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- Associate Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette and Indianapolis
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Pathologic findings included membranous 20 glomerulonephritis medicine 3604 pill buy oxybutynin 5 mg without a prescription, focal glomerulosclerosis medicine 95a pill purchase oxybutynin amex, and fibrillary glomerulonephritis medicine hat jobs generic oxybutynin 2.5mg with mastercard. The incidence of antibody formation is highly dependent on the sensitivity and the specificity of the assay symptoms rotator cuff injury oxybutynin 2.5mg without prescription. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, comparison of the incidence of antibodies to Herceptin with the incidence of antibodies to other products may be misleading. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Providers should consider additional monitoring and/or treatment as clinically indicated. If possible, physicians should avoid anthracycline-based therapy for up to 7 months after stopping Herceptin. If Herceptin is administered during pregnancy, or if a patient becomes pregnant while receiving Herceptin or within 7 months following the last dose of Herceptin, health care providers and patients should immediately report Herceptin exposure to Genentech at 1-888-835-2555. Risk Summary Herceptin can cause fetal harm when administered to a pregnant woman. In post-marketing reports, use of Herceptin during pregnancy resulted in cases of oligohydramnios and of oligohydramnios sequence, manifesting as pulmonary hypoplasia, skeletal abnormalities, and neonatal death [see Data]. There are clinical 21 considerations if Herceptin is used in a pregnant woman or if a patient becomes pregnant within 7 months following the last dose of Herceptin [see Clinical Considerations]. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. Clinical Considerations Fetal/Neonatal Adverse Reactions Monitor women who received Herceptin during pregnancy or within 7 months prior to conception for oligohydramnios. If oligohydramnios occurs, perform fetal testing that is appropriate for gestational age and consistent with community standards of care. Data Human Data In post-marketing reports, use of Herceptin during pregnancy resulted in cases of oligohydramnios and of oligohydramnios sequence, manifesting in the fetus as pulmonary hypoplasia, skeletal abnormalities, and neonatal death. These case reports described oligohydramnios in pregnant women who received Herceptin either alone or in combination with chemotherapy. In one case, Herceptin therapy resumed after amniotic index improved and oligohydramnios recurred. Animal Data In studies where trastuzumab was administered to pregnant Cynomolgus monkeys during the period of organogenesis at doses up to 25 mg/kg given twice weekly (up to 25 times the recommended weekly human dose of 2 mg/kg), trastuzumab crossed the placental barrier during the early (Gestation Days 20 to 50) and late (Gestation Days 120 to 150) phases of gestation. The resulting concentrations of trastuzumab in fetal serum and amniotic fluid were approximately 33% and 25%, respectively, of those present in the maternal serum but were not associated with adverse developmental effects. Published data suggest human IgG is present in human milk but does not enter the neonatal and infant circulation in substantial amounts. Trastuzumab was present in the milk of lactating Cynomolgus monkeys but not associated with neonatal toxicity [see Data]. This consideration should also take into account the trastuzumab wash out period of 7 months [see Clinical Pharmacology (12. Data In lactating Cynomolgus monkeys, trastuzumab was present in breast milk at about 0. Infant monkeys with detectable serum levels of trastuzumab did not exhibit any adverse effects on growth or development from birth to 1 month of age. Contraception Females Herceptin can cause embryo-fetal harm when administered during pregnancy. Advise females of reproductive potential to use effective contraception during treatment with Herceptin and for 7 months following the last dose of Herceptin [see Use in Specific Populations (8. The risk of cardiac dysfunction was increased in geriatric patients as compared to younger patients in both those receiving treatment for metastatic disease in Studies 5 and 6, or adjuvant therapy in Studies 1 and 2. Limitations in data collection and differences in study design of the 4 studies of Herceptin in adjuvant treatment of breast cancer preclude a determination of whether the toxicity profile of Herceptin in older patients is different from younger patients. In Study 7 (metastatic gastric cancer), of the 294 patients treated with Herceptin, 108 (37%) were 65 years of age or older, while 13 (4. Herceptin (trastuzumab) for injection is a sterile, white to pale yellow, preservative-free lyophilized powder with a cake-like appearance, for intravenous administration. Total trastuzumab clearance increases with decreasing concentrations due to parallel linear and non-linear elimination pathways. Although the average trastuzumab exposure was higher following the first cycle in breast cancer patients receiving the three-weekly schedule compared to the weekly schedule of Herceptin, the average steady-state exposure was essentially the same at both dosages. The pharmacokinetics of trastuzumab in patients with severe renal impairment, end-stage renal disease with or without hemodialysis, or hepatic impairment is unknown. Drug Interaction Studies There have been no formal drug interaction studies performed with Herceptin in humans. Clinically significant interactions between Herceptin and concomitant medications used in clinical trials have not been observed. Paclitaxel and doxorubicin: Concentrations of paclitaxel and doxorubicin and their major metabolites. Docetaxel and carboplatin: When Herceptin was administered in combination with docetaxel or carboplatin, neither the plasma concentrations of docetaxel or carboplatin nor the plasma concentrations of trastuzumab were altered. Cisplatin and capecitabine: In a drug interaction substudy conducted in patients in Study 7, the pharmacokinetics of cisplatin, capecitabine and their metabolites were not altered when administered in combination with Herceptin. No evidence of mutagenic activity was observed when trastuzumab was tested in the standard Ames bacterial and human peripheral blood lymphocyte mutagenicity assays at concentrations of up to 5000 mcg/mL. In an in vivo micronucleus assay, no evidence of chromosomal damage to mouse bone marrow cells was observed following bolus intravenous doses of up to 118 mg/kg of trastuzumab. Patients with a history of active cardiac disease based on symptoms, abnormal electrocardiographic, radiologic, or left ventricular ejection fraction findings or uncontrolled hypertension (diastolic > 100 mm Hg or systolic > 200 mm Hg) were not eligible. Paclitaxel was administered either weekly (80 mg/m) or every 3 weeks (175 mg/m) for a total of 12 weeks in Study 1; paclitaxel was administered only by the weekly schedule in Study 2. Herceptin was administered at 4 mg/kg on the day of initiation of paclitaxel and then at a dose of 2 mg/kg weekly for a total of 52 weeks. Radiation therapy, if administered, was initiated after the completion of chemotherapy. The data from both arms in Study 1 and two of the three study arms in Study 2 were pooled for efficacy analyses. Similar demographic and baseline characteristics were reported for the efficacy evaluable population, after 8. Patients were randomized (1:1:1) upon completion of definitive surgery, and at least four cycles of chemotherapy to receive no additional treatment, or one year of Herceptin treatment or two years of Herceptin treatment. Herceptin was administered with an initial dose of 8 mg/kg followed by subsequent doses of 6 mg/kg once every three weeks. A protocol specified interim efficacy analysis comparing one-year Herceptin treatment to observation was performed at a median follow-up duration of 12. Among the 3386 patients randomized to the observation (n = 1693) and Herceptin one-year (n = 1693) treatment arms, the median age was 49 years (range 21? Prior to randomization, 94% of patients had received anthracycline-based chemotherapy regimens. Radiation therapy, if administered, was initiated after completion of chemotherapy. Definitive conclusions cannot be drawn regarding efficacy within other subgroups due to the small number of events. Patients were eligible if they had 2 or 3 levels of overexpression (based on a 0 to 3 scale) by immunohistochemical assessment of tumor tissue performed by a central testing lab. Previously Untreated Metastatic Breast Cancer (Study 5) Study 5 was a multicenter, randomized, open-label clinical trial conducted in 469 women with metastatic breast cancer who had not been previously treated with chemotherapy for metastatic disease. Only patients with 2+ or 3+ positive tumors were eligible (about 33% of those screened). Patients were randomized to receive chemotherapy alone or in combination with Herceptin given intravenously as a 4 mg/kg loading dose followed by weekly doses of Herceptin at 2 mg/kg. Sixty-five percent of patients randomized to 32 receive chemotherapy alone in this study received Herceptin at the time of disease progression as part of a separate extension study. Patients randomized to Herceptin and chemotherapy also had a longer median survival (see Table 11).
An abnormal result medicine bow buy oxybutynin 2.5mg without a prescription, defined by increased impedance (mean resistance index of more than 0 medications emt can administer purchase oxybutynin cheap. The sensitivity of the test in predicting pre-eclampsia was 89% and for intrauterine growth restriction it was 67%; the specificities were 93% and 95% medicine 5277 order oxybutynin with amex, respectively treatment 12mm kidney stone buy genuine oxybutynin. The sensitivity for predicting nonproteinuric pregnancy-induced hypertension was 50%. The sensitivity of the test for pre-eclampsia was 27%, and for intrauterine growth restriction it was 47%; the respective specificities were 90% and 91%. The test detected women with severe disease requiring delivery before 37 weeks with a sensitivity of 83% and specificity of 88%. A screen-positive result, defined by a mean resistance index above the 90th centile and the presence of diastolic notches in both uterine arteries, was found in 4. The sensitivity of the test for pre-eclampsia was 22%, with a specificity of 97% and a positive predictive value of 35. Pre-eclampsia, intrauterine growth restriction and preterm delivery occurred in 4%, 11% and 7% of the pregnancies, respectively. When the uterine artery Doppler studies were normal, the odds ratio for developing pre-eclampsia was 0. It was concluded that women with normal uterine artery Doppler studies at 20 weeks constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency, whereas women with bilateral notches have an increased risk of the subsequent development of such complications, in particular those requiring delivery before term. Consequently, the results of Doppler studies of the uterine arteries at the time of the routine 20-week anomaly scan may be of use in determining the type and level of antenatal care that is offered to women. A screen-positive result (increased impedance at 24 weeks) was found in 12% of cases, and the sensitivity of the test for pre-eclampsia was 63% and for intrauterine growth restriction it was 43% (< 5th centile). In those with increased impedance to flow (resistance index greater than the 95th centile or early diastolic notch in either of the two uterine arteries), the Doppler studies were repeated by color Doppler at 24 weeks. It was reported that increased impedance provides good prediction of pre-eclampsia (but not of non-proteinuric pregnancy induced hypertension). Furthermore, in terms of low birth weight, abnormal waveforms provide better prediction of severe (below the 3rd centile) rather than mild (below the 10th centile) intrauterine growth restriction (Table 5). In those with increased impedance (resistance index greater than the 95th centile or early diastolic notch in either of the uterine arteries), the Doppler studies were repeated by color Doppler at 24 weeks. The sensitivity of the test for pre-eclampsia was 77%, and for intrauterine growth restriction it was 32%. The respective sensitivities for those complications leading to delivery before 35 weeks were 81% and 58%. The sensitivity of the test for pre-eclampsia was 50%, and for intrauterine growth restriction it was 43%. In the group with increased impedance at 20 weeks but normal results at 24 weeks, the prevalence of pregnancy complications was not increased compared to those with normal impedance at 20 weeks. These findings suggest that a one-stage color Doppler screening program at 23 weeks identifies most women who subsequently develop the serious complications of impaired placentation associated with delivery before 34 weeks. The Doppler studies were performed at 19?22 weeks and then at 32 weeks, unless the women were classified as being at high risk, in which case the Doppler studies were performed monthly. Continuous wave Doppler was used to obtain flow velocity waveforms in the lower lateral border of the uterus and an abnormal result was defined by the presence of an abnormal waveform bilaterally. There was a high frequency of pregnancy complications in women with abnormal uterine artery waveforms and it was concluded that abnormal waveforms are an indicator of subsequent fetal compromise. However, no improvement in neonatal outcome was demonstrated by routine Doppler screening. However, a series of randomized studies have shown no effect on the complications 23?27. In most studies, there were no adverse effects from aspirin, but in one study the incidence of antenatal, intrapartum and postpartum bleeding was increased 26. The results of the randomized studies have been criticized because the women examined were mostly at low risk for placental insufficiency. Three randomized studies have examined the value of prophylactic aspirin in women considered to be at high risk of pre-eclampsia and intrauterine growth restriction because they had increased impedance in the uterine arteries (Table 6) 28?30. The difference between the aspirin and placebo groups in the frequency of pregnancy-induced hypertension (13% vs. Fewer aspirin-treated than placebo-treated women had low birth weight babies (15% vs. The only perinatal death in the aspirin group followed a cord accident during labor, whereas the three perinatal deaths in the placebo group were all due to severe hypertensive disease. Those with persistently high resistance index or an early diastolic notch were randomized to aspirin (60 mg/day) or placebo. There was no significant difference in the incidence of intrauterine growth restriction (aspirin 26%, placebo 41%) or pre-eclampsia (aspirin 29%, placebo 41%), but severe pre-eclampsia (defined as a diastolic blood pressure of at least 110 mmHg with proteinuria of at least 300 mg/24 h or pre-eclampsia requiring treatment with intravenous antihypertensives and anticonvulsants) was significantly lower in the aspirin group (13%) than in the placebo group (38%). It was concluded that, in high risk pregnancy, low-dose aspirin commenced at 24 weeks may reduce the incidence of severe pre-eclampsia. An abnormal result (defined by a high resistance index and the presence of an ipsilateral early diastolic notch) was found in 186 women, and 102 of these agreed to randomization to either low-dose aspirin (100 mg/day) or placebo for the remainder of the pregnancy. Abnormal uterine artery flow velocity waveforms were associated with statistically significant increases in pre-eclampsia (11 vs. Prophylactic aspirin therapy did not result in a significant reduction in pregnancy complications. It was concluded that, although abnormal uteroplacental resistance at 18 weeks of gestation is associated with a significant increase in adverse pregnancy outcome, low-dose aspirin does not reduce pregnancy complications in women with uteroplacental insufficiency. Antioxidants Impaired placental perfusion is thought to stimulate the release of pre-eclamptic factors that enter the maternal circulation and cause vascular endothelial dysfunction. It was, therefore, hypothesized that early supplementation with antioxidants may be effective in decreasing oxidative stress and improving vascular endothelial function, thereby preventing, or ameliorating, the course of pre-eclampsia 31. In the intention-to-treat cohort, pre eclampsia occurred significantly more commonly in the placebo group (17% of 142 women) than in the vitamin group (8% of 141). These findings suggest that supplementation with vitamins C and E may be beneficial in the prevention of pre-eclampsia in women at increased risk of the disease. Multicenter trials are needed to show whether vitamin supplementation affects the occurrence of pre-eclampsia in low-risk women and to confirm these results in larger groups of high-risk women from different populations. Nitric oxide donors Nitric oxide, produced by the endothelium of blood vessels, is a potent vasodilator and inhibitor of platelet aggregation. Pre-eclampsia is associated with impaired production or function of nitric oxide and there is some evidence that treatment with the nitric oxide donor, glyceryl trinitrate, may reduce the prevalence or severity of this complication. Infusion of glyceryl trinitrate was associated with a dose dependent reduction in impedance to flow in the uterine arteries without a significant change in blood pressure, pulse rate or impedance in the umbilical artery or maternal carotid arteries. The effect of glyceryl trinitrate in this study may have been mediated by its placental transfer into the fetal vascular circuit, causing direct vasodilatation of the umbilical circulation. A similar effect has been shown using sublingual isosorbide dinitrate in healthy second-trimester pregnancy; umbilical and uterine artery impedances were lowered 35. Women were randomly allocated to receive transdermal glyceryl trinitrate 5-mg patches per day or equivalent placebo patches for 10 weeks or until delivery. The rates of pre-eclampsia, fetal growth restriction or preterm delivery were not significantly different in the two groups. The prevalence of high impedance at 20 weeks is about 2 3 times higher than at 24 weeks. Abnormal Doppler is better in predicting severe (birth weight below the 3rd centile or growth restriction requiring delivery before 35 weeks) rather than mild growth restriction. Uteroplacental blood flow velocity waveforms as predictors of pregnancy-induced hypertension. The value of Doppler assessment of the uteroplacental circulation in predicting preeclampsia or intrauterine growth retardation. Doppler assessment of the uterine and uteroplacental circulation in the second trimester in pregnancies at high risk for pre-eclampsia and/or intrauterine growth retardation: comparison and correlation between different Doppler parameters. Qualitative assessment of uteroplacental blood flow: early screening test for high-risk pregnancies. Doppler investigation of uteroplacental blood flow resistance in the second trimester: a screening study for pre-eclampsia and intrauterine growth retardation. Doppler ultrasound screening as part of routine antenatal scanning: prediction of pre-eclampsia and intrauterine growth retardation.
The lung field under a missing breast will appear a little darker than the other lung field treatment kidney cancer symptoms purchase oxybutynin visa. Difference in the Level of the Hemidiaphragms Right hemidiaphragm is normally a bit higher medications bad for your liver discount 5 mg oxybutynin with visa. Impaired mobility of diaphragm may be from paralysis of either phrenic nerve symptoms quitting smoking order oxybutynin 5 mg online, disease in abdomen such as a subdiaphragmatic abscess medications used to treat depression order oxybutynin once a day, pleurisy, pulmonary infarction, etc. Normal Position Distance from gastric bubble (if it is visible) to diaphragm should be very small. Heart and Great Vessels Size of Heart measure at widest point; compare to size of thorax; should be no more than 1/2 the width of the thorax. Then decide whether this width exceeds the distance from the midpoint (spine) to the inside of the rib cage (half the transthoracic diameter). Still more simply, you can measure from the midline to the right heart border and see whether that distance will fit into the piece of lung field to the left side of the heart. Assessment of the cardiovascular anatomy includes assessment of heart and chamber size as well as the position and size of the great vessels. Relative position of left and right main branches of pulmonary arteries in relation to left and right main bronchi. Upright most of perfusion goes to lower lungs so you should see it all the way out. Silhouette Sign 2 densities that are alike with margins adjacent to each other borders will be masked. Air Bronchogram Sign "butterfly" distribution of the abnormal densities or an anatomic distribution of abnormal densities restricted to lobar or sublobar portions of the lung. Temporally rapid (reckoned in days) changes in the appearance of the lung infiltrate. Demonstration of the air-filled bronchus as a radiolucent "tube" is dependent on its close association with alveoli that are fluid-filled rather than air-filled. Should not be able to follow airways any further out as they are very thin walled; if visible (air bronchogram sign) -? Heart and Great Vessels Assessment of the cardiovascular anatomy includes assessment of heart and chamber size as well as the position and size of the great vessels. Relative position of L and R main branches of pulmonary arteries in relation to L & R main bronchi K. Rotation of the patient produces appearance of widening of the heart and mediastinal shadows. Deformity of the thoracic cage severe scoliosis; depressed sternum (pectus excavatum) usually displaces heart to the left + right heart border not visible. Difference between heart volumes in systole and diastole usually not enough to affect rough estimate of the cardiothoracic ratio in adults. Mediastinal disease, pulmonary disease, or any density (consolidation, effusions, true mediastinal shift) may render the dimensions of the heart unobtainable. Rib notching = saucered erosions of the undersurface of the ribs where dilated intercostal arteries have developed as collateral pathways. Physiologic Analysis of the Pulmonary Vasculature appearance of the hilar and pulmonary vessels is an excellent indicator of the physiologic state of the heart. Pulmonary edema can also occur in noncardiac conditions such as fluid overload, renal failure, heroin overdose, and inhalation injury or burns. The echocardiogram is much more specific for identifying structural abnormalities and chamber enlargement. The echocardiogram also is very important for distinguishing hypertrophy from dilation and recognizing pericardial effusions. It has not had the test characteristics that were originally anticipated because calcification of the arterial walls is not necessarily a/w luminal occlusion, particularly in older individuals. Signs of pulmonary disease can suggest a noncardiac limitation to exercise and a large heart could suggest cardiac disease. However, finding problems that are often a/w arrhythmias, such as cardiac enlargement and lung disease, should alter one to the possibility of arrhythmias. Solitary Pulmonary Nodules Well-circumscribed, approximately round lesion that is < 4-6 cm. Calcification of the lesion, absence of a history of tobacco use, and age < 35 years are important factors that strongly correlate with benign nodules. Even benign calcification does not exclude the presence of coincidental malignancy in adjacent tissue or the subsequent degeneration of a previously benign process into a malignant lesion. Cavitating lesions, lesions with multilobulated or spiculated contours, and lesions with shaggy or extremely irregular borders tend to be malignant. The growth of a nodule is conventionally defined as the doubling time (time required for its volume to double) and corresponds to an increase in diameter by a factor of 1. In general, doubling times > 16 months or< 1 month are associated with benign processes. If a nodule has not increased in size over a 2-year period, the probability that it is benign is > 99%. Chronic disease abnormalities indistinguishable from fibrosing alveolitis are commonly found reticulonodular parenchymal infiltrates, dense fibrotic areas, and decreased lung volumes. Signs/Symptoms of Acute Exposure fever, chills, anorexia, shortness of breath, dry cough; tachypnea, pyrexia, tachycardia, dry basilar inspiratory rales without rhonchi; occasionally, cyanosis or restlessness indicating hypoxemia. Signs/Symptoms of Chronic Exposure shortness of breath, mild fever, weight loss, fatigue, malaise, dry cough, dyspnea on exertion, tachypnea; above signs +? Seen in disseminated interstitial diseases such as eosinophilic granuloma of the lung, scleroderma, pneumoconiosis (diseases caused by inhalation of organic or inorganic matter), idiopathic pulmonary fibrosis, sarcoidosis, and other, less common disorders. Seen in miliary tuberculosis, other fungal diseases (histoplasmosis), pneumoconiosis, histiocytosis X (early stage), pulmonary hemosiderosis (late stage) and primary amyloidosis. May represent a constant, irreversible finding in other interstitial disease, esp. Attributed to increased tissue and/or fluid accumulation in interlobular septa; also referred to as septal lines. Attributed to increased tissue and/or fluid accumulation in communicating lymphatics between veins and bronchi. May refer to a lack of crispness of the margins of structures initially giving rise to the linear densities within aerated lung. Caused by excessive tissue or fluid displacing air-filled lung from the interstitial structures. Principal exceptions are viral pneumonia, drug-induced pneumonia, and pulmonary edema. Presents acutely with chills, fever, quite severe dyspnea, and nonproductive cough within hours or days of the initiation of nitrofurantoin therapy. Apical redistribution of blood flow results in increased size of upper lung vasculature and background veiling of the pulmonary parenchyma initially. Subpleural edema, peribronchial cuffing, bronchiolar cuffing, hilar haziness, haziness of vessel detail, reticular pattern, and basilar septal lines. Kerley B lines are present at the periphery of the lung bases and may be quite prominent represent thickened interlobular septa. Usually, enlargement of the heart (if cardiogenic in origin) and redistribution of the pulmonary vasculature (appears esp. Intrathoracic lymphadenopathy (75%) Diffuse parenchymal disease (50%) Exclusively hilar lymphadenopathy initially (33%) Pulmonary disease without hilar lymph node enlargement (25%) Lung involvement varies from a miliary nodular pattern, to a reticulonodular pattern, to a purely reticular pattern (honeycombing). Progression to marked pulmonary fibrosis of bullous emphysema with disabling functional impairment, development of cor pulmonale, and death occurs in a small % of cases. Relatively fine network of reticular infiltrates (honeycombing); generally restricted to the lower lung zones. Radiologic demonstration of abnormalities of esophagus, duodenum, small bowel, or terminal phalanges more likely to be seen. Recurrent or chronic aspiration of ingested material may be underlying cause of pulmonary fibrosis. Individual cysts comprising the coarse reticular or honeycomb pattern are generally less than 5 mm in greatest dimension, although large cysts of up to 6 cm in diameter have been reported. Visualization of the more peripheral bronchi with air in them is usually not possible. Alveolar (consolidative) densities An abnormal density caused by the collapse or, more often, the filling of air spaces with abnormal material (blood, pus, water, protein, or cells).
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This approach to symptoms indigestion order oxybutynin 2.5 mg without prescription teaching uses specific patients to medicine of the prophet buy oxybutynin online pills illustrate particular illnesses treatment x time interaction discount oxybutynin master card, surgical procedures or interventions medications given for bipolar disorder oxybutynin 5mg line. Individual patients provide a starting point for a broader discussion which does not have to occur at the bedside and could continue later away from the wards. The bedside is also a good place to review clinical skills and specific physical findings. Traditionally, these rounds have been used for the instruction of junior doctors, but they can also be used for interdisciplinary teaching involving nursing, midwifery and pharmacy staff as well as medical officers. They also give patients and their families an opportunity to ask questions of all the people involved in their care. Any discussion of a patient on a bedside teaching round must be with the consent of the patient and should actively involve the patient. Formal educational rounds Unlike hand-over rounds or bedside teaching rounds, formal educational rounds are a clearly educational event and are separate from the service work of running the wards. They can be organized on a regular basis or when guests with unique experience or expertise are on site. Morbidity and mortality meetings Morbidity and mortality meetings are a periodic review of illness and deaths in the population served by the hospital. A systematic review of morbidity and mortality can assist practitioners in reviewing the management of cases and discussing ways of managing similar cases in the future. It is essential that discussions of this kind are used as a learning activity and not as a way of assigning blame. Team training in critical care practice If your hospital has a dedicated area to receive emergency patients, it can be helpful to designate time each week for staff to practise managing different scenarios. Have one person pretend to be the patient and work through all the actions and procedures that should take place when that patient arrives at the hospital. Rehearsing scenarios gives people a chance to practise their skills and working together as a team. As a group, decide what roles are needed and what tasks are required of each person. Once this has been decided, post this information for easy reference during a real emergency. The Annex: Primary Trauma Care Manual provides a structured outline for a short course in primary trauma care that can be used for staff, including medical, nursing and paramedical staff. If the hospital has a visitor who 1 offers teaching on a specific topic, or if people present useful information at educational rounds, designate someone to make notes and include them in the library. Designate a specific person to be responsible for the care and organization of the collection, including making a list of materials and keeping a record of items that are borrowed in order to ensure their return. Make known your interest in developing a library of learning materials to any external organizations or donor agencies with whom your hospital has contact and make specific requests and suggestions for books, journals and other resources. This requires well trained staff performed All records should be clear, as well as secure and dedicated space. Records are confidential and should be available only to people involved directly in the care of the patient. Even if your hospital maintains records, each patient should receive a written note of any diagnosis or procedure performed. If a woman has had a ruptured uterus, for example, it is essential that she knows this so that she can communicate this information to health care providers in the future. All members of the health care team are responsible for ensuring that records are: Complete Accurate Legible and easily understood Current, written at the time of patient contact, whenever possible Signed, with the date, time, name and position of the person making the entry. Standardized forms save time and encourage staff to record all required information. A theatre record usually includes: Patient identity Procedure performed Persons involved Complications. By looking at records of all procedures, a hospital can evaluate occurrences such as complications and postoperative wound infections or review the type and number of procedures being performed. Such evaluation, which should be the regular duty of one member of the hospital team, permits assessment of the application of aseptic routine within the hospital and allows for future planning. Delivery book the delivery book should contain a chronological list of deliveries and procedures, including interventions, complications and outcomes. It may contain some of the same information that would be included in a theatre record. Postoperative note All patients should be assessed at least once a day, even those who are not seriously ill. See Unit 3: the Surgical Patient for more detailed guidance on preoperative, 1 operative and postoperative notes. Standard operating procedures Create and record standard operating procedures for the hospital. Keep copies of these procedures in a central location as well as the place where each procedure is performed so they are available for easy reference. Interhospital communication Each patient who is transferred to another hospital should be accompanied by a letter of referral which includes: Patient identity Name and position of the practitioner making the referral Patient history, findings and management plan to date Reason for referral. With any change: Plan (observe, consult and At a district hospital, the act of evaluation will generate information that will set goals) enable a judgement to be made on whether the hospital is providing high Implement the change Evaluate the outcome. Evaluation is part of a continuous loop of information gathering, analysis, planning, intervention and further evaluation and involves the following steps. Evaluation may be as simple as asking the question Are all babies weighed in the outpatients department? For example, a hospital recognizes that it has very high postoperative wound infection rates. All potential sources and causes of postoperative infection are studied and, after careful review and consultation, a plan is developed and implemented. After a defined period of time, a review of postoperative wound infections is again undertaken as a measurement of observed achievement. If there has been a drop in the infection rate, the team can decide whether the desired outcome has been achieved and whether the measures taken should be adopted as regular practice. By changing only one thing at a time, it is possible to determine whether any improvement is related to the intervention. If the intervention does not result in the desired change, it is important to identify why it has been unsuccessful before trying another intervention. Chart audit Patient charts contain important information about individuals, their illnesses and course in hospital. If records are kept after patients have been discharged, a chart audit can assist in monitoring the services provided by a hospital, diagnosing areas of concern and identifying areas for improvement, including: Consistency of approach Infection rates Length of patient stay Transfusion rates Complication rates. After a period of time, a second chart review can be undertaken, the change evaluated and adjustments made to practice. Each country should have a national disaster plan, but it is the responsibility of the district hospital to plan and prepare for disaster situations at the local level. Disaster planning requires consultation and discussion to develop a realistic plan, made in advance, that anticipates a time when it will be too late to plan. It is impossible to anticipate every situation, but a disaster plan should include: Designating a senior person to be team leader Defining the roles and responsibilities of each member of staff Establishing disaster management protocols Setting up systems for: Identification of key personnel Communication within the hospital Calling in extra staff, if required Obtaining additional supplies, if required Triage 1?17 Surgical Care at the District Hospital Communicating patients triage level and medical need Transportation of patients to other hospitals, if possible Mapping evacuation priorities and designating evacuation facilities 1 Identifying training needs, including disaster management and trauma triage, and training staff Practising the management of disaster scenarios, including handling the arrival of a large number of patients at the same time Establishing a system for communication with other services, authorities and agencies and the media. In the event of a local disaster, such as a major road traffic accident involving many persons, systems will then be in place. These will help the staff on duty to deal with a sudden and dramatic increase in need for services and to summon help to deal with such a situation. It is vital to develop a written disaster plan if your hospital does not yet have one. Ensure that it is reviewed regularly and that staff practise implementing it using different scenarios so that any problems can be identified and resolved before a real disaster occurs. Triage Triage is a system of making a rapid assessment of each patient and assigning a priority rating on the basis of clinical need and urgency. It is not helpful to spend huge amounts of time and resources on individuals whose needs exceed the services available, especially if this is at the expense of other patients who could be helped with the skills and resources available locally. A trauma team that is experienced in working together in times of stress and urgency is also an important part of the disaster plan. Identify the different jobs to be undertaken in an emergency and ensure that all members of the team know what those roles are and are trained to perform their own role. The area in which emergency patients are received should be organized so that equipment and materials are easy to find. It is helpful to make a map showing where in the room/area people need to be stationed and the jobs that are associated with the different positions. Team leader A team leader should be designated to take charge in a disaster or trauma situation.