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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Scott R. Schulman, MD, MHSc
In particular treatment for dogs fever ethambutol 400 mg sale, we found that feelings related to imposter syndrome were named by seven individuals (15 antibiotics for uti otc cheap ethambutol 400 mg line. Although some may perceive imposter syndrome to be a deeply personal "issue virus 8 catamaran cheap ethambutol 400 mg online," it was in fact related to cultural and environmental barriers bacteria normally carried by about a third of the population buy ethambutol 400mg online. We intentionally end our discussion of the findings by noting barriers and the effects of the imposter syndrome, highlighting the system of interdependent variables affecting the participation of immigrants on these decision-making bodies and linking the challenges and opportunities they faced with other critical components present or missing in their respective localized community and the state at large. First, if information is challenging to access in a mostly rural state like Oregon-and if we treat our study results as a baseline-then it seems safe to assume that such access challenges would be multiplied exponentially in states with more rural jurisdictions and larger rural populations. We base this assumption in part on how it was most difficult to document the demographic composition of board members at the county level. As such, their membership should be easily discernible by any member of the public who wants to know who is involved in decisions that impact their lives and communities. Staff collaboration with the research team to compile the demographic information for these bodies ranged from enthusiastic collaboration to active resistance or dismissiveness toward the research altogether. This lack of transparency in relation to representation leads to the third reason for detailing our methodology and being explicit about the messiness and incompleteness of our inventories. Without readily available information about who sits on various bodies across the state, we find claims made by jurisdictions that their decision-making bodies are representative of the communities they serve difficult to believe. In fact, our research indicates that often this is not the case-or, worse, that there is no practical way for the public to confirm these claims given the lack of publicly accessible information. Of course, board membership is just one variable among many that influence civic participation on these bodies. Discussion and Policy Recommendations: Illuminating the Black Box of Participation It is clear from this research that involving members of the public in formal acts of governance is a common practice across jurisdictional levels. This practice has the potential to be transformative on multiple levels: for immigrant individuals serving; for the communities their decisions influence; and, subsequently, for the communities the individuals may represent. Knowing full well that meaningful bureaucratic diversity is rare across the state of Oregon (Nishishiba, 2012), these bodies may be one of the few outlets for immigrant communities to affect policy deliberation, influence, creation, and implementation. Yet, as this study illustrates, the vastness of decision-making bodies in Oregon reveals a practice that is not as transparent as it should be. For a variety of reasons, this lack of 55 In concluding our analysis, we offer some initial policy recommendations: Act more transparently Government websites, regardless of jurisdictional type, should include a page that describes the goals and objectives of said bodies, including their decision-making authority and application information. Additionally, all current members of the body should be listed on the site, along with the contact information for the staff liaison to the body. A State of Immigrants Landscape of Civic Participation Among Immigrants Put a face to a name Beyond just names, a short biography of each member goes a long way toward creating a sense of transparency for the body and its representation. This is more than is required by law and focuses on actualizing the spirit of engaging in democratic practice. Recognize the connection between onboarding and inclusion Onboarding of new members is key because it orients them to the mission and goals of board service. However, it is equally important to provide space for new and old board members to get to know each other. Creating a culture of inclusion is key for developing relationships and a subsequent community of practice for members of the body. These activities should be paired with the onboarding process of new individuals, whose initial impressions during onboarding establish expectations and comfort levels while providing an excellent opportunity for returning board members to engage in reflection. Move beyond mere communication Targeted outreach is good for recruiting members from underrepresented communities, but more concerted efforts should be made to extend already known networks to the wider community when vacancies become available. This should be accompanied with information about the application and selection processes. Moreover, this targeted outreach must be culturally relevant and specific, including the translation of materials and specification of the types of accommodations provided to reduce barriers to board service. The translation of applications is only relevant if resources are provided to remove language barriers from non-English-speaking participants on an ongoing basis. If these are not available, then the translation of an application is likely be interpreted as a superficial effort by jurisdictions to merely appear accessible. Create cohort-based leadership training As our participants made clear, targeted efforts to discuss open positions on boards with non-White immigrants would go much further than advertisements of any kind. These efforts could include providing stipends for participants, offering childcare, and opening pathways not only for employment but also volunteer positions. Create a mentor system to support new members A number of our participants talked about the sink-orswim mentality of some board cultures. We recommend that jurisdictions create a mentor system to prevent individuals from sinking and to decrease the amount of time it takes for them to become comfortable, contributing members of their respective boards. As with any good mentorship program, significant time and thought should be given to how it would function, as opposed to just pairing individuals without any training or expectations. Acknowledge and affirm the value of equity training Among our participants, the value of equity trainings, either prior to or during board service, was not lost on individuals. Issues of equity, access, and privilege should not be seen as just the domain of certain boards but as a central tenet to all. Enact term limits We also suggest that jurisdictions that do not already have some form of term limits for board service consider the value of having a good balance between returning and new participants. This will force jurisdictions to reflect continually on who is at the table and to prevent particular individuals from dominating group processes and/or knowledge or becoming overstretched across boards. Of course, this may create a conundrum: if different bodies start using different parliamentary procedures, this may create even more of a cognitive demand for individuals who serve over time across multiple bodies. Given the push by Oregon Governor Kate Brown to prioritize equity at the state level, we recommend establishing a task force to simulate the cost and benefits of different jurisdictions, even the statewide bodies, moving to more user-friendly parliamentary procedures. We end our policy recommendations with a word about returning to face-to-face meetings. We expect organizations will use a combination of practices that were "normal" before and became more accepted during the pandemic. We expect that virtual conferencing (Zoom) will be used more frequently, which may mitigate the transportation and travel barriers identified by those sitting on statewide bodies. There will be many additional changes as the two norms fuse to create a new one in the immediate post-pandemic world. We encourage sponsoring jurisdictions of decision-making bodies to be intentional about what they maintain or relinquish in the service of making civic engagement in decision-making bodies by immigrants and other underrepresented populations more accessible and welcoming. Concluding Thoughts Two of the participants in our study noted that, initially, they did not think they could apply to serve on their decision-making body because the application had the word citizen in the title. Whether intentional or not, this denoted to them that even though they were interested, they could not apply to be of service to their communities because they were not traditional U. Luckily, once they were on the boards and shared their thoughts with those in power, they noticed that at some point citizen was dropped from the titles. For us, this is a rich example of the multiple variables that shape how welcome or inclusive communities feel to their immigrant members. We argue that our study confirms that the ability and motivation to serve on decision-making bodies represents a third type of civic engagement that helps complete the civic engagement trajectory of immigrants finding their voice in and for their communities. Develop accommodations that address the particular needs of immigrant participants Without a doubt, the provision of resources that reduce or eliminate barriers faced by immigrants attempting to serve on decision-making bodies is critical. However, we do not recommend mandates alone, knowing full well that what may be a barrier for one person may not be for another, even if they have the same demographic profile. For example, one participant in our study did not like the real-time translation that was offered to her because it limited her cognitive processing in the moment, given the "extra voice" in her head. More importantly, jurisdictions should be transparent about what they provide, how they determine what is needed, and how they work with participants to make their service smoother. This transparency will reveal the intentionality that jurisdictions exercise in communicating the values, norms, and cultures of their decision-making bodies. One of the most powerful (but also most expensive and complicated) accommodations that jurisdictions could provide is childcare. One idea that a study participant proposed was offering stipends to pay for babysitters and pre-prepared meals for their children during meeting times. We believe this type of bottom-up problem solving can be effective if jurisdictions have 57 A State of Immigrants Landscape of Civic Participation Among Immigrants Sources Abrego, L. Legal consciousness of undocumented Latinos: Fear and stigma as barriers to claims making for first and1. Putting the public back into governance: the challenges of citizen participation and its future. Developing a citizen perspective of public participation: Identity construction as citizen motivation to participate. Latino immigrants in civil society: Addressing the double-bind of participation for expansive learning in participatory budgeting. Differentiating participation: identifying and defining civic capacities used by Latino Immigrants in Participatory Budgeting.
Diabetes J180 C169 E149 Code to cancer of stomach (C169) by applying Selection Rule 1 infection mercer generic ethambutol 800mg without a prescription. Terms that stop the sequence Includes: Cause not found Cause unknown Cause undetermined Could not be determined Etiology never determined Etiology not defined Etiology uncertain Etiology unexplained Etiology unknown Etiology undetermined Etiology unspecified Final event undetermined Immediate cause not determined I (a) Cardiac arrest (b) Stroke (c) Cause unknown (d) Diabetes Immediate cause unknown No specific etiology identified No specific known causes Nonspecific causes Not known Obscure etiology Undetermined Uncertain Unclear Unexplained cause Unknown Codes for Record J189 K566 K519 I (a) Pneumonia (b) Intestinal obstruction (c) Undetermined (d) Ulcerative colitis Code to ulcerative colitis (K519) antimicrobial bar soap ethambutol 400 mg without prescription. I (a) Gastric ulcer infection elite cme com continuing education generic 400mg ethambutol otc, cause unknown (b) Rheumatoid arthritis (c) M069 Codes for Record K259 Code to gastric ulcer (K259) antibiotic 3 times a day buy ethambutol 600 mg online. Querying cause of death Because the selection of the underlying cause of death is based on how the physician reports causes of death as well as what he reports, State and local vital statistics offices should query certifying physicians where there is doubt that the manner of reporting reflects the true underlying cause of death. Querying is most valuable when carried out by persons who are thoroughly familiar with mortality medical classifi-cation. It is possible to choose a presumptive underlying cause for any cause-of-death certification no matter how poorly reported. However, selecting the cause by arbitrary rules (Rules 1-3) is not only difficult and time consuming, but the end results often are not satisfactory. Querying can be used to great advantage to inform physicians of the proper method of reporting causes of death. It is hoped that intensive querying and other educational efforts will reduce the necessity of resorting to arbitrary rules, and at the same time improve the quality and completeness of the reporting. When a certifier is queried about a particular cause or for inadequate or missing information he may or may not have at hand, the query should be specific. When the queries are sufficiently specific to elicit specific replies, the final coding should reflect this additional information from the certifier. The additional information cannot be used to replace the reported underlying cause. If one of these conditions (see Appendix A) is reported as a cause of death, the diagnosis should have been confirmed by the certifier or the State Health Officer when it was first reported. Coding Specific Categories the following are the international linkages and notes with expansions and additions concerning the selection and modification of conditions classifiable to certain categories. Therefore, reference should be made to the category or code within parentheses before making the final code assignment. The following notes often indicate that if the provisionally selected code, as indicated in the left-hand column, is present with one of the conditions listed below it, the code to be used is the one shown in bold type. There are two types of combination: "with mention of" means that the other condition may appear anywhere on the certificate; "when reported as the originating antecedent cause of" means that the other condition must appear in a correct causal relationship or be otherwise indicated as being "due to" the originating antecedent cause. Specific disease conditions indicated to have been bacterial in origin are classified to the specified disease rather than to A49. B16 Acute hepatitis B B17 Other acute viral hepatitis when reported as the originating antecedent cause of: K72. Conditions classifiable to two or more subcategories of the same category should be coded to the. Specific disease conditions indicated to have been viral in origin are classified to the specific disease rather than to B34. Examples: adenovirus enteritis is classified to A082, and acute viral bronchitis is classified to J208. B95-B97 Bacterial, viral and other infectious agents Not to be used for underlying cause mortality coding. C00-D48 Neoplasms Separate categories are provided for coding malignant primary and secondary neoplasms (C00-C96), Malignant neoplasms of independent (primary) multiple sites (C97), carcinoma in situ (D00-D09), benign neoplasms (D10-D36), and neoplasms of uncertain or unknown behavior (D37-D48). Categories and subcategories within these groups identify sites and/or morphological types. Morphology describes the type and structure of cells or tissues (histology) as seen under the microscope and the behavior of neoplasms. They are also described in Volume 3 (the Alphabetical Index) with their morphology code and with an indication as to the coding by site. The morphological code numbers consist of five characters: the first four identify the histological type of the neoplasm and the fifth, following a slash, indicates its behavior. The following terms describe the behavior of neoplasms: Malignant, primary site (capable of rapid growth and of spreading to nearby and distant sites) Malignant secondary (spread from another C00-C76, C80-C97 C77-C79 site; metastasis) In-situ (confined to one site) Benign (non-malignant) Uncertain or unknown behavior (undetermined whether benign or malignant) D00-D09 D10-D36 D37-D48 Morphology, behavior, and site must all be considered when coding neoplasms. Always look up the morphological type in the Alphabetical Index before referring to the listing under "Neoplasm" for the site. This may take the form of a reference to the appropriate column in the "Neoplasm" listing in the Index when the morphological type could occur in several organs. For example: Adenoma, villous (M8261/1) - see Neoplasm, uncertain behavior Or to a particular part of that listing when the morphological type originates in a particular type of tissue. The Index may give the code for the site assumed to be most likely when no site is reported in a morphological type. For example: Adenocarcinoma - pseudomucinous (M8470/3) - - specified site - see Neoplasm, malignant - - unspecified site C56 Or the Index may give a code to be used regardless of the reported site when the vast majority of neoplasms of that particular morphological type occur in a particular site. For example: Nephroma (M8960/3) C64 Unless it is specifically indexed, code a morphological term ending in "osis" in the same way as the tumor name to which "osis" has been added is coded. However, do not code hemangiomatosis which is specifically indexed to a different category in the same way as hemangioma. All combinations of the order of prefixes in compound morphological terms are not indexed. For example, the term "chondrofibrosarcoma" does not appear in the Index, but "fibrochondrosarcoma" does. Since the two terms have the same prefixes (in a different order), code the chondrofibrosarcoma the same as fibrochondrosarcoma. Malignant neoplasms When a malignant neoplasm is considered to be the underlying cause of death, it is most important to determine the primary site. Cancer is a generic term and may be used for any morphological group, although it is rarely applied to malignant neoplasms of lymphatic, hematopoietic and related tissues. Some death certificates may be ambiguous if there was doubt about the primary site or imprecision in drafting the certificate. In these circumstances, if possible, the certifier should be asked to give clarification. The categories that have been provided for the classification of malignant neoplasms distinguish between those that are stated or presumed to be primary (originate in) of the particular site or types of tissue involved, those that are stated or presumed to be secondary (deposits, metastasis, or spread from a primary elsewhere) of specified sites, and malignant neoplasms without specification of site. These categories are the following: C00-C75 Malignant neoplasms, stated or presumed to be primary, of specified sites and different types of tissue, except lymphoid, hematopoietic, and related tissue C76 C77-C79 C80 C81-C96 C97 Malignant neoplasms of other and ill-defined sites Malignant secondary neoplasm, stated or presumed to be spread from another site, metastases of sites, regardless of morphological type of neoplasm Malignant neoplasm of unspecified site (primary) (secondary) Malignant neoplasms, stated or presumed to be primary, of lymphoid, hematopoietic, and related tissue Malignant neoplasms of independent (primary) multiple sites In order to determine the appropriate code for each reported neoplasm, a number of factors must be taken into account including the morphological type of neoplasm and qualifying terms. Assign malignant neoplasms to the appropriate category for the morphological type of neoplasm. Morphological types of neoplasm include categories C40-C41, C43, C44, C45, C46, C47, C49, C70-C72, and C80. Specific morphological types include: C40-C41 Malignant neoplasm of bone and articular cartilage of other and unspecified sites Osteosarcoma Osteochondrosarcoma Osteofibrosarcoma Any neoplasm cross-referenced as "See also Neoplasm, bone, malignant" I (a) Osteosarcoma of leg Code for Record C402 Code to osteosarcoma leg (C402). C43 Malignant melanoma of skin Melanosarcoma Melanoblastoma Any neoplasm cross-referenced as "See also Melanoma" I (a) Melanoma Code for Record C439 Code to melanoma, (C439) unspecified site as indexed. Code for Record C436 I (a) Melanoma of arm Code to melanoma of arm (C436) as indexed under site classification. I (a) Melanoma of stomach Code for Record C169 Code to melanoma of stomach (C169). Since stomach is not found under Melanoma in the Index, the term should be coded by site under Neoplasm, malignant, stomach. C44 Other malignant neoplasm of skin Basal cell carcinoma Sebaceous cell carcinoma Any neoplasm cross-referenced as "See also Neoplasm, skin, malignant" I (a) Sebaceous cell carcinoma nose Code for Record C443 Code to sebaceous cell carcinoma nose (C443). Code the morphological type "Sebaceous cell carcinoma" to Neoplasm, skin, malignant. C49 Malignant neoplasm of other connective and soft tissue Liposarcoma Rhabdomyosarcoma Any neoplasm cross-referenced as "See also Neoplasm, connective tissue, malignant" I (a) Rhabdomyosarcoma abdomen Code for Record C494 Code to rhabdomyosarcoma abdomen (C494). Code the morphological type "Rhabdomyosarcoma" to Neoplasm, connective tissue, malignant. Refer to the "Note" under Neoplasm, connective tissue, malignant, concerning sites which do not appear on this list.
Determine drained weight antibiotics for sinus infection in canada order ethambutol 400 mg overnight delivery, vacuum virus remover free buy ethambutol 800 mg low price, and headspace on a representative numbers of normal-appearing and abnormal cans bacterial plasmid generic 400 mg ethambutol visa, (see Official Methods of Analysis reference) virus e68 quality 800mg ethambutol. Examine metal container integrity of a representative number of normal and all abnormal cans that are not too badly buckled for this purpose (see Chapter 15). Inoculate each tube with 1-2 ml of product liquid or product-water mixture, or 1-2 g of solid material. After culturing and removing reserve sample, test material from cans (other than those classified as flat) whose pH is 4. If product is oily, add xylene to a warm, fixed film, using a dropper; rinse and stain. If product washes off slide during preparation, examine contents as wet mount or hanging drop, or prepare suspension of test material in drop of chopped liver broth before drying. Check liver broth before use to be sure no bacteria are present to contribute to the smear. Examine under microscope; record types of bacteria seen and estimate total number per field. After removing reserve sample from can, determine pH on remainder, using pH meter. At time growth is noted, streak 2 plates of liver-veal agar (without egg yolk) or nutrient agar from each positive tube. Incubate one plate aerobically and one anaerobically, as in schematic diagram (Table 20). If Gram-positive or Gram-variable rods typical of other Bacillus or Clostridium organisms are found in the absence of other morphological types, search to determine whether spores are present. In some cases, old vegetative cells may appear to be Gram negative and should be treated as if they are Gram positive. From each container, inoculate 4 tubes of acid broth and 2 tubes of malt extract broth with 1-2 ml or 1-2 g of product, using the same procedures as for low-acid foods, and incubate as in Table 21. Always test supernatants of cultures of this type for botulinum toxin even if no toxin was found in the product itself, since viable spores of this organism in canned foods indicate a potential public health hazard, requiring recall of all cans bearing the same code. No definitive conclusions may be drawn from inspection of cultures in broth if the food produced an initial turbidity on inoculation. Spoilage in acid products is usually caused by nonsporeforming lactobacilli and yeasts. Cans of spoiled tomatoes and tomato juice remain flat but the products have an off-odor, with or without lowered pH, due to aerobic, mesophilic, and thermopholic sporeformers. Spoilage of this type is an exception to the general rule that products below pH 4. Spoilage encountered in products such as tomatoes, pears, figs, and pineapples is occasionally caused by C. Cans which bypass the retort without heat processing usually are contaminated with nonsporeformers as well as sporeformers, a spoilage characteristic similar to that resulting from leakage. Can examination may not substantiate the bacteriological findings, but leakage at some time in the past must be presumed. Alternatively, the cans may have missed the retort altogether, in which case a high rate of swells would also be expected. A mixed microflora in the product, as shown by direct smear, in which there are large numbers of bacteria visible but no growth in the cultures, may indicate precanning spoilage. If no evidence of microbial growth can be found in swelled cans, the swelling may be due to development of hydrogen by chemical action of contents on container interiors. Thermophilic anaerobes produce gas, and since cells disintegrate rapidly after growth, it is possible to confuse thermophilic spoilage with hydrogen swells. This is particularly true of concentrated products containing sugar and some acid, such as tomato paste, molasses, mincemeats, and highly sugared fruits. Perform Gram stain on isolated colonies If mixed microflora is found only in bromcresol purple broth, report types. Prior to microbiological analysis, canned food samples must be incubated under appropriate conditions. Prior to being used, all the interior surfaces must be disinfected by a standard iodophore or quaternary ammonium compound at a concentration recommended by the manufacturer. After disinfection, the blower should be operated for at least one hour prior to initiating analyses. Efficiency of the unit should be monitored by using fallout plates exposed to the work station environment during the entire transfer period. There should be fallout plates to the left, right, and front of the samples undergoing analysis. Nondisposable plates should not be stored in pipet cans but should be wrapped no more than 5 to a package in heavy Kraft paper. Prior to beginning analysis, analysts should scrub hands and arms thoroughly with germicidal soap. Except for swollen cans, all incubated cans should be at room temperature before being opened. When the analyst is flaming sterilizing solution from lid, the side seam should be away from analyst. A common type kitchen can opener should not be used since the sample may become contaminated and the double seam may become distorted. Under no circumstances should the canned product be tasted since botulinum toxin may be present. If product misses retort completely, rods, cocci, yeasts or molds, or any combination of these may be present. Spoilage within the can may be caused by leakage, underprocessing, or elevated storage temperatures. Improper pressure control during retorting and cooling operations may stress the seam, resulting in poor seam integrity and subsequent leaker spoilage. Chemical corrosion that results in hydrogen swells and sulfide stains sometimes occurs. In addition, prolonged storage of cans at elevated temperatures is likely to promote corrosion which may result in perforations. Improper retorting operations, such as rapid pressure changes, may cause deformation of cans and damage the integrity of the seams. Postprocess contamination by nonchlorinated cooling water or excessive buildup of bacteria in can-handling equipment may also be responsible for many spoilage incidents. Sample adequate number of normal (flat) cans from same case or lot for can examination. Use same coding or subnumber system for product examination and container examination. Before any product sample is removed, container specialist should perform complete external can examination, observing such defects as evidence of leakage, pinholes, rusting, dents, and buckling, as well as general exterior conditions. Classify each can as (a) flat, (b) flipper, (c) springer, (d) soft swell, or (e) hard swell according to criteria in Chapter 14. However, these cans should be examined and then torn down and re-examined for seam defects that. The microbiologist should remove sample from uncoded end of can in manner that will not disturb double seam. If can end has been punctured as result of gas sampling, bacteriological can opener may be used if puncture is in center of end. Include the following in examination of container: Note condition of cans (exterior and interior) and quality of seams; observe and feel for gross abnormalities, mechanical defects, perforations, rust spots, and dents; perform pressure and/or vacuum tests to detect invisible microleaks either in double seam or side seam areas; measure seam dimensions and perform teardown examination; note condition of double seam formation and construction (by micrometer, seam scope, or seam projector). Visual examination the double seam (Figure 29) consists of 5 thicknesses of plate (7 thicknesses at the juncture of the end and the side seam for 3-piece cans) interlocked or folded and pressed firmly together, plus a thin layer of sealing compound. The side seam consists of 4 thicknesses of metal body plate, except at the lap or cross-over area, which has 2 thicknesses of metal. The side seam is bonded with solder, which is generally applied to the outer surface of the side seam. Welded 3-piece cans permit reduction of the side seam thickness and the double seam thickness at the cross-over juncture.
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The percentage of neutrophils is usually increased to 10-95% of total nucleated cells antibiotics for steroid acne purchase ethambutol 800mg visa, and they are typically non-degenerate bacteria 30 degrees celsius 400mg ethambutol mastercard. Joint sepsis and immune-mediated arthritis can produce very similar changes in total joint fluid nucleated and differential cell counts antibiotic resistance threat order ethambutol 600mg with visa. Although degenerate neutrophils are suggestive of bacterial or possibly a fungal joint infection antibiotics for dogs abscess purchase ethambutol 800 mg, neutrophils from infected joints are often not significantly degenerative. Consequently, further testing of joint fluid may be needed to distinguish infected from non-infected joints. If only small amounts of joint fluid are obtained, a drop of fluid can be added to culture medium. Alternatively, traces of synovial fluid can be washed from the syringe and needle by aspirating sterile saline or enrichment broth. Direct culture of joint fluid on blood agar, however, produces false negative results in 50-70% of patients with septic arthritis. One canine study demonstrated that inoculating a pediatric blood culture bottle with synovial fluid, incubating for at least 24 hours and then streaking the blood culture medium on appropriate plate media significantly reduced false negative culture results. Infectious agents are occasionally identified by direct cytologic examination of joint fluid. For example, rickettsial morulae have been found in neutrophils in the synovial fluid of up to 1% of affected patients. Other organisms that may be seen include bacteria within neutrophils, Borrelia burgdorferi spirochetes, Mycoplasma species, Leishmania amastigotes within macrophages, and fungal hyphae or yeast bodies. The overall goal of therapy is to achieve long term remission with the lowest possible dose of medication, and to prevent recurrence of joint inflammation. In areas where tick borne disorders such as Lyme disease and rickettsial infection are prevalent, initial therapy for polyarthritis should be limited to analgesics and empirical treatment with doxycycline. A recent American College of Veterinary Internal Medicine consensus statement on Lyme disease in dogs recommended treating with doxycycline at 10 mg/kg every 24 hours for 1 month. The same doxycycline dose should be effective for most common tick borne diseases. Dogs with polyarthritis induced by tick borne disease typically demonstrate clinical improvement within the first 7 days of doxycycline administration. It can, however, be dangerous in patients with bacterial arthritis, especially if this is related to a systemic bacterial infection. In patients where bacterial arthritis is suspected, treatment should be initiated with a broad spectrum, beta-lactamase-resistant bactericidal antibiotic until culture and sensitivity results return or until diagnostic test results suggest that a bacterial infection is not present. Specific treatment protocols have been described for the various manifestations of polyarthritis described previously. Treatment for drug induced polyarthritis, for example, requires discontinuation of the inciting drug and possibly a short tapering course of glucocorticoids. Dogs diagnosed with polyarthritis/polymyositis have been treated with a combination of cyclophosphamide and a tapering dose of prednisone with varying success. Juvenile onset polyarthritis in Akita dogs has also been treated with multi-drug protocols including a combination of prednisone and azathioprine, but with a less reliable positive outcome. Tick borne diseases, however, may benefit from concurrent treatment with doxycycline and a tapering dose of glucocorticoids. Once no underlying cause of polyarthritis has been identified, infection has been reasonably excluded, and a provisional diagnoses of Type I (uncomplicated) idiopathic polyarthritis has been established, a tapering dose of glucocorticoids is indicated if symptoms persist after more conservative treatment protocols have failed. Immunosuppressive doses of prednisone, prednisolone or methylprednisone (2-3 mg/kg/day once daily or divided) can be started initially. This dose is administered until there is no cytologic evidence of joint inflammation or the clinical signs of arthritis are no longer present. The dose can then be tapered every 2-3 weeks by 25-30% until the approximate physiologic dose of 0. Tapering glucocorticoids too quickly can lead to relapses that may be less responsive to treatment than the original manifestation of the disease. The addition of supplementary immunosuppressive agents should be considered if remission is not attained or if relapse occurs during treatment with steroids alone. If side effects with glucocorticoids or other immunosuppressive agents are intolerable, monotherapy with leflunomide can also be considered. When treating with a combination protocol, once remission of clinic signs is achieved, the drug causing the most concerning side effects (or, if no major side effects are seen, the most expensive drug) is typically tapered first. Therefore, if one immunosuppressive agent does not appear to be working, it can be replaced by another. In some patients, all drug therapy can gradually be tapered then discontinued without relapse. In other patients, an ongoing low dose of glucocorticoid is required in conjunction with an immunosuppressive agent. In these cases, the lowest possible doses that maintain clinical remission should be administered. Controlling pain is also an important part of restoring quality of life and allowing for tapering of immunosuppressive medications. After complete remission is attained, medications are tapered gradually over at least 6 months. Colchicine impairs the release of serum amyloid A from the liver by binding to hepatocyte microtubules and preventing amyloid secretion. Although colchicine is unable to reverse renal disease that has already occurred, the drug has been shown to decrease proteinuria in dogs with renal amyloidosis, slow disease progression and decrease the number or fever episodes. Colchicine should be started in any Shar-Pei with cyclic fevers since up to 30% of these dogs may develop life threatening renal amyloidosis. In addition to these supplements, a high quality, balanced, commercial dog food that contains an adequate level of Vitamin D3 that is low in simple carbohydrates and grains is recommended. Monitoring magnesium and cobalamin levels as well as careful attention to gastrointestinal, skin and thyroid health is also paramount. Erosive arthritis in dogs is more refractory to treatment and may require life long therapy. Since Mycoplasma has been found in the joints of some Greyhounds with erosive arthritis, a trial therapy using an antibiotic effective against this organism (such as tylosin) should be administered before considering immunosuppressive therapy. There is little published data available regarding the treatment of rheumatoid arthritis in dogs. Treatment recommendations are therefore usually extrapolated from the human literature. Chrysotherapy using gold salts has also been recommended for refractory cases of canine rheumatoid arthritis. Splenectomy is based on the presumption that the spleen is the site of immune-mediated neutrophil destruction. Urinary tract infections, often with minimal clinical signs and detectable only via culture, are commonly associated with chronic immunosuppressive therapy. Pneumonia is another possible infection that may go undiagnosed due to vague clinical signs such as lethargy and inappetence. Some dogs with Type I idiopathic polyarthritis, and most dogs with rheumatoid arthritis, will require long term or life-long management. Diets or dietary supplementations high in omega 3 fatty acids should also be considered in an effort to control inflammation. In these cases, surgical treatment of badly affected joints may be warranted, particularly if the underlying polyarthritis is in remission. Arthrodesis of collapsed joints may increase comfort, and synovectomy may help reduce local inflammation within that joint. Intra-articular injection of glucocorticoids such as triamcinolone or methylprednisolone has also been suggested as a means of controlling local inflammation. Monitoring Response to Therapy Swelling and pain associated with immune-mediated polyarthritis often respond to glucocorticoids, or a combination of glucocorticoids and other immunosuppressive agents, within 7 days of commencing therapy. Since significant joint inflammation may still be present despite resolution of clinical signs, the gold standard for monitoring response to therapy would be to repeat arthrocentesis before the first tapering of medication to ensure that the patient is in true remission. Documentation of a substantial decrease in total white cell count and neutrophils in synovial fluid on repeat joint taps is considered to be a good prognostic sign. If no significant improvement is observed in synovial fluid cytology, continuation of aggressive immunosuppression or commencement of alternative medications should be considered. C-reactive protein is an acute phase protein produced by the liver in response to inflammation that is commonly used in human medicine to monitor several inflammatory disorders, including rheumatoid arthritis. The rapid production of C-reactive protein in response to inflammation, and subsequent short circulating half-life, make the protein a good biologic marker of progression for many inflammatory diseases.
