A control chart (Answer C) is a tool used in quality control to analyze the variables in a process and monitor the effect of these variables on performance of a process olmesartan 40mg otc. A run chart (Answer A) is a graph of data over time and helps to assess the effectiveness of a change in the process buy olmesartan 20 mg fast delivery. A run chart is similar to a control chart but it does not show the control limits of a process buy generic olmesartan 20mg line. During a major power outage order olmesartan now, a blood bank technologist issued a unit of blood without a requisition form. The error was discovered on the following day during the morning administrative rounds in the blood bank. The blood bank team performs a root cause analysis and implements corrective action. The technologist is suspended for 2 weeks and told to review the standard operating procedures B. The technologist is given a quiz on various case scenarios to assess his knowledge of standard operating procedures C. The team’s root cause analysis revealed that the error partly occurred due to the lack of staff during the night, so the hospital hires two additional technologists for the night shift E. The technologist deviated from the established policy and created this nonconforming event. For each of these events, the facility should defne how to implement preventive and corrective actions and how to evaluate their effectiveness. Answer: E—Training the technologist on how to proceed during a power outage and where to fnd the requisition forms is a corrective action. Corrective action is defned as an activity performed to eliminate the cause of an existing nonconformance or other undesirable situation in order to prevent recurrence. Since the corrective action plan is a signifcant component of root cause analysis, it needs to be documented and reviewed. Hiring additional technologists (Answer D) would be considered a preventative action, since it would allow for sharing of work, additional expertise, and more time for handling any single blood order. Preventive action is defned as an action taken to reduce the potential for nonconformances or other undesirable situations. By having the technologists take a quiz, review the standard operating procedure, or shadow a senior technologist, the hope is that the technologists can acquire the skills necessary to perform their daily work tasks, which includes having a requisition form flled out when issuing blood products. However, the actual cause of the problem, such as the technologist doesn’t know where the requisition form is or how to fll it out, is not addressed. A new Rh reagent is purchased by your blood bank which is reported to be more accurate in identifying patients with D variants. A validation study at your blood bank reveals the old Rh reagent to be superior in identifying D variants. You continue using the old reagent for patient samples and temporarily remove the new reagent from testing. After contacting the manufacturer and reviewing the test procedure, you realize that your technologists are using only one drop instead of the recommended two drops of this new reagent. You immediately revise the standard operating procedure and over the next few weeks conduct daily short meetings to inform all the different work shifts of this new procedure. Preventive; immediately revising the standard operating procedure to refect the recommended two drops when using the new Rh reagent B. Remedial; continue using the old Rh reagent for patient samples until the issue with the new Rh reagent is resolved C. Corrective; switching from the old Rh reagent to the new Rh reagent to identify more weak D patients D. Corrective; continue using the old Rh reagent for patient samples until the issue with the new Rh reagent is resolved Concept: Evaluation and analysis of nonconformances resulting in near-miss events or actual adverse events are necessary steps for identifying the problem that led to the event. Once the issue is known, the next step is to correct it and put measures in place to prevent it from occurring again. Answer: B—Remedial action is taken with the goal of minimizing the damage of any existing nonconformance. It is a reactive approach to an existing problem in order to improve the current outcome. By temporarily using only the old reagent until the issue with the new reagent was resolved, the supervisor created more time to fgure out the problem and avoided missing additional patients with D variants. Preventive action (Answer A) reduces or eliminates the potential for an error or an undesirable situation from happening when the problem is still nonexistent. By introducing the new reagent to the blood bank, the supervisor was hoping to identify more D variant patients that may have been missed by the old reagent. Corrective action (Answers C and E) aims to eliminate the direct cause of a nonconformance with the goal of preventing it from occurring again. Incoming reagents and critical supplies must be received, inspected, and tested prior to using them, given their potential impact on the outcome of services provided or fnal product. Answer: D—Cell washing is a necessary component in carrying out routine and complex blood bank testing; however, the washing step can be performed manually and an automated cell washer does not have to be used; therefore it is considered a noncritical component. The other choices (Answers A, B, C, and E) represent critical reagents and equipment that are essential for being able to provide blood bank services and must be functioning properly, readily available, and used as intended by the manufacturer unless another method has been validated and approved by the medical director. You are a medical director of a small regional blood center which just experienced major fooding and subsequent damage to your donor center after a hurricane. You are in charge of leading a team to carry out your blood center’s disaster management program at this critical time. What is an example of a mitigation strategy within your disaster management program? Given your facility’s critical role in relief efforts, you request an emergency electrical generator from the city B. You increase the number of blood drives in anticipation of increased demand for blood C. You organize an emergency team that meets every 4 h to update the needs of your customers, status of your employees, and conduct feld operations D. You draft a proposal to have quarterly drills, which simulate actions to be taken during a potential disaster E. You move your fle cabinets with donor records from the basement to the frst foor and install more drains in the basement Concept: For an organization, a disaster may be defned as a serious event that disrupts the routine ways that the organization functions, in such a way that is beyond what the organization can handle on their own. The way an organization responds to a disaster depends in part on how prepared they were before it occurred. To help in preparation, a disaster management plan should be developed and distributed within the organization. This plan includes strategies or efforts, such as mitigation, preparedness, response, and recovery which allow for more effcient operations during a disaster. Answer: E—Mitigation efforts include making permanent changes, such as with a building’s structure, physical property within the facility, or environment directly outside the building. These strategies aim to provide more safety to the organization’s employees as well as protect the physical property within the facility. For example, building more drains, performing quality and safety checks on equipment, creating a new shelter for employees, or protecting vital records by moving fle cabinets to a relatively food-safe level are examples of mitigation strategies. Requesting an emergency generator (Answer A) refers to recovery or restoring a critical component of a facility’s operations, such as electrical power which is certainly necessary to run a blood center. Recovery is the last step in the disaster management cycle and during this step, more ideas for mitigation strategies are identifed. Organizing an emergency team (Answer C) refers to a response effort in which you maintain communication with your employees and customers to continue critical operations and regain some form of stability. Drafting a proposal for quarterly drills (Answer D) refers to a preparedness plan whereby the organization routinely simulates an unexpected event through drills to reinforce what needs to be done as well as to identify inconsistencies or lack of critical measures that need to be corrected. Increasing the number of blood drives (Answer B) is another example of preparedness. Which of the following is true regarding testing blood products in case of catastrophic events whereby blood is needed immediately to save lives? Infectious disease testing can be done retrospectively in certain circumstances C. Testing blood for infectious diseases is required from frst-time donors but not from your repeat donors D. Testing of plasma and platelet products for infectious diseases but not red cell products is always required Concept: A blood center is fully committed for making the blood supply as safe as possible by continuously adding sensitive and specifc infectious disease tests as part of donor testing. However, an exception to full testing is acceptable in certain circumstances that make holding back on releasing blood products life-threatening. Answer: B—When blood is in critical need for keeping patients alive, blood supplies are exhausted and resupply is not possible, full testing for infectious disease agents is not required (Answers A and C).
Supportive care and supplemental oxygen are effective according to research evidence purchase olmesartan 40mg otc. In contrast cheap 40 mg olmesartan, epiglottitis can affect infants order olmesartan online now, older although recommended for prophylaxis buy generic olmesartan online, is not felt to be children, or adults. Said to be “possibly effective” are tially life-threatening disease as it is in younger people. Of note is the fact that efficacy of glucosteroids and epinephrine is that many the stridor of epiglottitis is not as dramatic as that of patients who respond may have atopic disease with an croup. Respira- involvement, typically exhibits the symptoms of inspira- tory tract and mediastinum. On examination, she stay due to business in the Caribbean islands with a exhibits spider angiomata and dilated flank veins. She The pain has rapidly built over a period of about had not been taking antibiotics and had no history of 36 hours. She has lost weight and com- site the epigastric area and seems to be relieved by plains of fatigue. Each of the following is true regard- level of 10 g/dL with a mean cell volume measured at ing this case except for which statement? The stools are bulky, par- (A) The most sensitive diagnostic test is the serum ticularly foul smelling and they float. Upon readmission, she was placed on moxi- recommendations would be acceptable for a 35-year- floxin and doxycycline, based on x-ray findings of old woman whose father had colon cancer at the age pneumonia. There are no specific foods that seem to be associated with either diarrhea or constipation. Between bouts, stool are For Questions 8 through 12, match the numbered causes of well formed and of normal size. She has no fam- ily history of colorectal cancer; flexible sigmoidos- 8 Carcinoma of the colon copy and later colonoscopy, indicated on the basis of her lower bowel symptoms, have been negative on 9 Vascular ectasia (angiodysplasia) two occasions. Which of the following regimens is the most likely to provide relief from the diarrhea, 10 Blue rubber bleb nevus syndrome constipation, and abdominal pain? A 20 A 35-year-old male graduate student complains nausea treatment choice may be used for more than one of intermittent difficulty swallowing for the last cause of nausea. Which of the follow- 18 A 74-year-old man being treated for chronic renal ing symptoms would most enable you to reassure the failure has the rapid onset of hematochezia consist- patient that he does not have an organic basis for the ing of frequent maroon-colored stools. Radioisotope-tagged red cell scan years (Technetium 99) revealed a small bowel source. Which of the following is the most signifi- (D) Pyoderma gangrenosum cant disadvantage with that plan? A tetracycline course orally for 3 weeks the high-risk patient featured but not necessary until she will treat successfully tropical sprue. Alosetron (Lotronex), most likely ple who have resided long periods in a tropical region. It is among the choices to give global relief from the woman’s felt to be caused by changes in the bowel flora and responds symptoms. The severity of disease is not directly patients over 50 years of age with average risk based on proportionate to the size of the amylase elevation, so the family history should undergo standard screening for col- statement that it is directly related thereto is the incorrect orectal cancer according to American College of Gastroen- one. However, amylase is not the most specific, serum serotonin reuptake in inhibitors’ effectiveness has given the fact that other conditions, such as perforated pep- not been documented. A medication not among the tic ulcer, are characterized by elevated serum amylase. This fits the criterion based on the zoan is passed by the fecal–oral route and therefore occurs index patient having two first-degree relatives with either where water processing is less than optimal (being rela- colon cancer or adenomatous polyps before the age of 60 tively resistant to chlorination), such as in developing years. Colonoscopy every 10 years is appropriate for a per- countries and outdoor camping situations. Flexible scenario, it is enhanced in its communicability by its sur- sigmoidoscopy every 5 years also is approved for people of vivability in cold water. The pinworm, whose only host is average risk, again beginning at the age of 50 as is fecal occult humans, lives in the large intestine and lays eggs on the blood test annually (certainly the least advised routine perineum. It rarely results in more than perineal pruri- method due to the numerous false-positive and false-negative tus, but occasionally can cause weight loss, urinary tract examinations but often the most palatable for apprehensive infection, and appendicitis. The answer for vestibular nausea is D, histamine severe abdominal pain and may ultimately result in 1 blocker, anticholinergics. Each of the parasites discussed here that are passed through the fecal–oral route are 15. The answer for pregnancy-induced nausea is E, gin- more incident and prevalent in groups that practice oral– ger, vitamin B , promethazine. Pseudomembranous colitis is the most likely diagnosis in view of the woman’s recent and 17. These recommendations are based on the theories of the Although pneumonia may be recurrent or persistent and mechanisms involved in production of nausea associated antibiotics continue to be indicated, the diarrhea and with the five conditions. The nausea of migraine is associ- marked leukocytosis require a working diagnosis of ated with the neurotransmitter dopamine, antagonists of pseudomembranous colitis. Ulcerative colitis is unlikely in view of the clinical For nausea alone in migraine are recommended the fore- setting. Metronidazole is effective against ated by histamine and by acetylcholine, and hence, it is C. Each associated with pregnancy is poorly understood, but the of the other antibiotics mentioned is a risk factor for the recommendations made, that is, ginger and vitamin B ,6 disease, being broad spectrum and not specifically effec- are based on empiric response and safety for use during tive against C. The answer for carcinoma of the colon is D, age 50 patients and those with chronic renal failure, particularly years. The answer for vascular ectasia (angiodysplasia) is A, may be sources of small intestinal bleeding but relatively chronic renal failure. The answer for celiac sprue is C, chronic diarrhea, the lumen when the arterial blood supply to the bleeding abdominal pain. Clinical evidence: Irritable geal motor disorder is characterized by symptoms with bowel syndrome. Diagnosis of symptoms or spasmodic acute obstruction is characteristic gastrointestinal bleeding in adults. A new view of oc- to other causes, when of recent onset, usually indicates cult and gastrointestinal bleeding. Similarly, erythema nodosum is associated but less frequently than the other entities. Each of the following is a risk factor for stomach (D) Positive in pelvic appendicitis cancer except which one? It occurs in paroxysms that last for up to (E) To diagnose atrophic gastritis 20 to 30 minutes. Without further history, which of 7 You suspect atypical presentation of appendicitis in a the following is the most likely cause of the symptom? Pelvic examination reveals right adn- 10 A 70-year-old white woman is found to have a hemo- exal area tenderness but no cervical tenderness Which globin level of 4 g/100 mL and a macrocytosis. Serum of the following may be most helpful in determin- vitamin B12 level is abnormally low. The patient ing whether the patient has appendicitis, thus mak- denies history of diarrhea. Serum folic acid levels are ing it less likely for you to commit to unnecessary normal. As you begin treatment of this patient, which surgery or missing timely intervention in the event of of the following procedures comes under the heading appendicitis? The presentation of symptoms and signs, confers the most patient also has diarrhea, a problem he had not had favorable prognosis? He denies taking nonsteroidal anti- (A) Cecum inflammatory medication either by prescription or over (B) Ascending colon the counter. You treated the patient with a 3-week (C) Transverse colon course of the histamine 2 receptor blocking agent (H2 (D) Iliocolic junction receptor blocker) ranitidine, but the patient’s symp- (E) Sigmoid colon toms only slightly improved and recurred fully within days after discontinuance of the drug. You then pre- 12 A 35-year-old white man has had abdominal pain for scribed the hydrogen pump blocking agent omepra- the past 36 hours. Examination of the anterior aspect zole for 3 weeks with similar disappointing results. During the procedure, studies were done for to 19,000 with 80% neutrophils, of which 30% are H. You notice a peristaltic wave in the 9 A 55-year-old man is alcoholic and has an episode upper abdomen moving from left to right.
Note how close the furcation is to the mesiolingual (mesiopalatal) line angle of the tooth due to the wide mesiobuccal root purchase olmesartan 20 mg with amex. The probe is shown at the apical and horizontal extent of the penetration into the facial furcation best olmesartan 10mg. However buy olmesartan 10 mg mastercard, more cervically positioned furcations palatal and distobuccal roots as seen in Fig cheap olmesartan 10mg mastercard. The furcation probe is shown as it enters the potential furcation near the middle of the facial surface of this maxillary molar. Palatal view: The mesial furcation on a maxillary molar is accessed through the palatal embrasure since the mesiobuccal root is wider than the palatal root. Palatal view: The distal furcation on a maxillary molar is probed through the palatal embrasure here, although the distobuccal root is about as wide as C the palatal root. Divergent roots with the furcation in the coronal one third of the root with a short root trunk. Fused roots with Radiograph showing close root approxima- the furcation in the coronal one third of the root. Furcations and concavities like these are virtually inaccessible due in part to better access. When the base of the pocket is reached, the probe should be directed toward the tooth to see if it will engage the roof of the furcation. Deep horizontal penetration of the furcation probe indicates severe periodontal disease. The notation used to record each grade of furcation is summarized in Table 7-4, and examples of charting the degree of furcation involvement are presented in Figure 7-18. A caret (∨ or ∧) denotes beginning (incipient) involve- ment, an open triangle (Δ or ∇) denotes moderate involvement, and a solid triangle (▲ or ▼) over the areas of the root denotes a through-and-through furca- tion involvement. In health, it is desirable to have at least a minimal width Calculus deposit (arrow) in the longitudinal depression on the mesial side of the root of a maxillary first of keratinized gingiva that is firmly bound (attached) premolar. There is a lack of attached gin- junction can be distinguished since it is readily move- giva around the tooth if there is movement or blanch- able, more vascular (redder), less firm, and not kera- ing at the gingival margins when tension is applied to tinized. Keratinized gingiva is present, but there is no cent to movable alveolar mucosa—in other words, on attached gingiva. This condition is confirmed when the facial aspects of maxillary teeth and on the facial the periodontal probe depth of the gingival sulcus and lingual aspects of mandibular teeth. It is not likely reaches or exceeds (traverses) the level of the vis- for mucogingival defects to be present on the pala- ible mucogingival junction indicating an absence of tal aspects of maxillary teeth because the entire hard attached gingiva (Fig. In this case, if the probe depth had reached or exceeded 2 mm (the mucogingival junction), this would confirm that there is no attached gingiva. The periodontal probe is positioned at the mucogingival junction and moved incisocervically against the mucosa. Blanching or movement at the gingival margin is indicative of a mucogingival defect. In dontitis, and the destruction of mineralized tooth struc- the visual method, a mucogingival defect is confirmed ture during the formation of dental decay (dental caries). Then place the periodontal probe within the gingival sulcus, and if the periodontal probe depth reaches or exceeds the width of keratinized tis- sue, a mucogingival defect is confirmed. See a clinical example using measurements to confirm a mucogingi- val defect in Figure 7-33A and B. This can be charted as a horizontal wavy line placed over the root apical to recession readings (seen in the chart in Fig. Therefore, utilizing a mechanism to iden- plaque after staining with disclosing solution. Plaque is tify the location of this nearly invisible plaque can be most prominent at interproximal sites and the cervical third of helpful when teaching plaque removal techniques, and crowns, areas that are not self-cleaning (i. Note: Disclosing solutions should not be used until periodontal measurements and the Plaque can be stained with disclosing solution, a dye oral physical exam have been made and reviewed since that is absorbed by bacterial plaque (Fig. When the color change to oral tissues from the solution may this solution is swished in the mouth, four tooth sur- influence the ability to observe the initial findings. Care must be taken when increases the extent of supragingival tooth structure by restoring teeth to protect this biologic width of attach- removing gingival tissue or apical positioning gingival ment. If a restoration encroaches into the attachment, it tissue, and usually removing some supporting bone. Further, it is usu- may retain bacterial plaque more readily, so it could be ally recommended that the margins of artificial crowns an initiating factor for periodontal disease. These a mesial concavity is more resistant to buccolingual features greatly influence the resistance of a tooth to forces than a tooth that is conical or convex (Fig. Long roots and wide cross-sectional Likewise, multirooted teeth have increased support tooth diameters increase support. Relationship between the area of attach- ment and root length for a mandibular first premolar. Approximately 60% of the root area is present in the coronal Series of stained cross sections of a root of a 50% (one half) of the root, with only 40% of the area present in lower first molar from the crown to near the apices. These determinations were section, the mesial aspect is left, the lingual aspect is at the top, made by measuring the areas of many serial cross sections of the distal aspect is right, and the buccal aspect is toward the tooth roots similar to those shown in Figure 7. Cross section of the root trunk slightly half of the root, and much less area (only about 40%) coronal to the bifurcation (furcation). Cross root taper influences the support once periodontal dis- section of mesial and distal roots slightly apical to the bifurca- ease has occurred. Thickened cementum of the bone height may have lost more than 60% of its (darkly stained) is apparent on the furcal aspect (between the roots). This is because a smaller pro- There are pronounced concavities on the mesial aspect of the portion of the root area is present near the apex. Cross section severely conical roots, the apical half of the root may of the roots near the apex. The account for even less attachment area than seen in complex shape of molar roots helps provide a greater surface area Figure 7-37. Additionally, would expect maxillary first molars, with their three convergence or divergence of roots influences support. Teeth with conical excessive occlusal forces, may greatly influence tooth roots, such as mandibular first premolars, tend to have stability. Also, the density and structure of the support- the majority of their root area (>60%) in the coronal ing bone have an influence on tooth stability. This more difficult to clean once periodontal disease pro- occurs because the root curvature and the correspond- gression reaches them. Anomalies on roots that may contribute to increased plaque retention and subsequent bone loss and furca- tion involvement. Enamel extension (arrow) downward into the buccal furcation of a lower second molar. Periodontal probe in place showing a deep periodontal pocket formed where the groove extends apically on the root. The tooth was extracted because of severe periodontal disease on the palatal aspect. Radicular palatal grooves (pala- ture that weaken periodontal attachment and are tal gingival grooves) occur on maxillary incisors and potential areas for periodontal disease to develop. Root frac- molars, and enamel extensions frequently occur on tures also predispose periodontal destruction (loss mandibular molars (Fig. Both prevent a normal of attachment of the periodontal ligament) along the connective tissue attachment and may channel disease fracture line. Recent advances in removal of calculus and smoothing of the root using spe- the area of periodontal regeneration involve three basic cially designed dental instruments), oral hygiene instruc- strategies. In guided tissue regeneration, a resorbable or tions, and the use of systemically administered antibiotics. Bone agents that prevent breakdown in connective tissue (anti- grafting materials, both synthetic and from the patient collagenases) are being prescribed for systemic use. There are several surgical approaches surface and may allow the application of growth factors used to treat periodontal disease. However, if it is environment, products from blood and tissue fluids not removed frequently, it can calcify to form a hard, contribute to the calcification process and the deposits complex mineral layer called dental calculus (tartar) are dark brown (Fig. In the supragingival professional to remove these calcified deposits, both environment (coronal to the gingival margin), saliva supragingivally and subgingivally, and to teach patients 224 Part 2 | Application of Tooth Anatomy in Dental Practice covered with enamel that is the hardest substance in the body (95% calcified). Enamel is nonporous, so damage or removal of this tissue during instrumentation is not as likely as removal of cementum that is much less hard (less than about 65% calcified) and more porous. When periodontal disease progresses to a point where there is attachment loss, the normal insertion of connec- tive tissue fibers into cementum is lost.