X
|
STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
|
Juan C. Cendan, MD, FACS
Cytogenetic techniques indicated that the radiation doses of the patients in Rio de Janeiro ranged from 1 Gy to 7 Gy these cytogenetic dose estimates test cholesterol jeun generic lasuna 60caps with amex, although complicated by continuous radiation from internally deposited caesium-137 cholesterol medication niacin 60caps lasuna visa, were useful in prognosis and m anticipating medical management problems associated with bone marrow depression oxidized cholesterol in scrambled eggs lasuna 60 caps visa. Administration of irradiated (25 Gy) red packed cells and platelet infusions to maintain levels of haemoglobin above 1 home remedies cholesterol lowering foods 60 caps lasuna sale. Acyclovir, commencing about three weeks after radiation exposure, to prevent the activation of herpes virus. Antihelminthics, such as mebendazole and thiabendazole, according to the results of stool examinations or empirically (eosinophilia). Treatment of local radiation injuries Radiation induced skin injury was observed in 19 of 20 hospital patients. Patients exhibited swelling, erythema, bronzing, dry desquamation and blistering while in hospital in Goiania. Lesions were induced in hands, feet, legs, armpits and numerous small areas on the chest, abdomen, face, arms and the anteriomedial aspects of the legs. By 12 October the skin lesions exhibited drying, sloughing of necrotic skin and re-epithelization, confirming the occurrence of superficial injury by beta irradiation. Contamination levels were significantly reduced through sloughing of necrotic skin and by further attempts to decontaminate In both Rio de Janeiro and Goiania, localized burns were treated by topical applications of antiseptic and analgesic solutions, antibiotic creams, neomycin, juice of the aloe vera (thromboxane inhibitor) and alantoin (an anti-inflammatory agent) For patients m Goiania, two additional therapeutic approaches were adopted: injections of antiplatelet activating factor to lessen capillary injury and injections of vasodilators such as TrentalR and Iridux R. This was useful in determining the demarcation between injured and normal artenoles. Acceleration of decorporation the Goiania accident resulted in the highest levels of caesium-137 contamination clinically recorded. External contamination was observed in 249 persons out of some 112 000 people monitored in Goi&nia. Decontamination to remove externally deposited caesium-137 was successful in those individuals exhibiting little or no internal contamination. Internal contamination m other patients resulted in repeated recontammation of the skin due to sweating. The internally deposited caesium-137 presented a very different management problem, from both the medical and the health physics points of view. For those patients who had intakes of more than five times the annual limit of intake for caesium-137, the initial dose varied from 4 g-d" 1 to 6 g - d ~ l, taken in four to six equal doses. The effect of the administration-of-Prussian Blue: plot of content of radioactive material in the body versus time. From the results of the radiochemical analyses it was observed that increasing the dose of Prussian Blue resulted in higher radioactivities of faecal samples. From whole body measurements it was observed that an increase in the dose of Prussian Blue expedited the decorporation of caesium-137. More detailed studies of the effect of the administration of Prussian Blue on the biological half-life of caesium are being conducted. Radiochemical and in vivo analyses are being conducted periodically on patients with internal contamination. The serum levels of potassium were evaluated routinely twice a week and whenever there was a clinical indication to do so No significant variations in the serum levels of potassium were found One apparent side-effect was constipation in a very small number of patients; however, these patients responded well to diet control and laxatives Diuretics were used in patients having elevated rates of internal contamination and no clinical contra-mdication to such treatment. A total of 17 patients received diuretics, six of these patients also needed diuretics because of hypertension. Genera] support and psychological care the provisions described were intended to combat diseases identified during the hospital treatment, such as arterial hypertension, heart failure and arrhythmia or urinary infections Special emphasis was given to supportive psychological therapy, not only to minimize the psychological after-effects of the prolonged confinement and the stress sustained as a result of the accident itself, but also to ensure effective psychiatric treatment for some patients previously treated for psychiatric disorders. I: 38-year-old woman; died 23 October 1987 the external examination showed: Orbital haematomas; severe alopecia; mucosal pallor; and haemorrhages in the neck, thorax, conjunctivae, arms, legs and skin. The internal examination showed: Diffuse haemorrhages in all organs, most severe in the lungs and heart. Multiple areas of haemorrhage were present in the serosae of intestines and stomach. The lumina of these organs contained large amounts of haemorrhagic faecal material. There were diffuse oedema and petechiae throughout the intestinal and gastric mucosae. Gross impression: Widely disseminated haemorrhagic diathesis (the acute radiation syndrome). Cerebral oedema and petechial haemorrhages (possibly secondary to septic toxaemia). Areas of dermal ulceration, especially in the abdomen, periumbilical area and legs. The internal examination showed: Multiple areas of haemorrhage in plaques and spots through the entire skeletal musculature. The lumina of the stomach and intestines contained haemorrhagic material with involvement of the mucosae. Ecchymoses and petechial haemorrhages were also found in the serosae and in the cerebral and medullary leptomeninges. Gross impression: Disseminated haemorrhagic diathesis (secondary to the acute radiation syndrome). Multiple depigmented 49 dermal areas of desquamation Foci of necrosis and localized inflammation. These lesions were more severe on the internal surfaces of the thighs, scrotum and penis, and in the gluteal and inguinal regions. There were areas of epidermal desquamation and necrosis on the palms of the hands the internal examination showed. Haemorrhagic ecchymoses and petechiae of the serosae, most severe in the pericardium the lungs were firm, haemorrhagic and poorly aerated Their cut surface showed slightly elevated yellowish areas. The right ventricle of the heart was enlarged Haemorrhagic petechiae and ecchymoses were found in the mterventncular and subendocardial myocardium. There was generalized hyperplasia of the lymph nodes There was hyperaemia of the leptomeninges. Gross impression1 Bilateral haemorrhagic bronchopneumoma (secondary to total body irradiation) Fibrous pleuritis, right ventricular hypertrophy. Multiple areas of hyperchromasia in the epidermis with desquamating lesions, but with no inflammatory foci. The lungs were enlarged, showing haemorrhagic areas, particularly in the inferior lobes, where the cut surfaces had small elevated areas the heart was enlarged, mainly owing to the enlargement of the right ventricle. Haemorrhagic subendocardial and subpencardial petechiae were found the stomach and intestines showed mucosal petechial haemorrhages the skeletal muscles contained several haemorrhagic ecchymoses but less severe than those in the first two cases. The liver, spleen, kidneys, pancreas and adrenal glands showed petechial haemorrhages. Generalized systemic and cardiac haemorrhagic diathesis (secondary to the acute radiation syndrome) Right ventricular hypertrophy. Various dosimetry techniques were used to provide inputs to the initial screening of potentially exposed persons, the subsequent medical management of patients, and a general scientific assessment of the accident. The principal techniques used were as follows: - Internal dosimetry: bioassay and whole body monitoring; - Cytogenetics: estimation of doses by chromosomal aberration analysis; - External dosimetry: dose estimates from reconstructions and on the basis of radiation effects. These techniques, the facilities necessary, the difficulties encountered and the results obtained are described in the following sections. Methods the potential pathways for internal contamination were by inhalation, by ingestion and through wounds. Inhalation was not considered to be a major route, and air monitoring data and other data subsequently bore this out. The first step was to identify the people who had internal contamination, and the immediate action concentrated on estimating their intakes by monitoring urine and faecal samples. At the levels of radioactivity prevailing, samples had to be collected very carefully so as to prevent cross-contamination. The samples were collected in Goi^nia and were sent by air to Rio de Janeiro to be analysed. Many of the initial samples were so radioactive that a portable dose rate meter gave high readings. This simple means of monitoring was therefore used both to screen patients in hospital and to distinguish samples that required special handling.
The reported cases over the last three decades corresponds to an increase of 317 cholesterol levels malaysia buy 60caps lasuna visa,8% in Europe including Russia and 193 cholesterol ratio 3.4 discount lasuna 60 caps amex,2% in Europe without Russia (Suss cholesterol count for foods generic lasuna 60 caps online, 2008) cholesterol values blood purchase lasuna 60 caps without a prescription. The following data are mostly taken from (Suss, 2008, Suss, 2010) or referenced separately:! Cases averaged 27 during a period of 5 years between 2003 and 2007 (Suss, 2008, Suss, 2010). Denmark: Only the island of Bornholm with a few cases yearly is considered endemic, but first cases in Denmark outside Bornholm were reported. Estonia: With an incidence of 10,4-13,5 per 100,000 during 2003-2007, based on limited data, Estonia is considered to be highly endemic. Consuming unpasteurized dairy products contributes to nearly 30% (in 2005) of all cases (Kerbo et al. Finland: Endemic areas are mainly the Aland archipelago (66% reported cases, Incidence 80 per 100,000 in 2000), Turku and Kokkola and Simo, Lappeenranta. Germany experiences a steady increase in case reports and a steady expansion of endemic areas northwards and eastwards. Hungary: Incidence ranged between 1,3-3,8 per 100,000 until 1996, then a decrease was observed, which may be induced by reduced serological investigation in meningitis candidates (A. Italy: Northern Italy is considered to be endemic, case reports are increasing, currently around 20-30 per year. Kazakhstan: according to Suss, 2008 endemic regions are located around Almaty, underreporting seems to be common, total number of cases was between 6 and 34 cases annually. Poland: Many small parts of the country are considered to be endemic, mainly the north-eastern parts bordering Lithuania and Belarus and another hot spot are the regions adjacent to the Czech Republic (Kicman-Gawlowska et al. Western Siberia is the region with the highest incidence: 40 to >80 x10 per 100,000. Annual incidence rates tend to vary over the years, the reasons for this phenomenon are unclear. Slovakia: Most parts of the country are considered to be endemic, annual case numbers range between 46-92 during the period 1998-2007. Slovenia: 5 year average was 261 cases between 2001 and 2005, with increasing tendency. Switzerland and Liechtenstein: Switzerland has two high risk regions, the midland (except far western part) and the Rhine valley, including Liechtenstein. Switzerland 18 registered a continuous increase of cases, peaking in 2006 with 259 cases. Belarus, Bosnia, Moldavia, Albania: reporting of cases seems to be not established in these regions, although infected ticks are present. Mongolia: endemic areas exist close to the Russian border (Selenge and Bulgan, (Walder et al. Details are given in Table 2 (adapted and reprinted with permission from Donoso Mantke et al. For example, in Estonia, general practitioners, hospitals, and laboratories report cases to the regional health boards and these data are then collected by the national health board. However, as there are differences in development, preparation and use, the vaccines from Western Europe and those from Russia will be described separately. Table 3: Pharmaceutical composition of widely used tick borne encephalitis vaccines, past and present (Reprinted with permission from Zent and Broker, 2005). The production of the virus master seed is based on a mouse brain passage of the virus harvested from 5 infected ticks (Barrett et al. All purification and inactivation steps are nearly identical to those of Encepur. The pediatric formulation is licensed for children from 1-15 years of age (different from Encepur); the adult formulation from 16 years onwards. For concentration and further purification, ultracentrifugation in a sucrose gradient is performed. Historic versions of Encepur contained polygeline as stabilizer, but preparations since 2001 are free from any preservatives or additives. When the first pediatric formulation of a polygeline containing vaccine was introduced in 1994, infrequent (approximately 1/50. According to postmarketing surveillance in Germany, (Zent and Hennig, 2004), these reactions were presumably attributable to polygeline. This led to recall of the pediatric formulation in 1997 and to licensure of a new formulation of Encepur without polygeline as stabilizer in 2001. In the new formulation, a higher concentration of sucrose rendered another stabilizer unnecessary (Zent et al. However, in 1992 postmarketing surveillance in Germany revealed an increased incidence of adverse reactions in children as compared to adults (Zent and Broker, 2005); children suffered more often from febrile reactions, particularly after the first vaccination, and more often the younger the child. A new dose finding study demonstrated that half the amount of antigen was sufficient for an appropriate immune response in children, and that adverse reactions (especially fever) occurred less frequently with the new formulation (Girgsdies and Rosenkranz, 1996). In 2001, the manufacturer introduced separate formulations for children and adults, both formulations polygeline free (Zent and Broker, 2005), the only difference between the formulations being the amounts of antigen per dose (seeTtable 4). The pediatric formulation is licensed for children aged 1-12 years, the adult formulation for individuals #13 years of age. In the 1990s, the producer improved the purification process to remove heterologous proteins, following which the vaccine was approved for paediatric use. Following standard manufacturing practices, the harvested virus suspension is inactivated with formalin, then filtrated, concentrated, treated with protamine sulphate, and subsequently gel-filtrated. After addition of 250%g human serum albumin and 5mg gelatine and 37,5mg sucrose per final dose, the vaccine is lyophilized. The solvent contains aluminium hydroxide as gel, implying that adsorption takes place after reconstitution of the lyophilized vaccine. EnceVir contains human albumin as stabilizer, but no preservatives, and is free from formaldehyde, gelatine, and bovine serum albumin. The vaccine is not lyophilized (is a liquid formulation) and adsorption to aluminium hydroxide is performed before filling. Inactivation is controlled by biologic testing (intraperioneal and intracerebral inoculation of 30 mice per lot of vaccine). The mice are euthanized 6-8 days after infection and a suspension of harvested brain material is injected intracerebrally to another group of 30 outbred mice (2nd passage). However, the two vaccines show nearly identical immunogenicity results, both in children and adults, when vaccinated according to the conventional schedule (Table 5). The vaccines were compared with placebo, control vaccines, no intervention, or a different schedule or dose of the interventional vaccine. Demicheli et al conlude: i) Immunogenicity in children: With Encepur (old formulation with polygeline), the seroconversion rates were between 97% and 99-100% (Schondorf et al. This study revealed 95% seroconversion, after 2 or 3 vaccine doses; serological data following booster vaccination (9-12 months later) were not included in the review. With Encepur, there were no significant differences of seroconversion rates following the different immunization schedules, but slightly higher rates were obtained with the rapid immunization schedule. On the other hand, on day 300 the accelerated conventional schedule showed lower seroconversion rates. The review states that neither study, irrespective of age, provided evidence showing that the involved vaccines caused severe adverse reactions, although local reactions were commonly observed. Table 6 summarizes all published data from controlled trials on currently licensed Western vaccines (actual formulation after 2001). Four groups of adults (100 subjects per group) were vaccinated twice at intervals of 2 or 5 months. After two doses of EnceVir administered at the same intervals, antibody titres #1:80 were demonstrated in 82% and 89%, respectively. All vaccines were found to be highly immunogenic and were subsequently recommended for large-scale vaccination in Russia. Although the Russian vaccines have demonstrated their protective qualities in the field, randomized, controlled studies on their efficacy/effectiveness have not been conducted. Encepur) open-label, multicenter, uncontrolled, prospective follow-up Antibody persistence immunogenicity before and after booster: day 0, 21 safety (222) healthy, 1951 years antibody levels sustained up to 12-18 months, high antibody response after booster (after prim. Gov, 2010) Evaluation of vaccine Encepur Adult for induction of human neutralizing antibodies against recent Far Eastern subtype strains of tick-borne encephalitis virus. Gov, 2010) Antibody response following administration of two paediatric tick-borne encephalitis vaccines using two different vaccination schedules.
A small number of patients progress from chronic phase cholesterol in eggs and bacon buy generic lasuna 60 caps on line, which can usually be well managed cholesterol queen helene reviews discount 60 caps lasuna visa, to accelerated phase or blast crisis phase cholesterol guidelines chart 2011 generic lasuna 60caps without a prescription. Some of these additional chromosome abnormalities are identifiable by cytogenetic analysis cholesterol definition yahoo 60caps lasuna sale. In the chronic phase, fewer than 10 percent of the cells in the blood and bone marrow are immature white blood cells (blasts). In this phase, the number of blast cells in the peripheral blood and/or bone marrow is higher than normal. Hasford score uses the same factors as the Sokal system but it also includes the number of eosinophils and basophils circulating in the peripheral blood. For more information on the Hasford and Sokal scoring systems, see pages 46 and 50 in the Health Terms section. Some patients may have very high white blood cell counts at the time of diagnosis. This can create viscosity (thickness and stickiness of blood) problems and impair blood flow to the brain, lungs, eyes and other sites and also cause damage in small blood vessels. Chronic Myeloid Leukemia I page 15 Patients can be treated, at first, in two ways. Treatment {{Usually returns the blood cell counts to normal values within one month and maintains them either at or close to normal levels (slightly lower levels in blood cell counts are not uncommon) the size of the spleen quickly until it approaches its normal size prevent infections and abnormal bleeding patients to resume their previous levels of day-to-day activities. Individuals also need to have their tolerance to drugs assessed from time to time and may need dosage adjustments. If the first treatment does not work because of either intolerance or resistance to the therapy, a second treatment option is tried. If both the initial treatment and the subsequent treatment (second-line) fail to work, a third treatment option (third-line treatment) is offered to the patient. When Gleevec is not a treatment option, doctors decide, along with their patients, which of the other treatments will be the best alternative. Identifying the type of mutation responsible for resistance can help a doctor decide which drug to prescribe. When this happens, Sprycel, Tasigna, Bosulif and Iclusig can be alternative treatments. For instance, patients with Gleevec-resistant mutations V299 and F317 are not likely to respond to Sprycel or Bosulif and should be treated with Tasigna or Iclusig instead. Similarly, patients with Gleevec-resistant mutations G250, Y253, E255 and F359 are not likely to respond to Tasigna and should be treated with Sprycel, Bosulif or Iclusig. Interferon alfa (Roferon-A, Intron-A) Pegylated interferon alfa Hydroxyurea (Hydrea) Cytarabine (Cytosar-U) Busulfan (Myleran) Table 1. If patients are experiencing any side effects, they should let members of their healthcare team know right away because they will be able to provide necessary help. Common side effects from Gleevec may include {{Fluid retention (edema) around the eyes and vomiting cramps {{Puffiness {{Nausea {{Muscle {{Diarrhea {{Rash {{Chronic {{Possible fatigue cardiac effects (see page 22 for more information). However, it is possible that normal cells are also affected, which may cause these and other side effects. A "late effect" of treatment is a medical problem that does not show up or get noticed until years after the initial treatment. A rare but potential late effect of Gleevec therapy is the loss of the mineral phosphorus from bone which may lead to osteoporosis. Osteoporosis is a condition in which the normal balance of bone buildup and breakdown (an ongoing process in the body) shifts slightly-there is more bone breakdown and less bone buildup. In a one-to-one comparison with Gleevec, most side effects were reported less commonly in patients treated with Sprycel. Common side effects from Sprycel may include {{Low {{A white blood cell and platelet counts collection of fluid around the lungs (pleural effusion) I 800. In a one-to-one comparison with Gleevec, most side effects were reported less commonly in patients treated with Tasigna. For more information about the side effects of Gleevec, Sprycel or Tasigna, speak to your doctor and see the full prescribing information for these medications. Common side effects of Bosulif and Iclusig can be easily prevented or managed with appropriate supportive medication. They may include {{Diarrhea {{Nausea {{Vomiting {{Severe liver toxicity vascular events, such as arterial thrombosis. Patients with a history of cardiac disease need to be monitored carefully and frequently. It is unusual, but some patients who were treated with Gleevec, Sprycel and/or Tasigna have developed serious side effects such as {{Severe {{Left congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues) ventricular dysfunction (difficulty emptying blood from the left lower chamber of the heart). Your doctor will give you a list of medications to avoid, and will monitor you for these conditions, as needed, before and during treatment. The most common side effects include {{Low page 22 red and white blood cell counts I 800. Side effects can include {{Flulike symptoms such as fever, muscle aches and weakness fatigue and weight loss, which may require a reduction in dosage {{Prolonged {{Hair loss {{Diarrhea {{Depression {{Ulceration {{Cardiac {{Other of the lining of the mouth effects side effects that occasionally occur. Prior to these therapy options, allogeneic stem cell transplantation was the principal means of successful treatment for patients of an appropriate age, in generally good health and with an available donor. These patients are counseled by their doctors to weigh the benefits and risks of having an allogeneic stem cell transplant while they are still in remission after their initial Gleevec treatment and particularly after second-line treatment with Sprycel. This approach increases the likelihood of successful remission after transplantation, assuming that drug side effects are minimal. Although transplants are typically more successful in younger patients, there is no specific age cutoff for stem cell transplantation. These include percent of patients who undergo stem cell transplantation will die from complications of the procedure within one to two years. For information on other treatment options that are either being researched or are in clinical trials, please see page 36. In general terms, the greater the response to drug therapy, the longer the disease will be controlled. Longer-term safety data have also been reported for Sprycel (approved in 2006) and Tasigna (approved in 2007) in patients with Gleevec resistance or intolerance. In addition, the findings from the ongoing, careful monitoring for long-term or late effects is reassuring so far. It is important for patients to continue taking their medication to get the best response. Once blood counts return to normal levels, blood tests will generally be performed every three to six months. After achievement of a complete cytogenetic response, bone marrow testing can be performed infrequently. The inability to achieve a milestone at a certain time after the start of therapy may indicate a need to change the direction of treatment. Talk to your doctor about your milestones and if you have reached an appropriate response. Thus, if a person has a high white blood cell count at the beginning of therapy, a "complete hematologic response and some cytogenetic improvement" may occur later than "after three months of therapy. Some insurance carriers consider mutation assessment a "genetic" test and will only authorize a single such test per lifetime. Patients should talk to their doctors and members of their healthcare teams to ensure that, if needed, the mutation testing will be covered by their insurance companies. The features of disease at diagnosis and the response to therapy in children seem to be similar to that in adults. More than 80 percent of children with chronic phase disease treated with Gleevec achieve complete cytogenetic response. Stopping treatment with Gleevec can result in catch-up skeletal growth (when the body begins to grow again after a period of slowed development). Complications of a transplant remain challenging, so treatment with Gleevec continues to be the first choice for younger patients in chronic phase despite the potential side effects associated with its use. This can be overwhelming for parents of children and young adults because remembering to take the drug consistently and as ordered can be hard at times. It is important for your child to be seen by a doctor who specializes in pediatric leukemia. Data are available from a limited number of pregnancies that have occurred accidentally in women who were taking Gleevec. While many children who were exposed to Gleevec in the uterus have been born healthy and without apparent abnormalities, there have been a few abnormalities noted both in live births and in aborted or miscarried fetuses. There is hope that by achieving deep molecular responses in a higher proportion of patients that these new agents may facilitate more treatment interruptions, but this issue is not yet resolved.
Buy 60 caps lasuna overnight delivery. The Best Cooking Oils for Your Health and Heart [Hindi].
Several studies have reported that deep-level similarity is one of the most important predictors of team cohesion (Byrne cholesterol definition in food buy generic lasuna 60caps on-line, 1971; McGrath cholesterol ratio mercola buy lasuna 60 caps with amex, 1984) and long-term performance (Edwards et al cholesterol test not covered by insurance order lasuna 60 caps mastercard. In contrast cholesterol and testosterone buy lasuna 60 caps fast delivery, studies generally do not find support that surface-level diversity affects long-term performance; rather surface-level diversity affects short-term performance until team members have enough time to get to know each other, and the focus shifts away from surface-level differences. While some studies indicate that surface-level diversity affects performance and decision-making, these studies focus on short-term performance and decisions that require greater creativity. The effects of surface-level diversity dissipate over time and are not likely to enhance the ability of a team to avoid "group think" or to continue creative problem solving; whereas the effects of deep-level diversity have little impact on short-term performance but become more salient the longer that a team exists (Harrison et al. Research in identifying the right "mix" of team members indicates that different kinds of diversity have different consequences on team conflict and, in turn, on team performance (Pelled and Xin, 2000). An important distinction in team conflict literature is the distinction between interpersonal and task conflict (De Dreu and Weingart, 2003). In a review of the literature, Mannix and Neale (2005) conclude that surface-level differences. Deep-level diversity negatively impacts long-term performance only when teams are not provided with the training and incentives to manage interpersonal conflicts. When training and incentives for managing diversity are provided, deep-level diversity helps teams to maintain moderate amounts of the positive task conflict that supports team performance. Realistically, if future Exploration missions involve international partnerships, it may be difficult to schedule sufficient time for crew members to train together and learn to leverage their differing cultural norms. Future research should help to determine whether there are other viable means of training team members together. In summary, the relationship between deep-level diversity, conflict, leadership, and team performance is of more interest for long-duration missions than for surface-level diversity (refer to Table 2-2 for a summary of the evidence). However, the lack of extensive empirical research in these areas demonstrates the little that 54 Risk of Performance Errors Due to Poor Team Cohesion and Performance, Inadequate Selection/Team Composition, Inadequate Training, and Poor Psychosocial Adaptation Human Health and Performance Risks of Space Exploration Missions Chapter 2 is known about team composition and how the makeup of a crew may impact crew performance. Furthermore, the lack of empirical research conducted in a space flight or similar analog setting also brings into question the suitability of applying these findings of team composition to space flight. Thus, a further examination of crew composition, as it relates to optimal team performance, must be conducted (when in a space or similar analog setting) to help determine what deep-level diversity actually exists among crews, what deep-level characteristics impact astronaut performance, and what kinds of operational interventions. Summary of Findings Presented for Crew Composition Source Predictor Outcome Context Evidence Type Allen and West, 2005 Barry and Stewart, 1997 Harrison et al. Training and supporting optimal performance, as well as selecting high performers, is a more effective and efficient approach than simply selecting high performers (Holland et al. Training involves imparting knowledge and/or teaching skills to a group of individuals. However, training team skills and supporting optimal performance entails more than educating astronauts about the technical aspects of the job. When considering optimal performance, any training design should be accompanied by an evaluation to determine the standards of optimal, adequate, or inadequate performance, and what skills help differentiate expert from novice teams. In this way, training can be validated by checking student progression and the performance of teams before and after training. It is therefore recommended that team performance standards and levels be documented in the space flight context before effective training is designed. To date, this type of information is unavailable to researchers, and acquiring such performance data requires a better partnership between research and operations. Developing the right kind of training for team skills that will support astronaut performance is further complicated by other operational issues. To begin with, it is difficult to get an accurate picture of what knowledge and skills are required for successful performance. On an Exploration mission, new tasks may arise suddenly, so team training needs to be broad and flexible enough to support unexpected performance requirements. Another operational issue is that space exploration is a relatively new job, and not many Risk of Performance Errors Due to Poor Team Cohesion and Performance, Inadequate Selection/Team Composition, Inadequate Training, and Poor Psychosocial Adaptation 55 Chapter 2 Human Health and Performance Risks of Space Exploration Missions individuals have performed it, particularly for long-duration missions (only four individuals have lived and worked in space for 1 year). While all experienced astronauts are polled for this information on a regular basis, only a limited number of experienced astronauts can describe what kind of training they found useful on the job and what kind of training has not been critical to their performance. This situation makes describing successful performance reliably more difficult and evaluating the relationship between training and performance improvement more challenging, especially when considering the team context. Performance expectations include maintaining a healthy psychological and social environment in addition to achieving technical objectives. Subject matter experts within the various space agencies argue that teamwork skills are critical to accomplishing overall mission objectives safely. As astronauts perform complex technical tasks that are at the forefront of modern science and human limitations, they currently complete a rigorous technical training curriculum that can span from 2 to 5 years. Adding requirements that allow them to practice or perfect skills is a critical concern for schedulers. If, as research suggests, teaching team members to exchange mental models and perceptions concerning performance can reduce the amount of time that is required to master a skill (Cannon-Bowers and Salas, 1998b; Edwards et al. Accordingly, a meta-analysis of 97 studies, involving 11 different types of interventions, that was conducted by Guzzo et al. Evidence indicates that two facets of training are relevant to team performance: (1) individual training on teamwork and interpersonal skills, and (2) time training as a team. Teamwork and Interpersonal Skills for the Individual Space flight evidence regarding teamwork and interpersonal skills training is more limited than ground-based evidence. Many training efforts in industry and in the military focus on developing the interpersonal skills of group members to enhance team performance. Four different training criteria were also identified: 56 Risk of Performance Errors Due to Poor Team Cohesion and Performance, Inadequate Selection/Team Composition, Inadequate Training, and Poor Psychosocial Adaptation Human Health and Performance Risks of Space Exploration Missions Chapter 2 reaction (self-report), learning (test performance, usually pencil and paper), behavior (on-the-job performance, supervisor ratings, or objective measures), and results (company-category productivity, profits, or return-on-investment). These researchers concluded that cognitive and interpersonal skills training have the largest positive effects on behavioral criteria. The interpersonal skills that contributed to performance include: role clarification, goal setting, identifying work priorities, group problem solving, team coordination, interpersonal relations and understanding, consensus building, and conflict management. Dependent measures that showed improvements included: cohesion, personal growth, motivation, team performance, work efficiency, and job satisfaction. It may therefore be suggested that interpersonal skills training relates positively to team performance. In a review of the factors that determine the ability of a team to adapt its performance to successfully handle changing conditions, Burke et al. In a laboratory simulation, researchers found that training that is designed to improve individual communication and interaction skills improves team performance under novel work conditions (Marks et al. In a similar study that was done with 60 graduate students in assigned teams, SmithJentsch et al. Other studies suggest that teams that are composed of team members who have more knowledge concerning teamwork perform better than teams that are composed of team members who have less knowledge concerning teamwork (Morgeson and DeRue, 2006; Hirschfeld et al. In a manufacturing organization, Morgeson and DeRue (2006) observed that individual knowledge concerning teamwork helped to predict team performance. Outside of the field and laboratory setting, however, we find little empirical evidence that relates interpersonal skills to the individual in a space flight or an analog setting. Nevertheless, the overall conclusion of the evidence that has been presented suggests that teamwork and interpersonal skills training promote team performance. Research must still help to determine the best kinds of interpersonal and teamwork skills training as well as the best implementation means for supporting optimal team. Furthermore, research must be conducted in analog and/or extreme environments and space flight contexts to examine interpersonal and teamwork skills training so that these findings may be extended to space flight. Ground-based research supports the idea that employees who are interacting in stressful environments, with high workloads, or in environments that require coordination at a distance (similar to the manner in which ground support and flight crews operate together) need team training (Harrison et al. In a study of 27 manufacturing teams (263 individuals) who had worked together for an average of 1. Research indicates that more experience working together bolsters the performance of a team in a variety of ways, and that team training is one means of ensuring that team members gain some experience working together (Paris et al. More conflicts are generally associated with more stress, increases in errors, and decreases in productivity (Alper et al. This seems highly relevant when considering that current plans for astronaut teams include reducing the time that is spent training together. Reductions in team training will likely increase conflict and related performance decrements as the teams will be less able to create interpersonal ties and share mental models. The authors note that team training is one mechanism whereby team familiarity and the density of interpersonal ties can be increased; however, it is important to note that non-work-oriented team training may not be sufficient or worthwhile by itself. Studies with geographically distributed teams that compare task-based team training with more socially oriented time together indicate that team members who are familiar with one another socially, but have little to no experience working together as a team, do not realize the same performance benefits as teams that consists of members who are experienced in working together (Espinosa et al. In so far as team training requires that team members complete a task or objective as a team, it encourages better team performance (see Table 2-3 for a summary of the evidence that is cited). Interpersonal skills training that is intended to improve team member interactions and other teamwork skills training also encourages better individual and team performance.
One challenge that he sees in creating written discharge instructions is dealing with the fact that they are out of date almost from the moment they are created cholesterol medication pregnancy buy lasuna 60 caps amex. For example cholesterol in 2 scrambled eggs buy lasuna 60 caps otc, the discharge instructions may include medication that the patient needs to get after discharge cholesterol medication side effects simvastatin purchase lasuna 60 caps line, but perhaps the patient cannot get to the pharmacy to get the prescriptions filled cholesterol fluidity discount lasuna 60 caps overnight delivery. Unless someone takes the time to go over the discharge instructions before the health care provider hands those instructions to the patient, and unless the health care provider takes time to review the discharge instructions before talking to the patient about them, the opportunity is ripe for the patient to receive something with little value and for the health care provider to be embarrassed. Thinking of the care plan as a process instead of a form allows the health care provider to think about every document that goes to the patient in terms of how that document meets an educational agenda, explained Paasche-Orlow. It is important that the health care provider think about how a document will be empowering and activating for a patient and what educational process is required to support that document. Health care systems need to think about what training is necessary for staff and what supervision and monitoring processes are going to be needed for this process to take place. Another lesson, Paasche-Orlow said, was the need for a new position, the nurse discharge advocate, who takes responsibility for interacting with the care team, reconciling the medication list, scheduling appointments, facilitating the checklist, and ensuring that the care plan meets national guidelines. The nurse discharge advocate also teaches the care plan and makes sure that the patient understands the details of the plan. This section is followed by one in which patients can develop an agenda and write down questions for each health care provider at these future appointments. The communication areas we currently focus on include reducing medication errors, improving medication adherence, and effective transitions of care," explained Charles Lee, who founded the company in 2001. His approach is to consider health literacy as a personal skill for gathering, understanding, and then acting on appropriate health information. Improving understanding also requires the use of visual aids to reinforce written concepts and the use of font sizes that the elderly and visually impaired can actually read. Lee agreed with Paasche-Orlow that patient discharge is a process, not just a form, and it is essential then that the discharge instructions include specific actionable items presented in a way that is both personalized and encourages dialogue with the health care provider. The medication summary (see Figure 5-2) is organized by time of day in an easy-to-read chart format. The summary that Lee presented was written in Spanish, but the Polyglot system is currently capable of generating the summary in 19 different languages. A pilot study of this "Meducation calendar" showed that it reduced medication nonadherence by 56 percent over the first 90 days, compared to a baseline measurement taken prior to using this module (Zullig et al. These sheets can be generated in one of three font sizes for patients with visual impairments. A pilot study involving 94 bilingual patients found that these discharge instructions were considered the best among all the models from the 18 participating sites. Figure 5-3 Bitmapped study was that patients and physicians both preferred by a large margin a format that included both English and the second language in a dualcolumn format. Physicians preferred the dual-column format because they did not like handing out materials they could not read themselves. Patients preferred the dual-column format because it enabled other English speakers in their household to be able to read the instructions. He noted that one of the challenges to creating these types of documents is that they need to accommodate both science and art. The science part includes research-based best practices, such as the use of the Universal Medication Schedules; appropriate grade reading level; layouts that are visually pleasing and easy to read; and reinforcements of educational messages. The art part has to do with the intangibles-the key points that need to be included for a specific patient and the presentation for that particular patient given his or her cultural and language background. There are some positive indicators, though, Lee noted, particularly associated with accountable care organizations and patient-centered medical homes that receive payments on the basis of health outcomes. A key to making inroads, he added, is that these types of tools will have to be integrated into the current workflow. He added in closing that "we need to stop hoping that patients are going to figure this out by themselves and give them instructions that will get them engaged- instructions that they can actually read, understand, and then act on. Lee said that pharmacies might be a good target given that they deal directly with consumers. Paasche-Orlow added that patient satisfaction could be an important lever given that 30 percent of a value-based purchasing score will be based on satisfaction scores. Also, is there any integration of these instructions with how patients or their family members actually manage the counting out of tablets for each period Paasche-Orlow responded that a number of issues are involved in trying to turn this into a living tool. Another problem is that because patients have to pay different out-of-pocket amounts for medications, depending on their insurance coverage, some of them may not fill the prescriptions because of cost. Although there are great difficulties with relying too heavily on information technology, that is how we are going to be able to address these issues, he said. Benard Dreyer asked Paasche-Orlow what was known about which of the listed 12 steps for reinforcing components for discharge instructions were most important. Paasche-Orlow said the answer is unknown because they did not have a way to differentiate the relative effects of the different components. There is a change in the length of the process, moving from an 8-minute-per-discharge conversation with patients to 45 to 50 minutes of conversation, education, and confirmation of comprehension. And, he said, the follow-up telephone call appears important because about half the time even those individuals who received the full intervention still had something related to medication that needed to be dealt with in the call. It is interesting to note, he said, that about 30 percent of the prescriptions written were still not filled at the time of the follow-up call, a number that shows that there is great need for improvement. Wilma Alvarado-Little asked Lee what thoughts or ideas he has about adding languages, even languages with less diffusion, as the demographics of the United States change. Lee responded that the development of forms in different languages is market driven. For example, there are many German speakers in the United States, but they tend to speak English very well. The population of Chinatown, however, which is somewhat isolated from the rest of the city, and the Hmong population have more of an issue with understanding the English language. Once a form has been developed for a particular customer, it becomes instantly available for every other customer, he said. Given the complex issues involved in pain relief medication and the potential for abuse or unintentional habituation of pain medications, Isham asked, how does one deal with those challenges in discharge instructions for a low literacy population and those with limited English proficiency Lee responded that it is very complicated and that there is a big difference between unintentional habituation and intentional misuse. Acetaminophen is particularly difficult because not only do prescription products contain the drug but also so do many over-the-counter products. One must ask oneself whether the patient is a person who is at risk for diversion or for under management of his medications and proceed accordingly. Kim Parson said that the entire process has to be thought of in the context of a partnership between health care providers and their patients, a comment reiterated by Betsy Humphries, deputy director of the National Library of Medicine. Lori Hall, consultant for health education at Eli Lilly and Company, added that the discharge plan is a tool and cannot replace the human element when educating patients about the various aspects of their care after discharge. She also commented that it is important to remember that information overload is real and that handing a patient a thick booklet of instructions without having a person there to explain important items is likely to lead to more problems than it solves. Her colleague at Merck, Margaret Loveland, said that the presentations and discussions made it clear that, above all, discharge instructions have to be meaningful, succinct, up to date, and accurate and that they have to account for cultural and language issues specific to individual patients. Laurie Francis noted, too, that discharge summaries can be an important part of the process that helps patients navigate the system by increasing health literacy. Brach also reminded the roundtable of another workshop on patient-centered prescription labels at which a speaker challenged the attendees to step up and use the models that had been developed and tested. Pharmacopeia stepped up to the plate and proceeded to assemble an advisory group to come up with standards that they then published as recommendations for a patient-centered label," she recounted. Getting vendors, clinician associations, and patients together to help the market realize this opportunity is something where we could make a contribution as a group.
References