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Pneumonia occurring after inhalation injury usually is caused by gram-positive organisms capillaries pregnancy generic propranolol 80mg amex. Gramnegative pneumonias arteries that carry deoxygenated blood order propranolol online from canada, which now occur infrequently capillaries sentence discount propranolol 80 mg with amex, usually develop later in the hospital course. Therapy is initiated based on the results of the sputum Gram stain, with refinements of antibiotic choice depending on endobronchial culture and microbial sensitivity testing. However, when smoke inhalation occurs in the presence of moderate to severe cutaneous burn, mortality rates are increased by as much as 20% over those predicted by the age of the patient and the extent of injury. When pneumonia complicates inhalation, the mortality rate may rise to 60% above the predicted level. Infection Control Infectious complications always have been the predominant determinant of outcome in thermally injured patients. Improved care of critically ill patients and the control of burn wound sepsis through effective topical antimicrobial agents and timely excision and grafting have resulted in the salvage of more burn patients who previously would have died in the early postburn period. Since infection continues as the leading cause of morbidity and death in burn patients, prolonged hospitalization increases the risk of colonization and infection by nosocomial organisms that are predominantly true fungi, yeasts, and multiply-antibioticresistant bacteria. A strict infection control program can minimize the clinical impact of exposure to nosocomial pathogens during a prolonged hospital stay in an immunocompromised patient. Such a program might employ scheduled microbial surveillance, an actively functioning infection control committee, environmental monitoring procedures, biopsy monitoring of the burn wound, and cohort patient care as deemed necessary. The surveillance program includes thrice-weekly cultures of sputum and the burn wound surface and twice-weekly culturing of urine and stool. Multiple antibiotic sensitivities are determined for all staphylococci as well as all Pseudomonas species and other gram-negative organisms recovered from routine cultures. Reports are provided on a daily basis, enabling initial empirical selection of antibiotics to be made more precisely should an infection be diagnosed. Cohort patient care is initiated if a patient is admitted and found to be colonized or infected with an organism of broad antibiotic resistance or if this resistance pattern develops during broad-spectrum antibiotic therapy. Cross-contamination is minimized by strict enforcement of hand washing, gowning, and gloving policies. The establishment of patient care teams to provide care for only one specific patient or a limited number of patients and restriction of the traffic of convalescing patients (often colonized with resistant organisms) are imperative in reducing cross-contamination and eradicating endemic microorganisms. The infection control committee monitors infections occurring in the burn unit to identify changes in microbial prevalence, the incidence of infection, and evidence of crosscontamination. Strict criteria for the definition and identification of infections that occur in burn patients are necessary to avoid unnecessary and inappropriate antibiotic administration. Antibiotics are used only for specific indications to minimize the emergence of microbial resistance. Effective infection control policies require continual reevaluation of surveillance culture results and correlation with the sites and treatment of infections. Identification of bacteria within the vein necessitates excision of the entire length of involved vein to a level of patent normal vein and the administration of systemic antibiotics to which the causative microorganism is sensitive. This rare complication is treated with systemic antibiotics directed against the organism isolated by blood culture and anticoagulation with heparin. The efficacy of thrombolytic therapy in the treatment of central venous thrombosis is unclear. The failure of antibiotics and anticoagulation to eradicate the infectious focus mandates surgical exploration and vein excision. The true incidence of intravascular catheterrelated bacteremia in thermally injured patients is unknown. Vascular access through a densely colonized wound in those with extensive surface area burns limits the use and effectiveness of standard catheter care policies employed for other critically ill patients. Presumably, as a result of contamination by removal through colonized eschar and skin, catheter tip cultures frequently are positive even in the absence of sepsis or bacteremia. Consequently, central venous and pulmonary artery catheters are removed and a new catheter inserted at a different site every 3 days. This policy has resulted in a low incidence of bacteremia and sepsis clinically attributable to catheter-related infections. Dense bacterial colonization of the burn wound and the presence of immunosuppression associated with burn injury increase the likelihood of development of infectious complications. Pneumonia Pneumonia is the most frequent septic complication following thermal injury. As the occurrence of invasive burn wound infection has decreased, bronchopneumonia has surpassed hematogenous pneumonia as the predominant form. The increase in airborne pneumonia also may be attributable to improved survival in patients with severe inhalation injury. The appearance of an ill-defined irregular infiltrate on chest x-ray mandates Gram stain, culture, and sensitivity testing of endobronchial secretions. Empirical antibiotic treatment is begun as determined by microbiologic surveillance and Gram stain of the secretions. Compared with bronchopneumonia, hematogenous pneumonia usually occurs later in the hospital course. Remote septic foci such as invasive wound infection, endocarditis, and suppurative thrombophlebitis are common causes. The radiographic hallmark is a solitary nodular pulmonary infiltrate, but progression to multiple nodular infiltrates throughout the lungs may occur. All possible sites of infection must be evaluated if a characteristic nodular pulmonary infiltrate appears. The pneumonic process is treated by systemic administration of antibiotics directed against the causative organism and ventilatory support as needed. Aggressive pulmonary toilet to prevent atelectasis may help to decrease the occurrence of pneumonia, although most routine measures have little proved benefit. Endocarditis Acute infective endocarditis is an infrequent but consistent source of morbidity and mortality in burn patients (1. Preventive measures include effective topical antimicrobial therapy, timely excision and closure of the burn wound, and early discontinuation or frequent replacement of intravenous cannulas. Staphylococcus aureus is the most common causative organism, and the right side of the heart is affected most frequently. Recurrent staphylococcal bacteremia in a burn patient with sepsis and no other apparent identifiable source of infection should suggest the diagnosis. Transesophageal echocardiography is the preferred examination to detect valvular lesions, but small vegetations may remain undetected. On occasion, cardiac catheterization-to identify valvular vegetations or valvular incompetence-may be required for definitive diagnosis if echocardiographic findings are equivocal. Systemic maximaldose antibiotic therapy is directed against the causative organism. Antibiotic therapy is continued for 6 weeks after the last positive blood culture.
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Because it is in a neutral solution and does not contain propylene glycol heart disease prevention diet order propranolol 40 mg fast delivery, it can also be given intramuscularly (same dose as intravenously); however cardiovascular board review buy propranolol 40 mg, peak levels are reached in 3 hours coronary artery left buy 80mg propranolol amex. Phenytoin, when given intravenously, has rapid brain deposition but takes longer to control the seizure than a benzodiazepine (10 to 30 minutes). The loading dose is 20 mg/kg, which must be given slowly, 50 mg/min in adults or 1 mg/kg/min in children <50 kg. Phenytoin will precipitate in glucose solutions, so it should be given directly into the vein, or in saline. Phenobarbital is still a useful drug for treating status epilepticus, and it remains the drug of choice for neonatal seizures. Peak brain levels are reached in 10 to 20 minutes, and its duration of action is >48 hours. Side effects include respiratory depression (additive with benzodiazepines), sedation, and occasionally hypotension. If seizures stop before the entire loading dose is given, the remainder can be given intravenously or even orally within 1 to 2 hours If status persists after giving one dose of a benzodiazepine followed by phenytoin or phenobarbital, an additional dose of benzodiazepine can be given. If the seizure persists after phenytoin or phenobarbital is given, the alternate drug of the two can be administered. For refractory status, midazolam, pentobarbital, · · · · · propofol or valproic acid may be given as continuous infusions. Pentobarbital is given as a loading dose of 5 to 15 mg/ kg intravenously followed by an infusion of 0. However, side effects include hypotension with rapid infusion, as well as fatal acidosis and rhabdomyolysis with maintenance infusions. Therapy of nonconvulsive status epilepticus is similar to that of convulsive status, using a benzodiazepine, fosphenytoin, or phenytoin. For absence status, a benzodiazepine can be followed by oral or nasogastric ethosuximide. Febrile Seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Wilfong A: Overview of the classification, etiology, and clinical features of pediatric seizures and epilepsy. The patient describes feeling everything getting very small beforehand, She denies a headache or a history of head trauma. Completer blood count A 2-year-old had a generalized seizure at home lasting 30 seconds. She was full term, had no perinatal problems and was discharged 3 days ago with her mother. After establishing an airway, providing oxygen and establishing vascular access, the most appropriate medication is which of the following? The child is on gabapentin, levetiracetam, carbamazepine, topiramate, and carnitine. Juvenile myoclonic epilepsy (Janz syndrome) is characterized by myoclonic jerks of the arm after awakening, but can also include some generalized tonicclonic seizures and absence seizures. It begins between 8 and 18 years of age, and there is a strong family history of seizures. Sleep deprivation, hyperventilation, photosensitivity, and alcohol can trigger a seizure. LennoxGastaut syndrome has its onset at 1 to 8 years of age and consists of multiple seizure types. These children often have seizures every day, and there is an associated deterioration in intelligence, as well as behavior disorders. Cyanotic breath-holding spells usually occur after a crying episode, and result in limpness and loss of consciousness, occasionally with posturing. While this could be an afebrile seizure, the rapid return to normal level of consciousness makes this less likely. A pseudoseizure tends to be a diagnosis of exclusion, but the patient often avoids painful stimuli and returns to a normal level of consciousness after the seizure. Initial therapy consists of meticulous attention to maintaining patency of the airway and adequacy of oxygenation and ventilation. High-flow oxygen (15 L) is administered to all patients via non-rebreather mask or bag-mask ventilation. A bedside glucose check should be performed on all patients to detect hypoglycemia. Other laboratory studies are based on the type of seizure, history, and likely etiologies, and should be individualized. A lumbar puncture should be performed in any patient suspected of having a central nervous system infection. Complex partial seizures result in impaired consciousness and involve both sides of the brain. Motor involvement is not always present, complex somatosensory symptoms such as numbness, tingling, or paresthesias of an extremity, or visual phenomena are always present. Autonomic symptoms include sweating, change in heart rate, pupil size, and piloerection; psychic symptoms include aphasia, dйjа vu or jamias vu experiences, and illusions of perception (size and sound); and affective symptoms include such things as fear, anger or depression, and even hallucinations. Syncopal episodes are often preceded by blurred vision, followed by a loss of consciousness. A generalized seizure results in impaired consciousness, and bilateral motor symptoms. Benign childhood epilepsy with centrotemporal spikes, also known as benign rolandic epilepsy, has an onset between 3 and 13 years of age and is the most common partial epilepsy syndrome in children. It often occurs upon awakening, and consists of facial movements, grimacing, drooling, and vocalizations. West syndrome (infantile spasms), is characterized by sudden symmetric bilateral tonic contractions of the extremities, head, and trunk. Parental reassurance and education regarding the benign nature of febrile seizures, the low risk of recurrence, and the low incidence of subsequent epilepsy are part of the discharge instructions. Patients who have had a febrile seizure may be discharged, with follow-up by their primary care provider, unless an underlying infection precludes discharge. If a bacterial infection is the etiology of the fever, it is treated with appropriate antibiotics. Phenobarbital (20 mg/kg intravenously) is the drug of choice for neonatal seizures, with phenytoin (20 mg/kg) the second choice. In refractory seizures, pyridoxine (100 mg intravenously) is indicated to treat the potential for pyridoxine-dependent seizures. If the infant is hypoglycemic (<40 mg/dL), 2 mL/kg of D10 W is administered intravenously, followed by an infusion of D10 W.
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As a result heart disease mortality generic 40 mg propranolol otc, a drug overdose is seldom lethal unless other central depressants cardiovascular system anatomy purchase propranolol 80mg amex, such as alcohol coronary heart 0 chicago discount 40 mg propranolol with amex, are taken concurrently. Frequent administration may be necessary to maintain reversal of a long-acting benzodiazepine. Administration of flumazenil may precipitate withdrawal in dependent patients or cause seizures if a benzodiazepine is used to control seizure activity. The frequency of adverse effects is low, with the most common effects being headaches, dizziness, nervousness, and light-headedness. Sedation and psychomotor and cognitive dysfunction are minimal, and dependence is unlikely. It has a low tendency for habituation and, thus, is useful for patients with anxiety who have a history of drug abuse. Antidepressants Many antidepressants have proven efficacy in managing the long-term symptoms of chronic anxiety disorders and should be seriously considered as first-line agents, especially in patients with concerns for addiction or dependence or a history of addiction or dependence to other substances. Barbiturates the barbiturates were formerly the mainstay of treatment to sedate the patient or to induce and maintain sleep. Today, they have been largely replaced by the benzodiazepines, primarily because barbiturates induce tolerance, drug-metabolizing enzymes, physical dependence, and are associated with very severe withdrawal symptoms. Certain barbiturates, such as the very short-acting thiopental, are still used to induce anesthesia (see p. Anesthetic concentrations of pentobarbital also block high-frequency sodium channels. Actions Barbiturates are classified according to their duration of action (Figure 9. At higher doses, the drugs cause hypnosis, followed by anesthesia (loss of feeling or sensation), and finally, coma and death. Therefore, chronic barbiturate administration diminishes the action of many drugs that are dependent on P450 metabolism to reduce their concentration. Anesthesia: Selection of a barbiturate is strongly influenced by the desired duration of action. The ultrashortacting barbiturates, such as thiopental, are used intravenously to induce anesthesia. Anticonvulsant: Phenobarbital is used in long-term management of tonic-clonic seizures, status epilepticus, and eclampsia. Phenobarbital has been regarded as the drug of choice for treatment of young children P. However, phenobarbital can depress cognitive performance in children, and the drug should be used cautiously. Anxiety: Barbiturates have been used as mild sedatives to relieve anxiety, nervous tension, and insomnia. Pharmacokinetics Barbiturates are absorbed orally and distributed widely throughout the body. All barbiturates redistribute in the body from the brain to the splanchnic areas, to skeletal muscle, and finally, to adipose tissue. This movement is important in causing the short duration of action of thiopental and similar short-acting derivatives. Barbiturates are metabolized in the liver, and inactive metabolites are excreted in the urine. Drug hangover: Hypnotic doses of barbiturates produce a feeling of tiredness well after the patient wakes. This drug hangover may lead to impaired ability to function normally for many hours after waking. Precautions: As noted previously, barbiturates induce the P450 system and, therefore, may decrease the duration of action of drugs that are metabolized by these hepatic enzymes. Barbiturates increase porphyrin synthesis, and are contraindicated in patients with acute intermittent porphyria. Physical dependence: Abrupt withdrawal from barbiturates may cause tremors, anxiety, weakness, restlessness, nausea and vomiting, seizures, delirium, and cardiac arrest. Withdrawal is much more severe than that associated with opiates and can result in death. Poisoning: Barbiturate poisoning has been a leading cause of death resulting from drug overdoses for many decades. Severe depression of respiration is coupled with central cardiovascular depression, and results in a shock-like condition with shallow, infrequent breathing. Treatment includes artificial respiration and purging the stomach of its contents if the drug has been recently taken. Zolpidem is rapidly absorbed from the gastrointestinal tract, and it has a rapid onset of action and short elimination half-life (about 2 to 3 hours). Adverse effects of zolpidem include nightmares, agitation, headache, gastrointestinal upset, dizziness, and daytime drowsiness. This may be due to its rapid elimination, with a half-life that approximately 1 hour. Eszopiclone is rapidly absorbed (time to peak, 1 hour), extensively metabolized by oxidation and demethylation via the cytochrome enzyme system and mainly excreted in the urine. Adverse events reported with eszopiclone include anxiety, dry mouth, headache, peripheral edema, somnolence, and unpleasant taste. As darkness falls and light ceases to strike the retina, melatonin release from the pineal gland is no longer inhibited, and the gland begins to secrete melatonin. Ramelteon is indicated for the treatment of insomnia in which falling asleep (increased sleep latency) is the primary complaint. The potential for abuse of ramelteon is believed to be minimal, and no evidence of dependence or withdrawal effects has been observed. The drug is an effective sedative and hypnotic that induces sleep in about 30 minutes and the duration of sleep is about 6 hours. Chloral hydrate is irritating to the gastrointestinal tract and causes epigastric P. Antihistamines Nonprescription antihistamines with sedating properties, such as diphenhydramine and doxylamine, are effective in treating mild types of insomnia. However, these drugs are usually ineffective for all but the milder forms of situational insomnia. Furthermore, they have numerous undesirable side effects (such as anticholinergic effects) that make them less useful than the benzodiazepines. Ethanol Ethanol (ethyl alcohol) has anxiolytic and sedative effects, but its toxic potential outweighs its benefits. Ethanol has a shallow doseв"response curve; therefore, sedation occurs over a wide dosage range.
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Morphine causes respiratory depression through direct action on the pontine and medullary respiratory centers cardiovascular system documentation propranolol 40mg generic. In therapeutic doses coronary heart condition generic 40mg propranolol overnight delivery, morphine produces little change in the cardiovascular system other than occasional bradycardia and mild venodilation capillaries showing through skin buy generic propranolol canada. It also causes nausea and vomiting, bronchial constriction, spasm at the sphincter of Oddi, constipation, and urinary urgency and retention. In patients with renal, hepatic, or cardiac failure, smaller doses at less frequent intervals may be necessary. Sufentanil-Sufentanil, a thienyl analogue of fentanyl, has high affinity for opioid receptors and an analgesic potency 510 times that of fentanyl. Its lipophilic nature permits rapid diffusion across the blood-brain barrier followed by quick onset of analgesic effect. Sufentanil has an intermediate elimination half-time of 150 minutes and a smaller volume of distribution. Sufentanil may cause bradycardia, decreased cardiac output, and delayed depression of ventilation. Alfentanil-Alfentanil, a highly lipophilic narcotic, has a more rapid onset and a shorter duration of action than fentanyl. The serum elimination half-life of alfentanil is about 30 minutes because of redistribution to inactive tissue sites and metabolism. Continuous intravenous infusion of alfentanil does not lead to a significant cumulative effect. Alfentanil does not cause histamine release and thus tends not to cause hypotension and myocardial depression. The initial dose for intravenous injection is 1015 g/kg over 35 minutes, repeated every 30 minutes as needed. Reduction of dosage and increase in dosing interval are required in hepatic and renal dysfunction. Muscle rigidity and respiratory depression may develop following administration of alfentanil. Because of its rapid metabolism, the administration of remifentanil has to use continuous infusion. Butorphanol-Butorphanol, acting on different opioid receptors, has agonist and antagonist effects. However, in comparison with equianalgesic doses of morphine, it may cause similar ventilatory depression. It is metabolized in the liver to an inactive form that is largely eliminated in the bile. Following intravenous doses, butorphanol may increase mean arterial pressure, pulmonary wedge pressure, and pulmonary vascular resistance. Butorphanol may increase the cardiac workload, which limits its usefulness in acute myocardial infarction or coronary insufficiency and congestive heart failure. It has 50 times the affinity of morphine for the mu receptors and is a powerful analgesic drug. Two-thirds of the drug is excreted unchanged in the bile and one-third in the urine as inactive metabolites. Buprenorphine is indicated for the control of moderate to severe pain such as that of myocardial infarction, cancer, renal colic, and postoperative or posttraumatic discomfort. Drowsiness, nausea, vomiting, and depression of ventilation are common side effects. The duration of ventilatory depression may be prolonged and resistant to antagonism with naloxone. Opioid Agonist-Antagonists Opioid agonist-antagonists bind to opioid receptors and produce limited pharmacologic responses to opioids. They are effective analgesics but lack the efficacy of subsequently administered opioid agonists. The advantage of this group of drugs is the ability to provide analgesia with limited side effects, including ventilatory depression and physical dependence. Naloxone Naloxone, a synthetic congener of oxymorphone, competitively displaces opioid agonists from the mu receptors and thus reverses opioid-induced analgesia and ventilatory depression. Propofol has been used by continuous infusion without excessive cumulative effect. Hemodynamically, it may cause hypotension, especially in hypovolemic or elderly patients or those with heart failure. Propofol can produce transient ventilatory depression or apnea following rapid intravenous boluses. The dosage for sedation is 13 mg/kg per hour; for anesthesia, the dosage is 515 mg/kg per hour. Propofol may cause ventilatory and cardiovascular depression, particularly if given rapidly or in large amounts. After high-dose and long-term infusion, rhabdomyolysis, metabolic acidosis, and renal failure had been reported. Hypertriglyceridemia had been mentioned but has not been substantially related to propofol infusion. For this reason, repeated doses or continuous infusions are usually required for sustained antagonist effects. Naloxone is metabolized in the liver by conjugation, with an elimination half-life of 6090 minutes. Naloxone is used most commonly for the treatment of opioid-induced ventilatory depression and opioid overdosage. Intravenous doses of 14 g/kg are given to reverse opioid-induced ventilatory depression. Continuous infusion of 5 g/kg per hour may reverse ventilatory depression without affecting analgesia. Reversal of analgesia, nausea, and vomiting can occur following naloxone administration when it is given to antagonize ventilatory depression. Larger doses of naloxone have been associated with increased sympathetic activity manifested by tachycardia, hypertension, pulmonary edema, and cardiac arrhythmias. Haloperidol Haloperidol, a butyrophenone antipsychotic agent, produces rapid tranquilization and sedation of agitated or violent patients. The mechanism of action is unclear, although it may be related to antidopaminergic activity. Onset of action is 520 minutes when haloperidol is given intravenously or intramuscularly. Peak action is at 1545 minutes, although the duration of effect is highly variable (412 hours). Other complications include neuroleptic malignant syndrome, hypotension, seizures, and cardiac arrhythmias. Ketamine Ketamine, a phencyclidine derivative, produces dissociative anesthesia with profound analgesia and hypnosis. In contrast to inhalation anesthetics, ketamine is characterized by slightly increased skeletal muscle tone, normal pharyngeal and laryngeal reflexes with a patent airway, and cardiovascular stimulation secondary to sympathetic discharge.
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Based on global empirical research heart disease 19 years old propranolol 40 mg amex, the success of the digitalmasterliesonthedigitalcapabilityandleadership capabilities26 cardiovascular system structure and function powerpoint order 40 mg propranolol overnight delivery. Learningagilityisbelievedtobevalidtopredict currentperformance cardiovascular technology programs order online propranolol,futurepotentialandalsotheability to adapt to dynamic and full of change environments 12,13,14. Learning agility is based on the ability to gain relevantinsightfromtheexperienceandutilizedthose insightintonewlyandmoredifficultcontexts20. Most of management scholars defined learning agilityastheabilityorcompetenceindealingwiththe changes. The concept of digital mastery refers to sociotechnicaltheory 28,human-computerinteraction 29,and digital skills 30. Socio-technical theory 28 explains the interaction betweensocialaspects(society,relations,structure)and technological aspects (devices, processes, materials) along with environmental influences on both aspects. The optimal performance can be achieved if the interdependence and complex interactions between social and technical aspects are considered together 31. Meanwhile,human-computerinteraction29explainsthat human and computer interactions involve cognitive, informationalandvaluedphysicalresources. Therefore, itisnecessarytohavetheabilityforutilizingcomputers to benefit the human optimally 29,30 developed the concept of digital skills which explained the ability to usetheinternetforthebenefitofeconomicdevelopment orthefulfillmentofpersonalneeds. Based on systematic literature review of75articlesrelatingtowhatskillsindividualsneedto excelinthe21st century 32;digitalskillsdefinedinto12 skills which grouped in four skills groups; (1) digital technical,(2)digitalself-development,(3)socialdigital, and (4) digital solution. Meanwhile the other scholar 30 grouped six digital skills into two main categories, namelymedium-relatedskillsandcontent-relatedskills. Based on the literature review above, digital masteryinthisstudyisdefinedasawareness,attitudes, and individual skills in utilizing digital technology for the purposes of coordination, self-development, and business operations; thus helping companies become more effective. Digital mastery is reflected into three dimension: (1) digital communication skills - which indicates the ability to communicate digitally through theinternet;(2)contentcreationskillwhichdescribes the skills to design and create digital content that is appropriate, effective and interesting; (3) digital strategic skills which explains skill to gain as much benefitaspossiblefromdigitaltechnologyforpersonal development and personal future. Learning Dexterity: Learning dexterity is a technopsycho-socialconceptofagilitylearningbycombining theconceptsofdigitalmasteryandlearningagility. The exploitation function is relatedtocontinuousimprovement,efficiency,selection, and implementation. While the exploration function is relatedtoresearch,variation,experimentation,andnew discoveries 35. In line with the ambidexterity, learning dexterity also reflects a combination of two different and contradictorythings. Thosearetheabilitytomanaging selfandrelationshipwiththeothers(psycho-social,nontechnical aspects) and the ability to utilize technology (technological,technicalaspects). Thelearningdexterity is also in line with socio-technical theory 28 which explains that there are interactions between social aspects(society,relations,structures)andtechnological aspects (devices, processes, materials) of individual behavior, especially how individuals perceive and do work,playaroleintheorganization,andinteracteach others. Theoptimalperformancecanbeachievedifthe interdependence between social and technical aspects areconsideredtogether31. Learning dexterity is reflected into two dimensions:learningagilityanddigitalmastery. They are agronomy supervisors or managers in private companiesinpalmoilplantation. Thedata Indian Journal of Public Health Research & Development, January 2019, Vol. They come from nonfarming family (80%) and now have position as team leaderorsupervisor(60%). In the second-order construct, learning dexterity is reflected into learning agility and digital mastery dimension. In the third-order construct, learning dexterity is reflected into learning agility and digital mastery dimension. Learning agility is reflected into sub-dimensions such as: (1) change agility; (2) mental agility;(3)peopleagility;and(4)resultagility. Figure 1: Second-Order Construct 1300 Indian Journal of Public Health Research & Development, January 2019, Vol. Average variance extracted of all sub-dimensions of digital mastery and learning agility range from 0. It means that all sub-dimensions of digital mastery and learning agility are valid. Comparing the both construct; the third-order construct is better because the construct is validandreliable. Figure 2: Third-Order Construct Indian Journal of Public Health Research & Development, January 2019, Vol. It means that learning dexterity is reflected to digital mastery positively and significantly. Learning dexterity has been empirically tested on managerialresourcesofthepalmoilplantationcompanies inIndonesia. The digital mastery dimension can be positively and significantly reflected oncontentcreation,digitalcommunication,anddigital strategicskillssub-dimension. Whilethelearningagility dimension can be positively and significantly reflected into change agility, mental agility, people agility, and resultagilitysub-dimension. Meuse,Dai,Hallenbeck,&TangUsingLearning agility to identify high potentials around the world,2008,Korn/Ferry Institute. Perkebunan Kepala Sawit dalam Pembangunan Ekonomi Daerah / Pedesaan, Pengurangan Kemiskinan dan Pelestarian Lingkungan,2015. Derue, Ashford, & Myers Learning agility: In search of conceptual clarity and theoretical grounding. Mastering Turbulence: the Essential Capabilities of Agile and Resilient Individuals, Teams and Organizaitons, 2012. Explicating dynamic capabilities: the nature and microfoundations of (sustainable) enterprise performance. The role of learning agility in workplace performance and career advancement, 2011, UniversityofMinnesota. Lack of awareness in maintaining and caring for the environment and bad habits that are often preserved are crucial factors in influencing environmental sustainability. Personalityisastructure and tendency that explains their characteristic patterns ofthoughts,emotionsandbehavior. Theresultsoftheresearchfocusedonthreepersonalities, Indian Journal of Public Health Research & Development, January 2019, Vol. Theresultsofthestudyfocused on environmentally-friendly behavior carried out in the schoolenvironmentaffectingthebehaviorathome. The five dimensions of personality are conscientiousness, agreeableness,neuroticism,opennesstoexperience,and extraversion. Thus personality is predicted to have an effectonpositivebehaviorsrelatedtotheenvironment. Theintentiontobehaveisdeterminedby two things, namely: (1) attitude towards the behavior itselfand(2)subjectivenormsaboutthatbehavior. Pro ecological behavior is related to several variables,namely:(1)personalityfactors(attitude,locus of control, personal responsibility); (2) awareness; (3) knowledge of strategic actions; (4) acting skills; (5) intentiontoact;and(6)situationalfactors.
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Phone:+919830983496 cardiovascular disease mortality statistics quality 40 mg propranolol,+919830519741 shown different calcium levels in Hyperthyroidism heart disease tattoo designs cheap 40mg propranolol overnight delivery, very few studies have compared the calcium levels in Subclinical and Overt Hypothyroidism heart disease yellow skin purchase propranolol online from canada. A study had showed that hypothyroidism does not cause any abnormality in serum Calcium levels and was found to be associated with low trabecular resorption surface and increased bone cortical thickness№. Although progression of subclinical to overt hypothyroidism is very high in prospective studies with10yearsoffollowupperiodІ,ourswasaonetime study diagnosing subclinical and overt hypothyroidism. Thyroid hormones are known to have its effect on 140 Indian Journal of Public Health Research & Development, January 2019, Vol. The inclusion criteria of selecting the study groupwerenon-pregnantandnonlactatingfemales,not taking any medicine for thyroid disorders or taking any calcium supplements. They had no parathyroid or any renal dysfunction and were not taking any drugs that couldaffecttheirbloodcalciumlevels. Theserumcalciumwasmeasured by ion selective electrode method and was analyzed by chemical analyzer. Descriptivestatisticalanalysis was performed to calculate the mean and corresponding standard database. Pearson correlation coefficient was calculated to find correlation between two variables. Free T4 levels showed positivecorrelationwithserumcalciumlevelsinEuthyroid, SubclinicalandOvertHypothyroid,butthecorrelationwas significantonlywithfreeT4levelsinOverthypothyroidism whileallothervalueswerenotsignificant. In this study in both subclinical and overt hypothyroidism, calcium levels showed significant decrease P<. This decrease in calcium levels might be due to defective mobilization of calciumfrombone. Howevercomparingthecorrelation of thyroid hormones with calcium levels in individual groupswefoundfreeT4tobesignificantwithcalcium levels only in overt hypothyroidism. This also supports the theory that thyroxine hormone is responsible for releasing calcium from bone cells and as it level in overt hypothyroidism decreases so the calcium level in serum also decreases. Though Al-Hakim showed significant decrease in calcium levels in hypothyroid cases which issimilartoourfindings,therewassignificantdecrease in calcium levels between subclinical and overt hypothyroidism also. This might be due to the prompt action of the parathormone action to normalize the calcium levels. Serumlevelsoflipids,calcium and magnesium in women with hypothyroidism and cardiovascular diseases, J lab physicians 2009;1(2):49-52 7. Assessment of serum levels of calcium and phosphorus in Sudanese patient with hypothyroidism. Inthisresearch paperwewilltrytoanalysishowthewhistle-blowerpolicyadoptedbyhealthcareindustryinIndiawhich are playing crucial role so for. This is a quantitative study where researchers used exploratory research design to analyse various factors required for whistleblowing. Amit Kumar Pandey Assist Professor AmityBusinessSchool,AmityUniversityNoida Email:akpandey7@amity. Do investigations from individuals which are often referred as whistle-blower really tell corporate malpractices especially which are hidden in nature or are sources creditable enough to investigate, we know government do itself carry out investigation to check thesameespeciallyinallegationfor,manufacturingof fake generic products and failure to maintain quality standards9. Many cases explain that fraud can be when health institution provides certain service to its patients but charges a higher price for the single set of services by issuing separate bills which is known as upcoming but when there is group of related services is billed in single bill is referred as unbounding. It is also seen that a hospital or the doctor given a finance bribes for prescribing medicines generally such practices are not allowedlegally. Ontheotherhand,wehavefraudswhich off-labelmarketthishappenwhenmedicinesaremade with any compliance of drug regulator of the country; it istheseareaswherewhistle-blowersaysitsproblematic area to disclosure11. So,whentobelievethatwhistle-blowersinformation firstsourcecanbeinternalreportswhenlargeofdoctors or employers of the hospital establish a mechanism more ofconfidentialtypeofreportingsystemwherethrough easy channels within the internal environment of the organisation. Secondly proper handling of evidence such invoices, bills, agreements, payment information, etc. Finally, one should always consult with legal law authorises, in such a way that it is confidential in the sense that name should not be disclosed,ratherfocusshouldtoinvestigateirregularities in the companies12. Further Consistent promotion of such type practices results in lack of collaboration between them which gives further raise of malpractices, but only brave enough people will use this opportunity to disclose them and become whistle blower therefore should be provide with some legal protection to blower until proper legal proceedings are done6. But in case of India 2011 whistle-blowers act, still impact of this whistler will take years is quite doubtful,surprisinglyninety-sixpercentofIndianthink corruption is holding the country backwards therefore such act is more of mixed thing. Only thing which is good about the act is that penalty which is imposed on disclosureofidentityofwhistle-bloweruptoprisonfor 3yearsandfineofonlyfiftythousandrupeesonly8. Should there be proper protection been given to them, of course there can be dissent between one of best practice manage this issue, so once may say that system in which doctors do agree the medicines at times are not correctly manufactured the way they shouldbe,generallypublicmayeventhinktwiceabout talking about whistler-blower especially at health-care institution but when there negligence form the institution people will always blame them and whether his right to ask for compensation, this could seriously raise the question,ifthedoctorsknowinglyawareofmedicineare fake dose not wants disclose this patient this will raise high of fatality in the future14. Again, the argument arises with the increase on healthcareinstitutions,nearlyeveryonetryingtoreduce lowmaintainstobemorecompetitiveintheindustry,and therefore many people may believe that whistle blower practice is getting worse15. So ethics can play crucial role with age of digital era promoting virtue ethical practice forhealthcareagency,passingandaskingoforderwith proper conscience from main distributor via online portal,maygivesomehopeforwhistle-blowerprovide solid prof evidence yet very little legal support16. Understanding human being in sense of morally accepted practices both professional and personal setting is the source to understand relationship nature of different individual. Keeping this in mind ethics for nurses to protect and integrity is critical important to judge the owners of institutions to make standards in accordance something is morally right for them in this every changing ecological change in the minds of owners to support trust in order to build social acceptance17. So,studyitselfisexploratoryinnaturewheredifferent parameters of whist blower practises in supportive with malpractices and standard of services is covered. Here, is the population means from the sample selected,aisthehypothesizedvalueofthemean. Moreover,overthisstudyhasbeenconcludedwith the help of structured questionnaire in which researcher prepared set of questions which include dichotomous and Likert based question for the responses. Wehadoverall400responds,wereweselected 300 questionnaires randomly and data analysis has been done based responses of 300 respondents. Table 1: Paired Sample Correlation Pair1WhistleBlower&medicalPractices N 300 Correlation. Table 4: Paired Samples Correlations Pair2 Whistleblower&standardofservices N 300 Correlation. Even though Hypothesis proposed in this study Medical malpractices19 may have prevented with the help of whistle blowing policies in India. Standard of services utilizes their skill set, knowledge,competence,hospitalsystemandtechnology in treating the patient. Patient safety and patient recovery fully depend upon the nurses and staff, while depend upon the available tools and technology within the hospital. Thus, it has come out after the analysis that there is significance relationship between whistle blower will improve standard of services in India hospitals. Limitation of the study: Analysis of health care industry is slightly crucial than other industries. Since whistleblowing is a new terminology in India so literature is not available in prompt.
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Trouser pocket Shirt pocket Purse/bag In hand Tied to arteries gallery discount propranolol 80mg without prescription the arm Others(Morethanone option from above) 271 4 33 13 2 29 76 anatomy of blood vessels 21 order 40mg propranolol free shipping. Out of 352 students cardiovascular jvd buy propranolol visa, 127 students used their cell phones for socializing, 19 students for privacy, 44 students for safety and 2 as status symbol (21-24)(Table5). Table 6: Level of addiction for cell phone usage in participant students (f) Level of addiction a. If yes, do you feel addicted to your mobile phones (On a scale of 1 to 5, where 1 is very less and 5 is maximum). Among participants, 132 students claimed thattheywouldswitchofftheirmobilephonesifneed arises(lectures/cinemas)while220studentsstatedthat theywouldneverswitchofftheirmobilephones. Most of the Participants preferredusingmobilephonesonspeakermode/headsets to reduce their exposure to the radiations. Ethical Clearance: the study was approved by the Institutional Ethics committee and has been performed in accordance with the ethical standards as laid down in the 1964DeclarationofHelsinkianditslateramendments or comparable ethical standards. Effects of the exposure to mobile phones on male reproduction: a review of the literature. Resting blood pressure increase during exposure to a radio-frequency electromagnetic field. Awareness of mobile phone hazards among university students in a Malaysian medical school. Government Of India Ministry Of Communications & Information Technology Department Of Telecommunications. Mobile phone usage and awareness of health related issues among the male science students. Mobile Phone Induced Myocardial Oxidative Stress:ProtectionbyaNovelAntioxidantAgent Caffeic Acid Phenethyl Ester. The Impact of Cell Phone Use on Social Networking and Development among College Students. Studying the perceived benefits and barriers to exercise can help to improve physical activity among women. Objective: Tostudytheperceivedbenefitsandbarrierstoexerciseandtheassociatedfactorsamongwomen To assess the level of physical activity among the women Methodology: Acommunitybasedcrosssectionalstudywasconductedamongwomenaged18-49years. In 2010, 23% of adults aged 18 years and over were insufficiently physically active with women being less active than men(27%Vs. Regular physical activity (at least 150 minutes of moderate intensity per week for adults) reduces the risk of cardiovascular disease, Corresponding Author: Dr Pawan Kumar Professor,DepartmentofCommunityMedicine, KasturbaMedicalCollege,Manipal, ManipalAcademyofHigherEducation, Manipal,Karnataka,India-576104 Email:pawan. Several barriers to physical activity have been reported among women including lack of time and motivation,lackofinexpensivefacilities4. With a limited information on this issue in Indian context,thepresentstudywasplannedtoassessthelevel of physical activity among women and understand the perceivedbarriersandbenefitstoexercise. Incaseofmorethantwowomenwillingtoparticipate,the eldest and youngest among the women were requested to participate. Afterobtainingconsent,sociodemographic information was collected using a structured proforma. This scale has 43 items with each having four response,Likerttypeformatwithresponsesrangingfrom 4(stronglyagree)to1(stronglydisagree). Whilehighertotalandbenefit scores represented, greater positive perception of individualtowardsexercise,ahigherbarrierscoremeant the participants had lesser barrier towards exercise. The benefit and barrier scales have five and four domains respectively as shown in box no. Exercise improves the quality of my work Exercise improves overall body functioning for me. Social Interaction Exercising lets me have contact with friends and persons Ienjoy. Table 1 shows the domain wise frequencies and percentagesofvariousitemsofbenefitsubscaleamong the study participants. While improvement of physical 60 Indian Journal of Public Health Research & Development, January 2019, Vol. Table 2 shows the domain wise frequencies and percentages of various items of barrier subscale among the study participants. After combining the responses of women who either strongly agreed or agreed to various items,thetoptwoandleasttwoperceivedbarrieritems wereidentified. This indicates that women perceivethebenefitsofexercisepositivelynevertheless they identify certain barriers to the same. Inthisdiscussion,thebenefitsandbarrierssimilartothose studied in the present study have been highlighted. Benefits of exercise: A study by Duskapan A et al among women aged 24-63 yrs, found that 94. A study among employees of an educational institute in Mauritius, found that highest perceived benefits of exercise were improvement of physical fitness and getting better sleep at night 10. Barriers to exercise: the reported barriers to exercise by Duskapan A et al among women were: tiredness caused by exercise (8. A study among women aged 45-49 yrs in Malaysia, found that interference with social and family activities (26. A study in Southern California among18yearsandolderArabwomen,observedthat: not having enough time (56. A study from urban Kerala foundthathouseholdchores,lackofinterestandlackof encouragementweremajorperceivedbarriers13. A study by Giridhran P et al observed the low,moderateandhighphysicalactivitylevelsamong women to be 52. Since this survey was carried out during working hours,thestudypopulationpredominantlyconsistedof homemakers which may have underestimated physical activity among this population. Barriers to participation in physical activity and exercise among middle-aged and elderly individuals. ConsensusStatement forDiagnosisofObesity,AbdominalObesityand the Metabolic Syndrome for Asian Indians and RecommendationsforPhysicalActivity,Medical and Surgical Management. Exercise patterns and behaviour in Asian Indians: data from the baseline survey of the Diabetes Community Effect of Dispositional Mindfulness on Perceived Stress Scores of Engineering Students: An Empirical Study Ranju Lal1, Pramod Pathak2, K. A purposive random selection of 100 students in which 50 students were aware and practicing meditation to cope with stress on a daily basis and 50 students were not practicing any kind of meditation. Studyshowedsignificantdecreasesinstressperceptionlevelamongthosestudentswhoarepracticing meditations and high level of stress perception level among those who are not practicing any techniques to copewithstressrespectively. It is a primarytoolofmeditation,theawarenessthatweapply to our breath (or to whatever our object-or-focus-ofmeditationis,suchasaword,image,sound,orphysical sensation to which we return our attention after becoming distracted) can be expanded to include all physical and mental processes so that we may become more mindful ofourthoughtsandactions. Mindfulnessisnotthinking, interpreting, or evaluating; it is an awareness of perception. The mind and the body are intimately connected, our physical health being greatly determined by our mental and emotional disposition. Students mayexhibitstressbyactingangry,moodyorirritable, showing negative changes in behaviour, feeling sick a lot, and acting out in certain settings.
During priapism capillaries red blood cells buy propranolol 80 mg online, the edematous corporal state cardiovascular system lungs buy propranolol on line amex, septal and/or intra-corporal fibrosis may anchor the cavernous arteries to physioex 90 cardiovascular physiology purchase propranolol 80 mg online a more eccentric place immediately adjacent to the intercorporal septum. These arteries are therefore become relatively fixed and are possibly more susceptible to needle injury during corporal aspiration as happened in our case report13. Risperidone, quetiapine and chlorpromazine may have induced priapism in an adolescent. Recurrent idiopathic high-flow priapism treated with selective arterial embolization after repeated initial treatments for low-flow priapism. Two Priapism Cases Following Short-Term Use of Chlorpromazine Kisa Dцnem Klorpromazin Kullanimina Bali ki Priapizm Olgusu. High flow priapism due to an arterial-lacunar fistula complicating initial venoocclusive priapism. Highflow priapism caused by injury of the bilateral cavernosal artery after needle trauma in a patient with low-flow priapism. Main outcome measures are knowledge and practices score on occupational exposure and protection from infectious disease. M4 SelfReportedKnowledgeandPracticesofHealthcareWorkersonOccupationalExposureandProtectionfromInfectiousDiseaseattheMilitaryHospitalinSierraLeone Strictly as per the compliance and regulations of: © 2018. Yu-Ling Qin, Henry S Bangura, Bo Li, Yue-Su Zhou, Yue Yuan, Yi Sun, Jing Li, Zhong-Peng Zhao, Jun Jiao, Bing-Song, Stephen Sevalie, Ya-Jun Song, Jia-Fu Jiang, Foday Sahr & Tian-Jun Jiang. Methods: From December 9th to 23rd, 2016, questionnaires Results: A total of 190 (86. Knowledge, practice and the degree of training level was significant by occupation or department (P=0. Multivariate logistic regression analysis showed that the Under Fives Clinic (P = 0. The need for more intensive training and the establishment of the evaluation systems for occupational exposures are required for the study hospital. Keywords: healthcare workers: occupational exposure and protection: knowledge: practices: sierra leone. Proper training and safe practices help reduce the spread of disease, especially in outbreak scenarios. Ebola infection prevention and control in primary healthcare facilities located in Sierra Leone, gradually improved during the outbreak as preventative practices were followed . Methods a) Study Design and Population A descriptive cross-sectional study was conducted at the 34 Military Hospital, which has 200 beds for the admission of various medical conditions and is located at the Wilberforce Barracks, Freetown, Sierra Leone. This hospital provides both the secondary and tertiary health care for soldiers, their families and civilian workers in the Ministry of Defence. A few in hospital educational opportunities (such as lecture for occupational health) were held periodically in the hospital as a reason for extremely humble and broken lecture room etc. All health care workers at the Hospital must have completed the secondary school level of education before enrolling in any category of health related courses. The survey had questions on socio-demographic characteristics, and 45 questions across five themes, including actual practice of preventive measures (Q5-Q8, Q10-Q11,Q17-Q19 and Q29-31, Appendix), knowledge and perception of universal precautions and infectious disease (Q32-Q45), training level (Q20-Q26, Q28), and some probable © 2018 Global Journals 1 reasons for poor practice (Q9, Q12-Q15), as well as self-evaluation and external evaluation (Q1-Q4, Q16, Q27) (Appendix). Ten questions had binary (yes or no) responses, seventeen multi-items questions had one correct answer, and eighteen multiple choice questions focusing on practice and knowledge of infectious diseases which had more than one correct answers. For some volunteered nurses or low education level nurses who cannot really understand the meaning of some question and choices, the investigators from the hospital explained them. Three co-investigators from Chinese Military Medical Experts Group in Sierra Leone supervised data collection. The questions which had only one correct answer were graded in the categories of wrong and right. Eighteen multiple choice questions which had more than one correct answers were graded in the categories of completely wrong (very poor), poor, intermediate or adequate according to the combination of the response answer. These levels were given scores of zero, one, two and three for completely wrong (very poor), poor, intermediate or adequate (right), respectively. Total scores for knowledge, practice, and training were calculated and split into three cut-points based on quartiles of ranked data values. Results a) Participant Characteristics There were 190 respondents with valid questionnaires, giving a response rate of 86. This low insufficient knowledge and perception are at a similar level to that which was reported in Ethiopia  and Iran . It is also similar to same settings in South Africa  and lower than that (two third) at some regional hospitals in Tanzania , as well as the developed countries [15, 16]. In addition, the present study also showed that the proportion that received training among participants were very low according to self-assessment and objective assessment, with variations observed by occupation and department (Table 2). According to a retrospective descriptive study of Ebola virus disease transmission among health care workers in Sierra Leone from May to December 2014, 34 © 2018 Global Journals c) Knowledge & Practice & Training and Associated Factors Sixty (31. Findings also revealed that work experience years, type of occupation, type of department were associated significantly with knowledge on occupational exposure and protection. In addition, occupation, type of department and gender were also associated significantly with practice level. In addition, the level of received training among occupation or department was significantly different respectively (Table 2). The training level of staff from the surgical department and the Under Fives Clinic were also below other staff, with 61. Less than 10 % of staff knew exactly what scenarios required follow-up hand washing or disinfection, and 15. Of those who did report a previous sharps injury, 2376% was due to carelessness, in a hurry, inadequate lighting in the work place or not following the standardized sharps protocol. Among staff who were suffered from the sharp injury, the breakdown by department is as follows, 84. The participants with different education levels had significantly different responses based on the following questions: disinfecting nursing equipment (Q29), dealing with contaminated medical equipment (Q30), frequency of cleaning and disinfecting the surface of trolleys or desks (Q31) as well as when should you wash your hands (Q32) (Table 3, P<0. The military nurses and technicians had significantly more correct responses than those from other groups. It also showed that there are a higher proportion of participants from the laboratory who had correct practices (Q11, Q43). However, the participants from the Surgical Department and the Under Fives Clinic had more poor or incorrect responses (Q11, Q17, Q29, Q33, Q36-Q45). In addition, the training level of staff from the Surgical Department and Under Fives Clinic was deemed insufficient and most of the volunteer nurses received inadequate training. Receiving special training, such as post exposure prophylaxis and infection prevention and control , as well as stressing the importance and proper practice of hand hygiene along with improving hand sanitizer options in disinfection protocols can improve occupational protection from infectious disease . Needle-stick and sharps injuries carry the risk of infection and are occupational hazards for all health care professionals involved in clinical care. This is comparable to a multicenter research study in Lagos, Nigeria, which found that the most common activity leading to needle-stick and sharps injuries was recapping of needles (45%) . The reason and the risk factors maybe are that there is more outpatient volume as more free treatment, more frequency for re-capping of needles after injection procedures, or A more humble and crowded environment in this hospital. Good practice of basic hygiene need not only proper training, but also available amenities like portable water, hand washing stations and other enhanced infrastructure [21, 22].