, thus bringing about the change of the Library’s name to the Health Campus Library. Thesis and Dissertation 2, 011 (2, 277) Services The services provided by the library are divided into two major activities : 1. Technical Services The activities include the process of selection and purchase of library materials. The selection process focuses on materials to fulfill the teaching, learning and research requirements of the Health Campus. Technical processing of library materials includes the cataloguing and classification of library materials : 1. The Laboratory has 17 packages of learning programmes and 5 packages of multimedia programmes. It is also equipped with 85 computers which consist of 12 Apple Macintosh’s and 71 Acer Veriton. The undergraduate learning activity follows an organ-based system that complements topics covered in an Integrated Problem Based Learning Sessions. The focus of the teaching at the center is to bridge the acquisitions of the real clinical and procedural experience. This is done in a controlled environment to introduce and familiarize the student on skills before practicing on the real patients. The supervisor holds a B 41 grade post, 1 -B32, 3-B27 and the rest hold the B17 grade. The services provided by the Graphics Unit are computer- aided designs and graphic works including designing posters, booklets, brochures, artwork, certificates and backdrops. Besides design services, the Unit also offers advisory services pertaining to graphic designs. Besides these responsibilities, the Facilities Unit also administers the reservation of lecture theatres.

The reader is encouraged to begin with a topic of interest and follow the links and references included in the text for guidance to other chapters and sections buy 75mg clopidogrel with visa. If you are a wetland policy maker… We recommend that you read Chapters 1 and 2 in full clopidogrel 75 mg overnight delivery, which provide an introduction to disease in wetlands and the principles of disease management in wetlands buy clopidogrel 75 mg lowest price. These chapters explain the most important concepts in this Manual, namely why disease management is important, how to approach developing disease management strategies and the importance of considering disease management from an ecosystem perspective. We recommend, however, that the introductions to these Chapters and a sample of the other sections are read to illustrate some of the practical challenges facing wetland managers. In addition to text… This Manual contains information boxes, graphics, check lists and case studies to try to make the guidance as clear and useful as possible. There are many disease types, including: infectious, toxic, nutritional, traumatic, immunological, developmental, congenital/genetic and cancers. Disease is often viewed as a matter of survival or death when, in fact, effects are often far more subtle, and instead affecting productivity, development, behaviour, ability to compete for resources or evade predation, or susceptibility to other diseases factors which can consequentially influence population status. The recent rise in emerging infectious diseases has included considerable increases in the number of vector borne-emerging infectious diseases during the 1990s. Indeed, this issue was the theme of the tenth Conference of the Parties in 2008: "Healthy Wetlands, Healthy People". Such wetland services are especially important for impoverished communities, much of whose livelihoods or even food supplies may derive directly from wetland resources. Should the natural ecological functioning of wetlands be impacted, the services provided can be reduced or even eliminated. The Millennium Ecosystem Assessment documents multiple ways through which this occurs and the consequences not just for livelihoods but also for human 2,3 health. Disease represents one of the many ways in which services from well-functioning wetlands may be 4 affected. Prior to Ramsar’s work on the interactions between wetlands and human health and the specific case of guidance concerning highly pathogenic avian influenza H5N1 adopted by Ramsar in 5 2008 , the Convention has not substantively addressed the issue of wetlands and disease before. In 2008, CoP 10 requested Ramsar’s Scientific and Technical Review Panel — in collaboration with other relevant organisations — to consider how best to develop practical guidance on the prevention and control of diseases of either domestic or wild animals in wetlands, especially those diseases that have implications for human health and further, how such guidance can be best incorporated into management plans at Ramsar sites and other wetlands. It provides guidance and ‘tools’ for wetland managers and policy makers valuable in a range of contexts. Disease is a ‘cross-cutting’ issue that has implications for a range of other wetland policy areas. Within the context of the Ramsar Convention and its national implementation, some of these other areas are indicated in ►Table 0-2, together with other sources of relevant Ramsar guidance. Guidance on responding to the continued spread of highly pathogenic avian influenza H5N1. Issue Disease implications Source of further Ramsar or other relevant guidance International Potential disease spread Ramsar Handbook 17. Managing management which varying management Wetlands regimes can influence risk of Wetland Management Planning. Wetlands and poverty impacts on livelihoods derived reduction from wetland resources Resolution X. Wetlands and poverty including incomes eradication Biodiversity Disease can influence the Ramsar Handbook 17. Designating conservation status of individual species Ramsar Sites important as reasons for the qualification of wetlands as Ramsar sites Change in In some circumstances, Ramsar Handbook 15. Addressing ecological disease can influence the change in ecological character character nature of ecological communities and hence the ecological character of wetlands Wetlands and A substantive review of Ramsar Technical Report 6. Healthy human health relationship between well wetlands, healthy people functioning wetlands and human health Avian influenza and Preparing for and managing Handbook 4. Responses were received from 55 professionals from 17 countries (Argentina, China, India, Indonesia, Italy, Japan, Lebanon, Malaysia, Netherlands, Paraguay, Philippines, South Africa, Switzerland, Turkey, United Kingdom, United Arab Emirates and United States). These responses, such as that illustrated in ►Figure 0-2 from the group of respondents referring to themselves as ‘wardens’, helped to direct the structure and content of the Manual. Responses from ‘wetland wardens’ to the question, “What are your current priority needs for information with respect to the prevention or control of wildlife disease in protected areas? Additional information was gathered from: a review of existing sets of guidelines for managing animal disease; a review of guidelines for managing wetland sites; scientific articles in peer-reviewed journals; other published and unpublished documents; materials used in training courses; and the outputs and information gathered from two expert workshops. The following websites were the main providers of information not sourced from peer-reviewed journals: World Organisation for Animal Health (www. Animal Diseases Currently Causing Concern in Wetlands] were largely compiled from literature produced by the veterinary, wildlife management, agriculture and public health sectors together with the technical expertise of the contributors. The information has been re-packaged (with acknowledgment) into factsheets specifically for wetland managers and supplemented, where appropriate, with information from scientific articles on wetland management and wetland management guidelines as published by the Ramsar Convention. A summary of the impacts of wetland disease on biodiversity and the environment, livestock and human health and its economic implications. They support a high diversity and abundance of plants, birds, mammals, reptiles, amphibians, fish and invertebrates, as well as the millions of people who rely directly on wetlands for their health, livelihoods, welfare and safety. In addition, wetlands provide tremendous economic benefits, for example: Water supply (quantity and quality); Fisheries (over two thirds of the world’s fish harvest is linked to the health of coastal and inland wetland areas); Agriculture, through the maintenance of water tables and nutrient retention in floodplains; Timber production; Energy resources, such as peat and plant matter; Wildlife resources; Transport; and Recreation and tourism opportunities. Yet, in spite of their obvious importance, wetlands continue to be among the world’s most threatened ecosystems, owing mainly to ongoing drainage, conversion, pollution and over- exploitation of their resources.

The care beds and geographical layout of units and as a number of additional staff per minimum will require: shift will be incremental depending on the size and 11 – 20 beds = 1 additional supernumerary layout of the unit (e purchase clopidogrel 75mg otc. All registered Competency Framework nurses commencing in critical care should be for Adult Critical Care practice commenced on Step 1 of the National Competency Nurses trusted clopidogrel 75mg. The supernumerary period for newly qualified nurses should be a minimum of 6 weeks purchase clopidogrel 75mg; this time frame may need to be extended depending on the individual The length of supernumerary period for staff with previous experience will depend on the type and length of previous experience and how recently this was obtained. Newly appointed staff that have completed preceptorship should be allocated a mentor. Standards set in the stroke population for complex patient that is required, for a minimum rehabilitation should be mirrored for this patient of 5 days a week, at a level that cohort. Rehabilitation outcomes the patient’s pathway and able to facilitate care 2011 Apr 7;364(14):1293- quantified using a tool that can needs assessments. Follow-up appointments and discussed with the to facilitate care needs in the 2013 May 28;17(3):R100 patient and primary carer. Intensive have a Physiotherapist of in conjunction in order to optimize patient’s physical Care Med. Physiotherapy staffing should be adequate to provide both the respiratory management and rehabilitation components of care. Crit Care Med specific to critical care brings additional benefits 2006; 34: S46–S51 such as optimal staff skill mix and support. Br J Clin Pharmacol 2012, 74: 411- clear evidence they improve the safe and effective 423 use of medicines in critical care patients. As well as direct clinical activities (including prescribing), pharmacists should provide professional support activities (e. An example of the team used for a hospital with 100 critical care beds would be band 8 specialist critical care pharmacists, comprising: a band 8C consultant pharmacist, a band 8b (as deputy), 2 to 3 at band 8a and 3 to 4 at band 7. A band 7 pharmacist is considered a training grade for specialist pharmacy services. This allows the work to be completed with high grade pharmacy expertise available to bear on critically ill patients. Access to experience and expertise may Specialist Pharmacy areas and have the minimum be within the Trust, or perhaps externally (e. When highly Consultant Pharmacist care pharmacist (for advice and specialist advice is required, their expertise should Posts referrals) be sought. Clinical Medicine 2011; 11: 312– should be ideally available 7 frequent review and reassessment of therapies, this 16 days per week. Crit Care Med minimum the service should be Clinical Pharmacists attendance at Multidisciplinary 2013; 41:2015–2029 provided 5 days per week Ward Rounds increases the effectiveness of the (Monday-Friday). Services Alberda 2009 The lead dietitian may be supported by more junior dietetic staff, who will require regular supervision. A national prediction scale should be used to allow (2012) patient and a clearly peer comparison with other units. Good Medical Practice (2013) in the patient record of the for the National Critical Care Dash Board. In the critically ill 2013; 41(2): 580–637 making the decision to admit this is best delivered on the intensive care unit. Crit transferred to other Intensive the risks of transfer, prolongs stay on intensive care Care. If a unit usually provides Level 2 care, it must be capable of the immediate provision of short term Level 3 care without calling in extra staff members in order to provide optimal patient care. The unit should be capable of providing up to 24 hours of level 3 care prior to a patient being safely transferred to a more suitable unit. The staff of the Level 2 unit should have the competencies required to provide this level of care. There within 4 hours of the decision should not be a non-clinical reason preventing such a move. Weaning and long to a Regional Home Ventilation critical care will require a prolonged period of term ventilation and weaning unit. Many of these patients will have neuromuscular problems and will should be in place to Respiratory complex home benefit from non-invasive ventilation. Service specification 2013 with weaning difficulties and failure, including the transfer of These patients and others with weaning difficulties some patients with complex are best managed by Regional Home Ventilation services with the expertise and resources to provide weaning problems to the home support for this group of patients with Regional centre complex needs. Critically ill patients have been shown to have complex physical and psychological problems that can last for long time. The clinic does not necessarily have to be provided by the hospital that the patient was treated in. Crit Care should have an established invasive cardiovascular monitoring for more than 24 Med. If the treating specialist is not a Fellow / Associate Fellow of the Faculty, this provision should only occur within the context of ongoing daily discussion with the bigger centre. There should be mutual transfer and back transfer policies and an established joint review process. It is imperative that critical care is delivered in facilities designed for that purpose).