By L. Hassan. Sam Houston State University.
Recovery from substance use disorders • being caught drinking or self-administering drugs means improved physical hydroxyzine 10mg without a prescription, psychological buy generic hydroxyzine 25 mg online, social generic hydroxyzine 25mg with mastercard, familial generic hydroxyzine 10mg on-line, oc- at work, cupational and even spiritual health. It falls to each physician to protect the well-being of their col- leagues, to be watchful for signs of drug and alcohol problems, Intervention and to be prepared to respond. Waiting until a physician with a substance use problem asks for help, if that time ever comes, can have tragic results. We must pay attention to signs of distress in our colleagues, respecting Case resolution our own visceral empathy and formulating an intervention plan The resident’s colleague alerts the chief resident and as soon as possible. At the least, one or two friendly colleagues program director of her concerns discreetly. They can mediately meet with the resident and request that they make time to talk, offer helpful suggestions and resources, and proceed to the emergency room for an assessment. They can do this without needing to know resident complies, and it becomes clear that the resident with certainty just what the problem might be. The physician health program is notifed, and arrangements are made for an urgent assessment. The If this intervention is rejected or proves to be unhelpful, the resident is placed on medical leave. Two or of treatment, the resident is able to return to work, more individuals, respected by the physician and in a position participate in treatment services and health monitoring, of authority, must intervene in a timely, planned and rehearsed and enjoy a full recovery. They should offer their observations of concern, pref- offers to conduct a course for earlier stage intervention as erably in documented form, and frmly request an expert this resident’s condition should have been identifed and clinical assessment—or immediate treatment, if the physician diagnosed by their colleagues sooner. Physician substance abuse and addiction: Time away from clinical duties or other work will often Recognition, intervention and recovery. Ontario Medical Review; be required, both to enable the physician to recover and to October 2002; 43-7. Yet, they provide good physician-patient • describe the inherent challenges of caring for physician relationships and relationship-centred care for their patients. The treating physician and the physician patient can both con- tribute challenges to good care. Perhaps the physician patient in other Case circumstances was their teacher, or has an impressive reputa- A second-year resident is stunned to receive a complaint tion for a particular area of expertise. Physician-providers are about the care offered to a physician patient in the emer- encouraged to draw upon Richard Frankel’s model of com- gency department the week before. The patient had pre- munication in health care and consider the following when sented with chest pain in the context of a recent history of providing care to a colleague (Maier 2008): angina and a strong family history of cardiac disease. Breathe and remember physician patient reported that the resident was abrubt, that an important part of developing rapport is setting the judgemental and dismissive during their encounter. Elicit the patient’s concerns and listen without interrupt- diagnosis brief and the discharge planning suboptimal. As with other patients, the most important The resident remembered the encounter and indicated concern may only be brought up after the third concern that, since the patient was a physician, the resident did is presented. Don’t assume that physician patients need less explana- recommendations as with other patients. Remember that a physician’s knowledge of therapeutics in an area of practice not his or her own Introduction quickly become dated after medical school. Intellectualizing for your own self-comfort or being drawn helping doctors,” or “extending professional courtesy,” caring into talking shop is not in the best service of your pa- for colleagues is an important tradition in medicine. They may quoted maxim that “The physician who treats himself has a have specifc ideas or concerns that are not shared by other fool for a patient. What does it mean to “immi- Within our current medical culture there is clear endorsement grate to the nation of the sick? For • Physicians should have a family physician and an age- example, not all physicians are fnancially sound or have appropriate health assessment as an occupational overhead and/or disability insurance. Thoroughness, including a complete physical examination, • Physicians should not self-medicate through self- cannot be sacrifced. Physicians are observant and expect prescribing, the sample cupboard or workplace supplies. It provides comfort and trust in the physician– Robert Klitzman has invited physicians to be aware of “post- patient relationship. The demonstration of empathy is as important as in other and denying symptoms, worrying too little, self-diagnosing and physician–patient relationships. Physicians worry about the transforma- colleagues we need to be aware of our own reactions. At times, particularly if they our physician patient’s response to illness close to home? The end of the visit should involve more than education, Case resolution involvement in decision-making and enquiring whether The program director reviewed some of the key prin- your patient got what they needed. As treating physicians ciples involved in treating colleagues and the importance we need to be clear and explicit about our practice with of maintaining appropriate roles and boundaries in such regard to prescriptions, consultations and investigations. The resident acknowledged being irritable, not download the physician roles and responsibilities to fatigued and hungry that evening after being on call your physician patient. We all deserve confdentiality and privacy in our health ing in the emergency room for a second opinion refused. However, we may also need to refect with our physi- The resident and program director discussed a mutually cian patient on how privacy issues or maintaining secrets agreeable approach to address the complaint. This may be especially relevant when physician patients the frustration, fear, and disappointment the patient had are suffering from diseases of degeneration (including experienced. As a result, the resident gained a deeper aging), psychiatric illness or substance use disorders. We must be aware that illness is not unprofessional conduct and that there is a difference between illness and impairment. Physicians for physicians: when doctors be- treatment are as effective for physicians as they are for come patients. In caring for our colleagues we would do well to remember the words of Rabia Elizabeth Roberts: “We learn that our human- ity is more powerful than our expertise alone” (Hanlon 2008). Richard Gunderman would invite us to adopt our part of the highway and to care for one another as colleagues the best way we can. By practising the best kind of philanthropy; the result will beneft the health of all our patients. If a physician is diagnosed with a reportable condi- tory agency, tion, the treating physician is required to report the case to the • outline the consequences of a failure to report, and individual or offce designated in the legislation. Residents who • identify sources of support to guide decision-making in are being treated for serious health issues must also consider this area. A number of colleges include questions Case on licence applications or renewal forms pertaining to alcohol A third-year resident involved in treating a surgeon in or drug dependence and any physical or mental conditions Manitoba is aware that the surgeon suffers from alcohol that might affect ftness to practise. The resident suggests that the surgeon not per- more information in these circumstances. The surgeon continues to practise medicine, Reporting a physician who is not a patient but has assured the resident that they do not drink or take Residents may also have an ethical and legal duty to report a drugs before performing surgeries. What are the resident’s colleague to their governing college in certain circumstances, obligations in the circumstances? Introduction Most statutes and policies require the reporting physician to Reporting another physician to a medical regulatory authority have reasonable grounds for reporting. Terms such as incom- (college) or public health offcial can be diffcult and stressful, petence, incapacity or unft are commonly used in this context particularly for postgraduate trainees or those who supervise but are not typically defned in the pertinent statute or policy them. Some jurisdictions have adopted specifc reporting require- ments for certain conduct issues, such as suspected sexual Residents may become aware of these concerns in the course impropriety by another physician toward a patient. Such an of treating other physicians or through day-to-day contact with obligation most often arises when the physician has reason- colleagues. This section is intended to help residents cope with able grounds, based on information obtained in their medical the stress that arises from uncertainty about their obligations practice, to believe that another physician (whether a patient to report impairment in their colleagues. Some colleges have also adopted policies imposing mandatory reporting ob- Reporting a physician who is your patient ligations in such cases. Various provinces and territories have conduct by other physicians, including so-called disruptive be- also enacted legislation that legally requires physicians to report haviour, to an appropriate authority in the institution, often the a colleague to their governing college in circumstances when chief of the department. Physicians may also have a duty to health issues render the physician patient unft to practise. The Canadian Medical Association’s Code recommended and reasonable treatment, such as medications, of Ethics states that physicians are ethically bound to report safety precautions or a leave of absence.
But medical science undeservedly took and received the greatest credit and public acclaim for these tremendous health improvements purchase hydroxyzine mastercard. And the medical community today is still trying to convince us that no matter what goes wrong with our bodies best 10mg hydroxyzine, the solution will always be found within the realm of drugs and surgery generic hydroxyzine 10 mg with mastercard. Western culture made a grave error when it eliminated all natural approaches to health in favor of drugs and surgery buy hydroxyzine with visa. And as Beasely points out, it was extremely ironic that even though modem science has proven the importance and impact of such common sense factors as diet and relaxation on health, the medical community and consumers have almost completely ignored these findings. Medical scientists have proven the medical efficacy of natural urine and urea over and over again, but the medical community and drug companies have completely ignored these research findings – unless of course, a patentable drug form of urine such as Pergonal or Urokinase, can be developed. During this century, researchers sat in their laboratories and watched as simple urea or whole urine completely destroyed rabies and polio viruses, tuberculosis, typhoid, gonorrhea, dysentery bacteria and cáncer cells. They found that urine contains a huge array of incredibly valuable and medically important elements and they injected and orally administered urine and urea to thousands of patients in clinical tests. They watched as it saved the lives of cancer patients, cured and relieved asthma, eczema, whooping cough, migraines, diabetes, glaucoma, rheumatoid arthritis, and a host of other illnesses. Doctors and consumers today are given access to urine-related drugs, but have no idea of the tremendous overall value and health benefits of the natural urine that the drug was derived from. And medical researchers see absolutely no reason why any of us should know about it. Unlike naturally occurring medicines, chemical drugs are extremely concentrated synthetic substances. Yes, these abnormally high concentrations may seem to produce a "knock-out punch" to 40 disease symptoms, but what good is it if the drug delivers the same knock-out punch to your health as a whole? And one of the biggest reasons for this failure is that these modem epidemics are immune deficiency diseases which cannot be treated by immune-suppressing therapies such as drugs and surgery. They seem to temporarily win the battle against the symptoms of illness, but in the end they lose the wax because they suppress and destroy the very thing that makes and keeps us well – our own natural body defenses. Natural urine therapy was abandoned and forgotten by the public in the twentieth century because we were so sure that drugs and surgery were the answers to all our health problems. As we watch the often terrible and fatal consequences of decades of complete reliance on immune-suppressing synthetic drugs and surgical techniques unfold, we worriedly search the pages of history to rediscover and relearn the lost arts of caring for ourselves with simple, safe. Urine therapy is a natural therapy that is not widely known today, but in reality, it is not a lost healing art. As the material in this book shows, urine therapy has been kept very much alive by modem medical science throughout the twentieth century, even though it has rarely been publicized. In reality,-urine therapy cannot even be accurately classed as a traditional folk- remedy today, because during the twentieth century it has been used almost 41 exclusively by mainstream medical scientists and researchers and not by consumers themselves, but this is changing. So, in conclusion, it is the "surgery and drugs are all we need" philosophy of the present conventional medical system that is one major reason why you and your doctors have never heard of mine therapy. The reality is that medical researchers are not the ones who ultimately decide what medical treatments the public receives as a result of medical research studies. Medical research requires funding and from the very beginning of the age of modem medicine, researchers have largely depended on pharmaceutical companies to supply those funds. So many times we hear what the companies, and not the researchers, want us to hear about research discoveries. Now, while the owners of these drug companies may have had some altruistic interests, the lifeblood of their companies was not medicine, but money. And in simple economic terms, this is how any business survives and prospers — by selling and promoting the products that make the most money. Pharmaceutical firms by their very nature must promote profit-making medicines to keep their companies alive. The way our medical system works today, drug companies are the primary entities that fund research, and test and prepare medical treatments for government approval, and this is also true in many countries throughout the world. So a pharmaceutical company has to promote the medical approaches that will assure big "pay offs" in order for the company to survive. Metabolic synthetic steroids, once hailed as miracle muscle- builders and used freely, are now killing and maiming many of their users. Aspirin was considered to be the ultimate miracle fever and pain reducer until it was discovered that it causes the Reyes syndrome that can kill children and can also cause severe abdominal bleeding in adults. In a regrettable Catch-22, the main sources of information for the regulation of the pharmaceutical industry are the companies themselves. Despite the conflict of interest inherent in such situations, drug companies continue to be the major fonder of research on most common diseases and their potential treatment. And it is no surprise that the research focuses on finding new chemical methods of managing disease — or at least symptoms. Robbins or SmithKline or Ciba-Geigy to fund research on therapies (such as nutrition) that cannot be patented and will not significantly increase their market share? For example, 44 urea, has been shown to be a much safer, simpler, less expensive and more effective diuretic than the diuretic drug, Diamox (see Urea — New Use Of An Old Agent, next chapter). There are numerous research studies proving the effectiveness, safety and diverse medical applications of herbs, yet any conventional doctor you talk to will tell you that herbal medicine is ridiculously unscientific and ineffective. For instance, the herb Cinchona was originally used for treating malaria and has been clinically proven to be just as effective as the synthetic drug quinine - and the herb is safe and non-toxic. But even though millions of pounds of Cinchona were imported for medical use into the U. Because synthetic drugs, unlike herbs or other simple medicines, can be patented and sold for much more profit. But urea itself is extremely inexpensive and non-patentable so the truly important and often astounding medical breakthroughs using simple urea in research studies have never been given proper recognition, even though the researchers themselves have often stressed its importance and made repeated but unsuccessful attempts to bring the information to the attention of the medical community. Consumers, and especially doctors, over the last 50 years have been thoroughly and completely indoctrinated with the "a drug a day keeps disease away" promotion of the drug companies, and have neglected the simpler, safer methods like natural urine or urea therapy. And like the uninformed health-care consumers that so many of us are, we believe them. On the other hand, of the more than edicin that are available to anyone at anytime off any drug store or grocery store shelf, only 1/3 of them have ever been demonstrated to be safe or effective and all are proven to have dangerous potential side effects and overdoses can even cause death. So you are not only wasting your money when you buy products with such ingredients, but you are also risking your health and that of your family. William Gilbertson, only “about 1/3 of the ingredients reviewed by the panels have been shown to be safe and effective for their intended uses. You are listened to (sometimes), examined, tested and then the doctor usually writes one or more prescriptions for you. Neither you nor, in some instances, even your doctor realices that one out of every eight prescriptions filled. Since all drugs involve risks, this lack of effectiveness means you are exposing yourself to dangers without gaining compensating benefits. In other words, balancing the benefits versus the risks, these drugs are not soft. Unfortunately, consumers in many cases are learning this error in medical thinking the hard way. The federal Food and Drug Administration, which had given approval for the human trials is investigating what went wrong. The best-known example was the tragedy of thalidomide, the tranquilizer that resulted in thousands of deformed children in Europe and Great Britain. Yet the pharmaceutical industry continues to produce and market drugs that have the potential to cause a comparable tragedy. Advertisements on television or in magazines, they say, have left the impression that there is a pill to make every pain or problem go away… But consumers may nevertheless find themselves in the doctor’s office either for complications arising from prolonged use of over-the-counter drugs themselves or for failing to recognize the [underlying] presence of a more serious illness. But one important thing we have to remember in caring for ourselves is that there is no such thing as a generalized body or a specific cause for every illness. And in reality, there is no such thing as a completely conclusive doubleblind drug study because no two people are exactly the same even if they happen to have the same disease. As a result, no double- blind drug study is ever going to be completely objective or ultimately prove how a drug will affect everyone who takes it, which is another reason why drug fatalities and unforeseen side effects occur. But the truth is that urine therapy is proven and is safe, far more so than chemical drugs. When it comes to personal health there are innumerable variables or differences in individual body chemistry, absorption rates, reactions, etc. But it is this fact that each body is so different that makes whole, natural urine so tremendously valuable as a medicine.
Adolescents cheap hydroxyzine online american express, social support and help-seeking behaviour: an international literature review and programme consultation with recommendations for action 25mg hydroxyzine fast delivery. Reducing by half the percentage of late-stage presentation for breast and cervix cancer over 4 years: a pilot study of clinical downstaging in Sarawak discount generic hydroxyzine canada, Malaysia safe 10 mg hydroxyzine. Planning and implementing palliative care services: a guide for programme managers. Improving healthcare empowerment through breast cancer patient navigation: a mixed methods evaluation in a safety-net setting. An mHealth model to increase clinic attendance for breast symptoms in rural Bangladesh: Can bridging the digital divide help close the cancer divide? Improving breast cancer control via the use of community health workers in South Africa: a critical review. Patient-centered cancer treatment planning: improving the quality of oncology care. Planning and developing population-based cancer registration in low- and middle-income settings. Prohibition of advertisement of certain drugs for treatment of certain diseases and disorders. Prohibition of advertisement of magic remedies of treatment of certain diseases and disorders. Venereal diseases, including syphilis, gonorrhea, soft chancre, venereal granuloma and lymphgranuloma. Many of the ideas expressed here emerged from discussions at a meeting among the authors in Naples, Florida, in December 2006 that was sponsored by the University of Alabama at Birmingham with support from the Paul Mongerson Foundation. Statement of Peer Review: All supplement manuscripts submitted to The American Journal of Medicine for publication are reviewed by the Guest Editor(s) of the supplement, by an outside peer reviewer who is independent of the supplement project, and by the Journal’s Supplement Editor (who ensures that questions raised in peer review have been addressed appropriately and that the supplement has an educational focus that is of interest to our readership). Author Disclosure Policy: All authors contributing to supplements in The American Journal of Medicine are required to fully disclose any primary ﬁnancial relationship with a company that has a direct ﬁscal or ﬁnancial interest in the subject matter or products discussed in the submitted manuscripts, or with a company that produces a competing product. I believe that the accuracy of diagnosis can be sis and Treatment Foundation to improve the accuracy of best improved by informing physicians of the extent of their medical diagnosis. The foundation has sponsored pro- own (not others’) errors and urging them to personally take grams to develop and evaluate computerized programs steps to reduce their own mistakes. My role was insigniﬁ- ity inadvertently reduces the attention they give to reducing cant, but as the result of much work by many people, their own diagnostic errors. This clearly more accepting of computer assistance and this supplement to The American Journal of Medicine, which movement is accelerating. Graber’s compre- However, in 2006, I became worried after questioning hensive review of a broad range of literature on the extent of my personal physicians as to why they did not use comput- diagnostic errors, the causes, and strategies to reduce them, ers for diagnosis more often. However, I had read that studies of diag- and developed a framework for strategies to address the nostic problem solving showed an error rate ranging from problem. The physicians attributed the higher error rates our understanding of the causes of errors and the strategies to “other” less skilled physicians; few felt a need to improve to reduce them. In my view, diagnostic Hopefully this set of articles will inspire us to improve error will be reduced only if physicians have a more realistic our own diagnostic accuracy and to develop systems that will provide diagnostic feedback to all physicians. Schiff explicates the numerous barriers errors in medical practice, especially in medical diagnosis. Graber identiﬁes stakeholders convincingly demonstrate that we physicians lack strong interested in medical diagnosis and provides recommenda- direct and timely feedback about our decisions. The ex- other words, the average day does not confront us with our ception is the case already recognized to be miserably com- errors. Its purpose was to increase the likelihood that decision making as it relates to diagnostic error and over- the correct diagnosis appeared on the list of differential conﬁdence, which is expanded upon by their colleagues. Pat Croskerry and Geoff Norman ingly apt (and offered free of charge by Missouri Regional review 2 modes of clinical reasoning in an effort to better Medical Program), the system produced many astonishing understand the processes underlying overconﬁdence. Wears highlight gaps in garding “tough” cases, but no rush to employment or major knowledge about the nature of diagnostic problems, empha- changes in mortality rates. Clearly, many experts are con- these present efforts to study diagnostic decision making cerned about these processes. In closing, I applaud espe- professional or lay reader who thinks it is easy to bring cially the suggestions to systematize the incorporation of the medical decision making closer to the ideal. Schiff in lems likely will not get better until the average day does the fourth commentary, “Learning and feedback are insep- confront us with our errors. This analytic review concerns the exceptions: the times when these cognitive processes fail and the ﬁnal diagnosis is missed or wrong. We argue that physicians in general underappreciate the likelihood that their diagnoses are wrong and that this tendency to overconﬁdence is related to both intrinsic and systemically reinforced factors. We present a comprehensive review of the available literature and current thinking related to these issues. The review covers the incidence and impact of diagnostic error, data on physician overconﬁdence as a contributing cause of errors, strategies to improve the accuracy of diagnostic decision making, and recommendations for future research. In that survey, 35% 1 —Fran Lowry experienced a medical mistake in the past 5 years involving 2 themselves, their family, or friends; half of the mistakes were Mongerson describes in poignant detail the impact of a described as diagnostic errors. Interestingly, 55% of respondents listed veys of patients have shown that patients and their physi- misdiagnosis as the greatest concern when seeing a physician cians perceive that medical errors in general, and diagnostic in the outpatient setting, while 23% listed it as the error of most errors in particular, are common and of concern. Concerns about medical errors stance, Blendon and colleagues surveyed patients and phy- also were reported by 38% of patients who had recently visited sicians on the extent to which they or a member of their an emergency department; of these, the most common worry family had experienced medical errors, deﬁned as mistakes 5 was misdiagnosis (22%). For this reason, we have Statement of author disclosures: Please see the Author Disclosures reviewed the scientiﬁc literature on the incidence and im- section at the end of this article. Department of Health Services Administration, School of Health Profes- In the latter portion of this article we review the literature on sions, University of Alabama at Birmingham, 1675 University Boulevard, Room 544, Birmingham, Alabama 35294-3361. In 1 such generally lowest for the 2 perceptual specialties, radiology study, the pathology department at the Johns Hopkins Hos- and pathology, which rely heavily on visual interpretation. A similar study at ology and anatomic pathology probably range from 2% to Hershey Medical Center in Pennsylvania identiﬁed a 5. The typically low error rates in these specialties should not be expected in those practices in tissues from the female reproductive tract and 10% in and institutions that allow x-rays to be read by frontline cancer patients. Certain tissues are notoriously difﬁcult; for clinicians who are not trained radiologists. For example, in example, discordance rates range from 20% to 25% for 21,22 a study of x-rays interpreted by emergency department lymphomas and sarcomas. A study of admissions to dance rate in practice seems to be 5% in most British hospitals reported that 6% of the admitting diag- 25,26 cases. The emergency department requires Mammography has attracted the most attention in re- complex decision making in settings of above-average un- gard to diagnostic error in radiology. The rate of diagnostic error in this arena variability from one radiologist to another in the ability to 14,15 ranges from 0. A recent study of breast cancer found that the nostic error in clinical medicine was approximately 15%. In diagnosis was inappropriately delayed in 9%, and a third this section, we review data from a wide variety of sources 29 of these reﬂected misreading of the mammogram. Several studies have ex- frequently recommending biopsies for what turn out to be amined changes in diagnosis after a second opinion. Given the differences regarding insurance 17 coverage and the medical malpractice systems between and associates, using telemedicine consultations with spe- cialists in a variety of ﬁelds, found a 5% change in diagno- the United States and the United Kingdom, it is not sis. There is a wealth of information in the perceptual surprising that women in the United States are twice as specialties using second opinions to judge the rate of diag- likely as women in the United Kingdom to have a neg- 30 nostic error. It is important to emphasize that only a fraction of the 18,27,31–46 studies that have measured the rate of diagnos- discordance in these studies was found to cause harm. An unsettling consistency emerges: the frequency of diagnostic error is disappoint- Dermatology. For exam- tions and disorders where rapid and accurate diagnosis is ple, in a study of 5,136 biopsies, a major change in diag- essential, such as myocardial infarction, pulmonary em- nosis was encountered in 11% on second review. Of6 at ien t w ho died o fp ulm o n ar y em b o li m , he diagn o s i w as n o t us ect ed clin ically in L eder le et al( up ur ed ao r ic an eur ys m eview o fallcas es at a in gle m edicalcen t er o ver a yr er io d. Of2 cas es in vo lvin g ab do m in alan eur ys m s vo n o do li ch et al diagn o s i o fr up ur ed an eur ys m w as in iially m i ed in in at ien t es en t in g w ih ches ain , ( diagn o s i o fdi ect in g an eur ys m o ft he p o xim alao r a w as m i ed in o fcas es E dlo w Sub ar achn o id hem o r hage Up dat ed eview o fp ub li hed udies o n ub ar achn o id hem o r hage: ar e m i diagn o s ed o n in iialevaluat io n B ur o n et al( an cer det ect io n ut o p y s udy at a in gle ho s ial o ft he 2 m align an t n eo p las m s fo un d at aut o p y, w er e eiher m i diagn o s ed o r un diagn o s ed, an d in o ft he cas es he caus e o fdeat h w as judged o b e r elat ed o he can cer B eam et al( eas can cer accr edied cen t er agr eed o eview m am m o gr am s o f7 w o m en , o fw ho m had b r eas can cer he can cer w o uld have b een m i ed in M cG in n i et al( elan o m a Seco n d eview o f5 b io p y s am p les diagn o s i chan ged in fo m b en ign o m align an t fo m m align an t o b en ign , an d had a chan ge in um o r gr ade) Per li i o lar di o r der The in iialdiagn o s i w as w r o n g in o fp at ien t w ih b i o lar di o r der an d delays in es ab li hin g he co r ect diagn o s i w er e co m m o n G affet al( en dicii et o s ect ive s udy at ho s ial o fp at ien t w ih ab do m in alp ain an d o p er at io n s fo r ap en dicii Of1 p at ien t w ho had ur ger y, her e w as n o ap en dicii in o f9 at ien t w ih a ﬁn aldiagn o s i o f ap en dicii he diagn o s i w as m i ed o r w r o n g in R aab et al( an cer at ho lo gy The feq uen cy o fer o r in diagn o s in g can cer w as m eas ur ed at ho s ial o ver a yr er io d.
Information marked on carcase tags should include: name order discount hydroxyzine, address and telephone number of the person submitting the carcase collection site date reference number whether the animal was found dead or euthanised (plus method of euthanasia) brief summary of clinical signs generic hydroxyzine 10mg with visa. Tissue samples taken into plastic bottles should be labelled on the outside of the bottle or a piece of masking tape placed around the tube purchase hydroxyzine 10 mg. The label should include: date type of animal from which the sample came the type of tissue reference number purchase genuine hydroxyzine line. Do not insert tags into bottles or bags with samples as they may contaminate the sample. Preservation of specimens Chill or freeze all specimens depending on the length of time it will take for them to reach a diagnostic laboratory (understanding that chilled is preferable), unless they are chemically fixed, in which case samples can be kept at ambient temperature. Freezing can damage tissue or kill pathogens and hence reduce options for diagnosis. However, if samples must be held for more than a few days they should be frozen on the day of collection to minimise decomposition. Chapter 2, Field manual of wildlife diseases: general field procedures and diseases of birds. Where samples need to be chilled or frozen an understanding of the concept of the ‘cold-chain’ is required. This refers to the need for samples to remain at the desired temperature and not to experience cycles of change (e. The requirements for sample packaging and shipment vary between countries and diagnostic laboratories. It is, therefore, essential to contact the laboratory that will analyse samples to find out any specific shipping requirements as early as possible in the procedure. This will help with processing samples upon their arrival at the laboratory and reduce the risk of sample quality being compromised. Transporting and/or shipping samples must not pose a biosecurity or human health risk. Seek advice from veterinary authorities about safety and regulations for transporting and shipping samples. The most important considerations for successful sample transport and shipment are: prevent cross-contamination between specimens prevent decomposition of the specimen prevent leakage of fluids preserve individual identity of specimens properly label each specimen and the package in which they are sent. Prevent breakage and leakage Isolate individual specimens in their own containers and plastic bags. Protect samples from direct contact with coolants such as dry ice or freezer blocks. Ensure that if any sample breaks or leaks the liquid does not leak to the outside of the package by containing all materials inside plastic bags, or other leak-proof containers, where possible. Containing specimens The plastic bags for containing specimens need to be strong enough to resist being punctured by the materials they hold and those adjacent to them. Polystyrene boxes within cardboard boxes are useful for their insulating and shock absorbing properties. If polystyrene boxes are not available, sheets of this material can be cut to fit inside cardboard boxes with a similar effect (though the package is less leak-proof). The strength of the cardboard box needs to be sufficient for the weight of the package. If hard plastic or metal insulated boxes are used for transport, cardboard boxes around them can be used for protection and to attach labels. It is possible to make ice packs by freezing water inside a plastic bottle that is sealed (not filled completely and taped closed to prevent the top coming off in transit) and then placed in a sealed plastic bag to further prevent leakage. If frozen carcases are being transported they can act as a cool pack for other samples sent in the same container. When using ice packs they should be interspersed between samples to achieve a uniform temperature throughout. When submitting dead fish for post mortem examination they should be wrapped in moist paper to prevent them drying out and then refrigerated but not frozen. Fish decay very quickly but a fish refrigerated soon after death may be held for up to twelve hours before examination and sample fixation. Keeping samples frozen Dry ice (solid carbon dioxide) or in some circumstances liquid nitrogen can be used to ship frozen specimens. The gaseous carbon dioxide given off by dry ice can also damage some disease agents and this must be considered before using it for tissue transport. As the volume of both dry ice and liquid nitrogen expand as they change to gas, specialist containers that allow for this expansion are needed for their transportation. Note: Shipment of formalin, dry ice, liquid nitrogen and alcohol is regulated in many countries and must be cleared with a carrier before shipping. Samples preserved in formalin, other chemical fixative or alcohol can be transported without chilling. Shipping It is important to pack any space within packages with a substance such as newspaper which will prevent movement of containers, act as a shock absorber and may also soak up any potential leakages. Packaging and labelling Packaging and labelling of specimens must conform to the regulations of the country from which the package is sent and also those of the country in which it will be received (if it is being sent to a laboratory in another country). It is important to mark the outside of the package with the required labelling regarding the type of specimen being transferred and where necessary the method of cooling (e. Advice from national authorities about permit requirements must be sought prior to collection and transportation of samples. Carriers Samples should be shipped where possible by carriers that can guarantee 24-hour delivery to the diagnostic laboratory. Where possible arrange for collection of sample packages from the point of origin to avoid delays. When shipping arrangements have been made, contact the diagnostic laboratory to provide them with further details including estimated time of arrival and any shipping reference numbers. Chapter 3, Field manual of wildlife diseases: general field procedures and diseases of birds. Detailed field observations during the course of an outbreak and information about events preceding it, may provide valuable data on which to base a diagnosis and corrective actions. It is important for the information gatherer to keep an open mind about the potential cause of the problem. Some information which may seem irrelevant in the field may become very important when piecing together the events leading up to an outbreak. A thorough chronology of events is key to diagnosis and disease control operations, and is almost impossible to obtain some time after the outbreak has occurred. A key concept is that of explaining to the diagnostician how the affected individuals relate to the whole population at risk. As an example, 100% of the dead animals may be adult males but the population present (i. How to record data It is important to record as much relevant information as possible as soon as events unfold. Photographs and video footage can quickly convey specific information such as land use, landscape, environmental conditions, gross lesions and the appearance of clinical signs in sick animals. Sources of information may include local people, landowners and agencies working in the area preceding or during an outbreak. Information should be passed to the diagnosticians as soon as possible, updating them as appropriate. Which data to collect Checklist 3-3 provides a summary of the information to collect at a suspected outbreak. A broad range of data should be collected at a suspected outbreak, including: Population(s) at risk i. A broad range of affected host species may suggest a storm, other sudden environmental event or toxic/poisoning incident, whereas a narrow host range, with other species present and at risk yet unaffected, may indicate a specific infectious agent. The proportion of animals affected in the population provides information about the nature and seriousness of the problem. Statements such as ‘100 dead birds were found’ are meaningless without an indication of what proportion of the population this constitutes. Ensure that demographic data collected from affected animals are related to that of the wider population present. For example, if all the animals were juveniles yet this was the population present and at risk at the time, then this needs to be explicit to the diagnostician. Species affected It is important to note as much detail as possible regarding the species affected.