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The local health officer hypertension 4011 buy generic labetalol from india, in consultation with the superintendent can take whatever action deemed necessary to arrhythmia heart beats labetalol 100 mg sale control or eliminate the spread of disease blood pressure eating order labetalol 100 mg with amex, including closing a school heart attack early symptoms order 100mg labetalol visa. List of Reportable Diseases In consultation with the school nurse arrhythmia pvc treatment buy labetalol 100mg mastercard, the district will report suspected disease or disease with known diagnosis to the local health department as indicated on the Notifiable Conditions page of the Washington Department of Health’s website. When symptoms of communicable disease are detected in a student who is at school, the regular procedure for the disposition of ill or injured students will be followed unless the student is fourteen years or older and the symptoms are of a sexually transmitted disease. Call the parent, guardian or emergency phone number to advise him/her of the signs and symptoms; 2. Keep the student isolated but observed until the parent or guardian arrives; and 4. Notify the teacher of the arrangements that have been made prior to removing the student from school; 5. Notify the school nurse to ensure appropriate health-related interventions are in place. Students should be asked to wash their own minor wound areas with soap and water under staff guidance when practicable. Gloves must be worn when cleansing wounds which may put the staff member in contact with wound secretions or when contact with any bodily fluids is possible; 3. Body fluids include blood, semen, vaginal secretions, drainage from scrapes and cuts, feces, urine, vomitus, saliva, and respiratory secretions; B. Sharps containers must be maintained upright throughout use, be tamper-proof and safely out of students’ reach, be replaced routinely and not be allowed to overfill. To be effective, a release must be signed and dated, must specify to whom the release may be made and the time period for which the release is effective. Students thirteen and older must authorize disclosure regarding drug or alcohol treatment or mental health treatment. Students of any age must authorize disclosure regarding family planning or abortion. A general authorization for the release of medical or other information is not sufficient for this purpose. New employee training will be provided within six months from the first day of employment in the district. The following definitions shall apply in the interpretation and the enforcement of these rules and regulations: (1) "School" Shall mean any publicly financed or private or parochial school or facility used for the purpose of school instruction, from the kindergarten through twelfth grade. Ceiling height shall be the clear vertical distance from the finished floor to the finished ceiling. No projections from the finished ceiling shall be less than 7 feet vertical distance from the finished floor. No student shall occupy an instructional area without windows more than 50 percent of the school day. However, local code requirements shall prevail, when these requirements are more stringent or in excess of the state building code. If hand operated self-closing faucets are used, they must be of a metering type capable of providing at least ten seconds of running water. All sewage and waste water from a school shall be drained to a sewerage disposal system which is approved by the jurisdictional agency. Only closed vehicles shall be used in transporting foods from central kitchens to other schools. The board of health may, at its discretion, exempt a school from complying with parts of these regulations when it has been found after thorough investigation and consideration that such exemption may be made in an individual case without placing the health or safety of the students or staff of the school in danger and that strict enforcement of the regulation would create an undue hardship upon the school. Standard Precautions (includes universal precautions) Standard precautions are a newer approach to infection control. They combine the major features of universal precautions, and body substance isolation, and are based on the principle that all blood, body fluids, secretions (including respiratory secretions), excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions include a group of infection prevention practices that apply to all persons, regardless of suspected or confirmed infection status, in any setting with delivery of healthcare, including first aid. Enough sanitizer should be used to wet the hands for at least 15 seconds or longer if indicated by the manufacturer. Remember, alcohol hand sanitizers have not been shown to be effective against norovirus or Clostridium difficile spores or for soiled hands. Use of Gloves • When possible, direct skin contact with body fluids should be avoided. However, utility gloves must be discarded if they are cracked, peeling, torn, punctured, or exhibit other signs of deterioration, or when their ability to function as a barrier is compromised. Staff with sores or cuts on their hands (non-intact skin) having contact with blood or body fluids should always double glove if lesions are extensive. Contaminated Sharps • Students should be advised to report found needles, broken glass, or other sharps, but not touch them. Cleanup must be accomplished using mechanical means such as a brush and dustpan, tongs, or forceps, by staff wearing appropriate protective gloves. Broken glass should be disposed of in a container which keeps others from being cut. The secondary container must be closable, constructed to contain all contents, and prevent leakage during handling, storage, transport, or shipping. Sterilizers destroy or eliminate all forms of microbial life including fungi, viruses, and all forms of bacteria and their spores. Manufacturer label instructions must be followed, including those for personal protective equipment. The area to be disinfected must stay wet for the length of time indicated on the label to kill the microorganisms. For general disinfection, choose a product that is effective against most bacteria and viruses and lists schools as a recommended site. A 1:10 bleach solution of household (5-6%) bleach with a minimum five-minute wet contact time is necessary to kill C. Never mix cleaners and disinfectants, or any other chemicals, unless the labels indicate it is safe to do so. Never soak wipe cloths or mops in a class of disinfectant that is different from the disinfectant you were using on the cloth or mop to clean a surface or item. For example, chlorine bleach must never be mixed with ammonia or acids such as vinegar. Never use disinfectant or pesticide foggers in schools or spray disinfectants into the air. Procedures for Cleaning and Disinfection of Hard Surfaces • the employer must ensure those who are cleaning wear non-latex or utility gloves or other protective equipment. There should not be exposure of open skin or mucous membranes to blood or body fluids being cleaned. When products contain both detergents and disinfectants, you can clean first with the product; then use a fresh wipe or cloth to disinfect the surface. If a surface is visibly dirty, a cleaner or detergent must be used first, then the surface disinfected. Blood or Body Fluid Spills • Many schools stock sanitary absorbent agents specifically intended for cleaning body fluid spills. The dry material is applied to the area, left for a few minutes to absorb the fluid. Paper towels or other towels used to clean-up vomit should be immediately placed in a sealed trash bag for disposal. Microfiber clothes and mops have been shown to be more effective, easier to clean, and use, than the old cloth ones. Procedures for Cleaning and Disinfection of Carpets/Rugs • the employer must ensure that those who are cleaning wear non-latex or utility gloves or other protective equipment and avoid exposure of open skin or mucous membranes to blood or body fluids. Disposal of Blood-Containing Materials • the employer must ensure school custodians wear utility gloves for disposing of soiled items, plastic bags containing soiled items, and whenever there is a risk of puncture. Procedures for Cleaning and Disinfection of Cleaning Equipment • the employer must ensure employees who have contact with cleaning equipment wear protective gloves. This determination should not be based on actual volume of blood, but rather on the potential to release blood. Those involved in the care and education of children should respect the individual’s right to privacy and the confidentiality of school and medical records. Law prohibits unauthorized disclosure of a person’s status with regard to any sexually transmitted disease. The nurse might further protect the confidentiality of this information by using broad language when describing the need for the accommodation rather than providing a specific diagnosis. Individual judgments need to be made regarding the placement of children with questionable behavior, impaired neurologic development, or other medical conditions in the typical school or child care setting. These decisions, for children Grades K–12, are best made at the local school district level using the team approach. A minor fourteen years of age or older who may have come in contact with any sexually transmitted disease or suspected sexually transmitted disease may give consent to the furnishing of hospital, medical and surgical care related to the diagnosis or treatment of such disease. All common schools shall give instruction in reading, penmanship, orthography, written and mental arithmetic, geography, the history of the United States, English grammar, physiology and hygiene with special reference to the effects of alcohol and drug abuse on the human system, science with special reference to the environment, and such other studies as may be prescribed by rule or regulation of the state board of education. Occupational Exposure to Bloodborne Pathogens, National Association of School Nurses, Inc. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. Washington State Department of Health—Immunization and Child Profile Office Forms and Publications (flyers, fact sheets, brochures, letters). Washington State School Nurse Corps Resources: • Online School Nurse Resource Guide: library. Questions and complaints of alleged discrimination should be directed to the Equity and Civil Rights Director at (360) 725-6162 or P. Sukardi Department of Biomedical Science, Faculty of Medicine and Health Sciences, University Putra Malaysia, 43400 Serdang, Selangor Darul Ehsan Abstract: Vitamin E is divided equally into 2 families, tocopherols and tocotrienols. Being an antioxidant, vitamin E has been reported to improve disorders related to oxidative damage in many organ systems. Sources of vitamin E can be found in many foods including palm oil which is rich in tocotrienols. Studies on the effects of vitamin E on male fertility have shown encouraging results. This study was conducted to observe the effects of feeding tocotrienols from palm oil to male Sprague-Dawley rats on sperm parameters, testes weight and sperm ultrastructure. Thirty-five rats were separated equally into 5 groups: initial group (sacrificed before experiment for base line values), control group (fed commercial pellets only), vehicle group (palm oil), low dose and high dose of tocotrienol treatment groups. High dose of tocotrienol increase sperm parameters suggesting that the mechanism for better male fertility is related to better cristae membrane integrity in sperm. Introduction Most studies focus on the consequences of a lack of vitamin E on the biological body.

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Department of Justice; Randy Hanzlick blood pressure chart 50 year old male cheap labetalol 100mg without a prescription, Fulton County Medical Examiner’s Center and Emory Uni ersity School of Medicine; Carol Henderson blood pressure medication photosensitivity cheap labetalol 100mg otc, National Clearinghouse for Science blood pressure app cheap 100mg labetalol with visa, Technology and the Law and Stetson Uni ersity; Matthew J arrhythmia tutorial cheap 100 mg labetalol mastercard. Johnson blood pressure chart in hindi order labetalol american express, Illinois State Police; Jay Kadane, Carnegie Mellon Uni ersity; David Kaye, Arizona State Uni ersity; Peter D. Koppl, Farleigh Dickinson Uni ersity; Glenn Langenburg, Minnesota Bureau of Criminal Apprehension; Deborah Leben, U. Leshner, American Association for the Ad ancement of Sci ence; William MacCrehan, National Institute of Standards and Technology; Bill Marbaker, American Society of Crime Laboratory Directors; Kenneth F. Martin, Massachusetts State Police; Carole McCartney, Uni ersity of Leeds; Stephen B. Peterson, Hennepin County Medical Examiner’s Offce and National Association of Medical Examiners; Joseph L. Peterson, California State Uni ersity, Los Angeles; Peter Pizzola, New York Police Department Crime Laboratory; Joe Polski, Consortium of Forensic Science Organizations and International Association for Identifcation; Larry Quarino, Cedar Crest College; Irma Rios, City of Houston Crime Lab; Michael Risinger, Seton Hall Law School; Michael J. Senn, the Uni ersity of Texas Health Science Center at San Antonio; Robert Stacey, American Society of Crime Laboratory Directors, Laboratory Accreditation Board; David Stoney, Stoney Forensic, Inc. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confdential to protect the integrity of the process. Stephen Berry, University of Chicago; Christophe Champod, Universite de Lausanne, Switzerland; William Chisum, Retired, National Crime Investigation and Training; Joel Cohen, Rockefeller University; Peter DeForest, John Jay College of Criminal Justice; Stephen Fienberg, Carnegie Mellon University; Barry Fisher, Los Angeles County Sheriff’s Depart ment; Mark Flomenbaum, Boston University; Ross Gardner, Gardner Fo rensic Consulting; Paul Giannelli, Case Western Reserve University; Randy Hanzlick, Emory University; Keith Inman, Forensic Analytical Sciences, Inc. Owen Lovejoy, Kent State University; Kenneth Melson, George Washington University; Michael Murphy, Offce of the Coroner/Medical Examiner, Las Vegas, Nevada; Hyla Napadensky, Retired, Napadensky Energetics, Inc. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the fnal draft of the report before its release. The review of this report was overseen by John Bailar, University of Chicago, and Royce Murray, University of North Carolina, Chapel Hill. Appointed by the National Academies, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the fnal content of this report rests entirely with the authoring committee and the institution. There are scores of talented and dedicated people in the forensic science community, and the work that they perform is vitally important. They are often strapped in their work, however, for lack of adequate resources, sound policies, and national support. It is clear that change and advancements, both systemic and scientifc, are needed in a number of forensic science disciplines—to ensure the reliability of the disciplines, establish enforceable standards, and promote best practices and their consistent application. In adopting this report, the aim of our committee is to chart an agenda for progress in the forensic science community and its scientifc disciplines. Because the work of forensic science practitioners is so obviously wide reaching and important—affecting criminal investigation and prosecution, civil litigation, legal reform, the investigation of insurance claims, national disaster planning and preparedness, homeland security, and the advance ment of technology—the committee worked with a sense of great commit ment and spent countless hours deliberating over the recommendations that are included in the report. These recommendations, which are inexorably interconnected, refect the committee’s strong views on policy initiatives that must be adopted in any plan to improve the forensic science disciplines and to allow the forensic science community to serve society more effectively. The task Congress assigned our committee was daunting and required serious thought and the consideration of an extremely complex and decen tralized system, with various players, jurisdictions, demands, and limita tions. Throughout our lengthy deliberations, the committee heard testimony xix this document is a research report submitted to the U. We also heard from professionals who manage forensic laboratories and medical examiner/ coroner offces; teachers who are devoted to training the next generation of forensic scientists; scholars who have conducted important research in a number of forensic science felds; and members of the legal profession and law enforcement agencies who understand how forensic science evidence is collected, analyzed, and used in connection with criminal investigations and prosecutions. We are deeply grateful to all of the presenters who spoke to the committee and/or submitted papers for our consideration. In considering the testimony and evidence that was presented to the committee, what surprised us the most was the consistency of the message that we heard: the forensic science system, encompassing both research and practice, has serious problems that can only be addressed by a national commitment to overhaul the current structure that supports the forensic science commu nity in this country. This can only be done with effective leadership at the highest levels of both federal and state governments, pursuant to national standards, and with a signifcant infusion of federal funds. The recommendations in this report represent the committee’s studied opin ion on how best to achieve this critical goal. We had the good fortune to serve as co-chairs of the committee en trusted with addressing Congress’ charge. The committee, formed under the auspices of the National Academies’ Committee on Science, Technol ogy, and Law and Committee on Applied and Theoretical Statistics, was composed of many talented professionals, some expert in various areas of forensic science, others in law, and still others in different felds of science and engineering. They listened, read, questioned, vigorously discussed the fndings and recommendations offered in this report, and then worked hard to complete the research and writing required to produce the report. We are indebted to our colleagues for all the time and energy they gave to this effort. We are also most grateful to the staff, Anne-Marie Mazza, Scott Weidman, Steven Kendall, and the consultant writer, Kathi Hanna, for their superb work and dedication to this project; to staff members David Padgham and John Sislin, and editor, Sara Maddox, for their assistance; and to Paige Herwig, Laurie Richardson, and Judith A. Hunt for their ster ling contributions in checking source materials and assisting with the fnal production of the report. This Committee shall include members of the forensics community represent ing operational crime laboratories, medical examiners, and coroners; legal experts; and other scientists as determined appropriate. As recommended in the Senate Report, the persons selected to serve included members of the forensic science community, members of the legal community, and a diverse group of scientists. Operating under the project title “Identifying the Needs of the Forensic Science Community,” the committee met on eight occasions: January 25-26, April 23-24, June 5-6, September 20-21, and December 6-7, 2007, and March 24-25, June 23-24, and November 14-15, 2008. During these meetings, the committee heard expert testimony and deliberated over the information it heard and received. Between meetings, committee mem bers reviewed numerous published materials, studies, and reports related to the forensic science disciplines, engaged in independent research on the subject, and worked on drafts of the fnal report. Experts who provided testimony included federal agency offcials; aca demics and research scholars; private consultants; federal, state, and local law enforcement offcials; scientists; medical examiners; a coroner; crime laboratory offcials from the public and private sectors; independent inves tigators; defense attorneys; forensic science practitioners; and leadership of professional and standard setting organizations (see the Acknowledgments and Appendix B for a complete listing of presenters). The testimonial and documentary evidence considered by the commit tee was detailed, complex, and sometimes controversial. Given this reality, the committee could not possibly answer every question that it confronted, nor could it devise specifc solutions for every problem that it identifed. Rather, it reached a consensus on the most important issues now facing the forensic science community and medical examiner system and agreed on 13 specifc recommendations to address these issues. Challenges Facing the Forensic Science Community For decades, the forensic science disciplines have produced valuable evidence that has contributed to the successful prosecution and conviction of criminals as well as to the exoneration of innocent people. Many crimes that may have gone unsolved are now being solved because forensic science is helping to identify the perpetrators. Those advances, however, also have revealed that, in some cases, sub stantive information and testimony based on faulty forensic science analyses may have contributed to wrongful convictions of innocent people. This fact has demonstrated the potential danger of giving undue weight to evidence and testimony derived from imperfect testing and analysis. Moreover, im precise or exaggerated expert testimony has sometimes contributed to the admission of erroneous or misleading evidence. Further advances in the forensic science disciplines will serve three im portant purposes. First, further improvements will assist law enforcement offcials in the course of their investigations to identify perpetrators with higher reliability. Second, further improvements in forensic science practices this document is a research report submitted to the U. Third, any improvements in the forensic science disciplines will undoubtedly enhance the Nation’s ability to address the needs of homeland security. Numerous professionals in the forensic science community and the medical examiner system have worked for years to achieve excellence in their felds, aiming to follow high ethical norms, develop sound profes sional standards, ensure accurate results in their practices, and improve the processes by which accuracy is determined. Although the work of these dedicated professionals has resulted in signifcant progress in the forensic science disciplines in recent decades, major challenges still face the forensic science community. It is therefore unsurprising that Congress instructed this committee to, among other things, “assess the present and future re source needs of the forensic science community,” “make recommendations for maximizing the use of forensic technologies and techniques,” “make recommendations for programs that will increase the number of qualifed forensic scientists and medical examiners,” and “disseminate best practices and guidelines concerning the collection and analysis of forensic evidence to help ensure quality and consistency in the use of forensic technologies and techniques. The best professionals in the forensic science disciplines invari ably are hindered in their work because these and other problems persist. The length of the congressional charge and the complexity of the mate rial under review made the committee’s assignment challenging. In under taking it, the committee frst had to gain an understanding of the various disciplines within the forensic science community, as well as the communi ty’s history, its strengths and weaknesses, and the roles of the people and agencies that constitute the community and make use of its services. In so doing, the committee was able to better comprehend some of the major problems facing the forensic science community and the medical examiner system. This is true with respect to funding, access to analytical instrumentation, the avail ability of skilled and well-trained personnel, certifcation, accreditation, and 5 In this report, the “forensic science community,” broadly speaking, is meant to include forensic pathology and medicolegal death investigation, which is sometimes referred to as “the medical examiner system” or “the medicolegal death investigation system. As a result, it is not easy to generalize about current practices within the forensic science community. It is clear, however, that any ap proach to overhauling the existing system needs to address and help mini mize the community’s current fragmentation and inconsistent practices. Although the vast majority of criminal law enforcement is handled by state and local jurisdictions, these entities often are sorely lacking in the resources (money, staff, training, and equipment) necessary to promote and maintain strong forensic science laboratory systems. It is also noteworthy that the resources, the extent of services, and the amount of expertise that medical examiners and forensic pathologists can provide vary widely in dif ferent jurisdictions. As a result, the depth, reliability, and overall quality of substantive information arising from the forensic examination of evidence available to the legal system vary substantially across the country. Lack of Mandatory Standardization, Certifcation, and Accreditation the fragmentation problem is compounded because operational prin ciples and procedures for many forensic science disciplines are not stan dardized or embraced, either between or within jurisdictions. There is no uniformity in the certifcation of forensic practitioners, or in the accredita tion of crime laboratories. Indeed, most jurisdictions do not require forensic practitioners to be certifed, and most forensic science disciplines have no mandatory certifcation programs. Moreover, accreditation of crime labo ratories is not required in most jurisdictions. Often there are no standard protocols governing forensic practice in a given discipline. In short, the quality of forensic practice in most disciplines varies greatly because of the absence of adequate training and continuing education, rigorous mandatory certifcation and accredita tion programs, adherence to robust performance standards, and effective oversight. The Broad Range of Forensic Science Disciplines the term “forensic science” encompasses a broad range of forensic dis ciplines, each with its own set of technologies and practices. In other words, there is wide variability across forensic science disciplines with regard to 6 See. The “forensic science community,” in turn, consists of a host of practitioners, including scientists (some with advanced degrees) in the felds of chemistry, biochem istry, biology, and medicine; laboratory technicians; crime scene investiga tors; and law enforcement offcers. There are very important differences, however, between forensic laboratory work and crime scene investigations. There are also sharp distinctions between forensic practitioners who have been trained in chemistry, biochemistry, biology, and medicine (and who bring these disciplines to bear in their work) and technicians who lend sup port to forensic science enterprises. The committee decided early in its work that it would not be feasible to develop a detailed evaluation of each discipline in terms of its scientifc underpinning, level of development, and ability to provide evidence to ad dress the major types of questions raised in criminal prosecutions and civil litigation. However, the committee solicited testimony on a broad range of forensic science disciplines and sought to identify issues relevant across defnable classes of disciplines. As a result of listening to this testimony and reviewing related written materials, the committee found substantial evidence indicating that the level of scientifc development and evaluation varies substantially among the forensic science disciplines. Problems Relating to the Interpretation of Forensic Evidence Often in criminal prosecutions and civil litigation, forensic evidence is offered to support conclusions about “individualization” (sometimes referred to as “matching” a specimen to a particular individual or other source) or about classifcation of the source of the specimen into one of several categories.

However blood pressure chart high purchase labetalol online pills, comprehensive blood pressure chart sample purchase labetalol with amex, psycho metrically-sophisticated guidelines for identifying and quantifying cognitive impair ment blood pressure after eating 100 mg labetalol free shipping, across a battery of tests arrhythmia associates fairfax order 100 mg labetalol free shipping, are not clearly outlined in the neuropsychological literature arteria 23 purchase discount labetalol line. Iverson British Columbia Mental Health & Addictions, University of British Columbia, Vancouver, Canada e-mail: giverson@interchange. Considerable psychometric work has been done regard ing how to interpret combinations of scores derived from these batteries. The purpose of this chapter is to provide clinicians with psychometrically sophis ticated information that is designed to improve their accuracy for identifying cogni tive problems in daily practice. This chapter begins by presenting information on current definitions of cognitive impairment (Conceptualizing Cognitive Impairment). In the second section, we describe some of the various classification systems for conceptualizing cognitive impairment (Classifying Cognitive Impairment). Fundamental psychometric principles, derived from analyses on co-normed batteries of tests, are illustrated in the third section (Evaluating Cognitive Impairment: Five Psychometric Principles to Consider). Key Points and Chapter Summary • Cognitive diminishment or impairment can result from a variety of medi cal, psychiatric, and/or neurological conditions. Conceptualizing Cognitive Impairment There is no universally agreed upon definition of cognitive impairment. Establishing a level of cognitive impairment sometimes requires multiple sources of information, including input from family members, review of medical records, review of collateral 32 Improving Accuracy for Identifying Cognitive Impairment 925 records. Iverson and colleagues have suggested five categories of cognitive impair ment that illustrate a continuum of severity (Iverson et al. However, the specific criteria for each level have not been codified or agreed upon. Neuropsychology, unfortunately, remains far from having uniform psychometric criteria for interpreting the severity of cognitive impairment using neurocognitive tests, nor do we have specific behavioral criteria for quantifying impairment or diminishment in everyday functioning. Research is needed to develop and empiri cally test criteria for cognitive impairment and impairment in social or occupational functioning. For now, the diagnosis of cognitive impairment, and level of cognitive impairment, is primarily based upon clinical judgment. Mild Cognitive Diminishment Mild diminishment in cognitive functioning may or may not be identifiable using neuropsychological tests. This diminishment can, but does not always, have a mild adverse impact on a person’s social and/or occupational functioning. Mild Cognitive Impairment Mild cognitive impairment should be identifiable using neuropsychological tests. This impairment has a mild (sometimes moderate) adverse impact on a person’s social and/or occupational functioning. Moderate Cognitive Impairment Moderate cognitive impairment has a substantial impact on everyday functioning. This impairment would be noticeable to others in regards to the person’s social and/or occupational functioning. Severe Cognitive Impairment Severe cognitive impairment has a substantial adverse impact on everyday functioning. The person is incapable of competitive employment, should not be driving a motor vehicle, and would likely have difficulty with activities of daily living. Profound Cognitive Impairment the cognitive impairment would render the person incapable of living outside of a nursing home or an institution. Brooks Classifying Cognitive Impairment In addition to a lack of consensus on defining cognitive impairment, there are no widely accepted, empirically-validated psychometric criteria for identifying the cognitive disorders. In clinical situations when the cognitive impairment is obvious, widespread, and associated with poor daily functioning. One area of research and clinical practice that has had numerous suggestions for how to define cognitive impairment has been identifying memory impairment in older adults. This has been related to an enormous research effort to identify Alzheimer’s disease at a very early stage. The psychometric criterion for an unusually low score has generally been set at 1. Even the authors of the recent consensus-based research criteria for probable Alzheimer’s disease (Dubois et al. The clinical implications for assessing memory functioning in older adults with out a solid psychometric foundation are striking. However, that false positive rate applies to a single test score in relation to a theoretical population of healthy older adults. Because a single test score is rarely relied upon, this theoretical false positive rate is not accu rate. Thus, the false positive rate for having at least one low score will be considerably greater than 5%. Those older adults with below average intelligence will have more low scores than those with above average intelligence (Brooks et al. Notice that, for healthy older adults of average intelligence, 22–38% will have one or more scores 5th percentile across a battery of memory tests. As seen in this figure, the number of low (“abnormal”) memory scores in healthy older adults varies considerably by level of intelligence. Unfortunately, there are no specific empirically-derived, evidence-based criteria for this disorder. To identify mild neurocognitive disorder, there must be impairment in at least two domains, which can include attention or speed of information processing, language, learning and memory, perceptual-motor abilities, and/or executive functioning (see Fig. These cognitive impairments must be due to a neurological or general medical condition, be considered abnormal or a decline from previous functioning, and cause marked psychological distress or impairment in social, occupational, or other areas of functioning. These criteria require the person to have one or more test scores, in two or more cognitive domains, below 1 standard deviation from the mean on age, sex, and education adjusted normative data. The seven domains of functioning include: attention/working memory; speed of information processing; verbal/language; memory (learning; recall); abstraction/executive; sensory-perceptual; and motor skills (Antinori et al. Impairment in 2 or more domains is required for diagnosis 32 Improving Accuracy for Identifying Cognitive Impairment 929 Clinicians and researchers should note that specific methodological issues can adversely affect diagnostic accuracy of these new consensus-based criteria. Thus, diagnostic accu racy can vary based on the number of tests a clinician or researcher chooses to administer. Regarding intelligence, this will result in a substantial number of false positives for people with below average intelligence and an increased rate of false negatives for people with above average intelligence. Evaluating Cognitive Impairment: Five Psychometric Principles to Consider Neuropsychologists typically administer numerous tests that can yield dozens of scores. As part of the interpretive procedure, the neuropsychologist must use his or her clinical judgment to consider all of the test scores simultaneously and make sense of the patient’s performance. Although a low score might be suggestive of an acquired impairment, it is important to consider that having inter-subtest variability and obtaining a low score might be “normal” for that person. Obtaining low scores might be attributable to measurement error (broadly defined), normative sample characteristics. This section introduces and discusses five psychometric principles to consider when evaluating a person for cognitive impairment. Although an understanding of these psychometric principles is invaluable for any clinician, it is important for clinicians to utilize these principles when simultaneously interpreting test scores across a battery of neuropsychological tests. Principle 1: Low Scores Are Common across All Test Batteries Any battery of tests, whether fixed or flexible, will have a certain number of low scores when administered to healthy people (Axelrod and Wall 2007; Binder et al. This is because there is a substantial amount of intraindi vidual variability in the cognitive abilities of healthy people. Moreover, a substantial percentage have two or more scores 5th percentile on all three batteries (Fig. Rule of thumb: Evaluating cognitive impairment – Principle 1 • Low scores are relatively common in healthy individuals Principle 2: Low Scores Depend on Where You Set Your Cutoff Score There is no universal agreement on the definition of a low score. Bars represent percent of healthy adults from standardization samples who had (1) 2 or more or (2) 5 or more scores at or below 5th percentile. For exam ple, for a highly educated person, or a person with a superior level of intelligence, the neuropsychologist might choose to interpret some average scores as “low” and some low average scores as “mildly impaired. The key is to carefully define the psychometric strengths and limitations of the specific approach taken for interpreting neuropsy chological tests. The balance between sensitivity and specificity is related to the cutoff score used. Higher cutoff scores are more likely to correctly identify those who have cognitive problems (improved sensitivity), but they are also more likely to include those who do not have cognitive problems (reduced specificity). As the cutoff score gets progressively lower, the number of healthy people who would be incorrectly identified. As the number of tests administered and interpreted increases, the likelihood of having low scores also increases. It should be noted that regardless of which cutoff score is used, the expected number of low scores increases with lengthier test batteries. Rule of thumb: Evaluating cognitive impairment – Principle 3 • the more tests that are administered, and scores interpreted, the more likely it is to find low scores in healthy adults Principle 4: Low Scores Vary by Demographic Characteristics of the Examinee It is well established that many cognitive abilities vary by demographic characteris tics. Bars represent per cent of healthy adults from standardization samples who had (1) 2 or more or (2) 5 or more scores at or below 5th percentile. The raw scores correspond ing to an age corrected scaled score of 10 are portrayed for each age group (The data was obtained from Sheslow and Adams 2003) For example, performance on tests of memory and processing speed is lower in older adults versus younger adults. The literature on sex differences suggests that women perform better on tasks of verbal learning and memory, verbal fluency, 32 Improving Accuracy for Identifying Cognitive Impairment 935 and processing speed (Beatty et al. Motor dexterity has also been shown to be a strength for women compared to men (Schmidt et al. As a result of known differences in cognitive abilities, many normative scores for traditional, paper–pencil, neuropsycho logical measures. Education is an important variable to consider when interpreting cognitive test results (Heaton et al. It has long been recognized that education is correlated with cognitive test performance. Normative scores on each test for 35 year olds, adjusted for sex and education, are presented. A raw score of 13 corresponds to a T score of 53 for men with 9 years of education 65 Ed = 9, Male 59 Ed = 9, Female 60 58 Ed = 16, Male Ed = 16, Female 55 54 53 52 51 50 47 47 46 45 44 45 43 42 40 39 40 40 35 Arithmetic Digit Symbol-Coding Design Construction Story Learning Fig. Men outperform women on the Arithmetic test; thus, the normative T scores for women are higher than the normative T scores for men. In con trast, women outperform men on Digit Symbol-Coding, a measure of visual-motor processing speed, and immediate memory for stories (thus, the same raw score results in a higher normative T score for men versus women). Men outperformed women on the Design Construction test, a measure of visual-spatial ability. Reading ability, as a correlate of both education and intelligence, is also related to neuropsychological test performance. Reading is believed to be relatively resis tant to the effects of brain injury and disease (Bright et al. The relation between reading test scores and cognitive functioning is presented in Fig. Researchers working with diverse groups of people, in different settings and in dif ferent countries, have repeatedly demonstrated that ethnic groups frequently perform differently on cognitive testing (Ardila 1995; Brickman et al.


Note: If a member needs a second transplant blood pressure effects 100mg labetalol fast delivery, a new authorization request will need to pulse pressure by age purchase labetalol 100mg mastercard be done hypertension 40 mg purchase labetalol 100 mg with mastercard. The usual turn-around time frame for all transplant approval letters is 2-4 business days provided all necessary documentation has been received heart attack unnoticed labetalol 100 mg fast delivery. If the recipient of the transplant is a dependent child arteria oftalmica cheap labetalol 100 mg on-line, benefits for transportation, lodging, meals will be provided for the transplant recipient and two companions. For benefits to be available, the member’s place of residency must be more than 50 miles from the Hospital where the transplant will be performed. The member and the companion are each entitled to benefits for lodging and meals up to a combined maximum of $200 per day. Benefits for transportation, lodging and meals are limited to a maximum of $10,000 per transplant. Interpretation: Orthodontic (braces) and related services and supplies are covered under the following limited circumstances: • Treatment of teeth that have been injured in an accident. The tooth had to have had an intact root or been part of a permanent bridge, prior to the injury. Only the portion of the orthodontic (braces) directly supporting the affected tooth is covered. With the exception of accidental injury of the teeth, services for conditions that are of dental origin. Such surgery may be covered if the member’s general health is affected, if he/she has difficulty living normally because of the orofacial condition, or if he/she needs to take medication frequently to treat pain related to the deformity. Interpretation: Gross defects in the facial skeleton may cause disharmony in jaw relationships. Abnormalities of jaw-to-face size and shape may include excessive or deficient bone-to-bone, tooth-to-bone and bone-to-soft tissue relations. Diagnostic Work-up Facial skeletal deformities may be identified and measured by: • Clinical examination • Intraoral plaster study casts • Cephalometric radiographs & analysis • Oral and facial photographs 3. Absolute medical criteria justifying surgical intervention include but may not be limited to, one or more of the following: • Significant symptoms refractory to conservative treatment • Serious comorbidity which can only be resolved surgically • Chronic severe pain requiring frequent medication. Second Opinion: If there are questions about the course of treatment, or use of one surgical procedure over another, a second opinion from another oral maxillofacial surgeon and/or appropriate health professional should be obtained. The opinion of a Board Certified Orthodontic specialist may be particularly useful. Exclusions: Orthodontic and/or prosthodontic services of a dentist are excluded, including pre-surgical services. Interpretation: An orthotic device is a rigid or semi-rigid supportive device that assists body function by restricting or eliminating motion of a weak or diseased body member. Wedges, elevations, pockets and other corrections can be incorporated into the orthotic to treat many foot ailments. Prescription foot orthotics or splints are those which are custom-made for the member. Stock foot orthotics which are pre-formed, available in standard sizes and not custom made for the member are not in benefit. These include arch supports, orthotic splints, shoe inserts and other foot support devices. Note: Effective July 1, 2013, Medicare Primary members must use a Medicare Contracted Provider to ensure coverage by Medicare. The Medical Service Agreement should be consulted for unit charge towards the Utilization Management Fund. Interpretation: Oxygen and oxygen supplies furnished to a member in the home setting are covered as Durable Medical Equipment. Such pain can be addressed in a coordinated, multidisciplinary pain management program that may be either inpatient or outpatient. Inpatient: A short hospital (or institutional) stay may be required for a member needing an intense pain rehabilitation program that includes a multidisciplinary coordinated team approach. Such a member typically will have failed all attempts at treatment with less intense modalities. Outpatient: Coordinated, multi-disciplinary outpatient pain rehabilitation programs may be appropriate for members with chronic pain. Outpatient therapy visits in such a program are charged against the cumulative outpatient physical therapy benefit. Anticipation of significant improvement, not necessarily complete recovery, meets the criteria. Interpretation: Physical therapy is the treatment of disease or injury by physical means, thermal modalities, physical agents, bio-mechanical and neuro-physiological principles, and devices to relieve pain, restore maximum function and prevent disability following disease, injury or loss of a body part. The therapy must be performed by a physician or by a licensed registered physical therapist upon a physician’s order. Sometimes, a trial of therapy is helpful in determining whether or not ongoing physical therapy is appropriate. Physical therapy not expected to result in significant improvement within two months is not in benefit. Range of motion and passive exercises used for paralyzed extremities are not in benefit. General exercise programs, work hardening programs, functional capacity assessment or other therapy services recommended by an employer are not considered in benefit even when recommended by a physician. In accordance with Illinois State Bill 2917, there is coverage for medically necessary preventative physical therapy for members diagnosed with multiple sclerosis. Preventative physical therapy includes reasonably defined goals, including, but not limited to, sustaining the level of function the person has achieved, with periodic evaluation of the efficacy of the physical therapy against those goals. The coverage is subject to the same copayments and calendar year maximum as provided for other physical therapy benefits covered under the policy. Most benefit plans have a maximum number of treatments that are in benefit for outpatient rehabilitation therapies (Speech Therapy, Physical Therapy and Occupational Therapy). However, routine foot care (such as treatment or removal of corns and calluses) is not covered. Interpretation: Non-routine foot care, such as diabetic foot care or treatment of infections, is covered. The Primary Care Physician determines whether the member should be seen by a podiatrist or by another specialist, such as an orthopedist or sports medicine physician. This technique can identify certain genetic abnormalities in the embryo at a stage before it is implanted in the uterus. This would also include testing for purposes of gender selection related to the specific maternal abnormality. Definitions: Private Duty Nursing Service means Skilled Nursing Service provided on a oneto one basis by an actively practicing registered nurse or licensed practical nurse. Benefits for Skilled Nursing Service will not be provided due to the lack of willing or available nonprofessional personnel. The member must be homebound (that is, unable to leave home without assistance and requiring supportive devices or special transportation) and must require Skilled Nursing Service on an intermittent basis under the direction of your Physician. This program includes Skilled Nursing Service by a registered professional nurse, the services of physical, occupational and speech therapists, Hospital laboratories and necessary medical supplies. The program does not include and is not intended to provide benefits for Private Duty Nursing Service. It also does not cover services for activities of daily living (personal hygiene, cleaning, cooking, etc. These services can be safely provided by trained or capable nonprofessional personnel, are to assist with routine medical needs. Respite Care Services means those services provided at home or in a facility to temporarily relieve the family or other caregivers (nonprofessional personnel) that usually provide or are able to provide such services. Respite Care is not in benefit except under a Hospice Program – refer to the Hospice Care Benefits Interpretation. The Skilled Nursing Services may include, but not exclusively or in all instances, the management of a tracheostomy and ventilator. The number of hours of Skilled Nursing Service required on a daily basis must exceed those which can be provided by a Coordinated Home Care Program. In addition, the nursing services involved cannot constitute Custodial or Respite Care Services. Interpretation: Balloon dilatation of the prostatic urethra may be indicated if the member has a small but obstructive prostate, is not a candidate for other procedures, and if retrograde ejaculation is particularly undesirable. Cryosurgery consists of the administration of liquid nitrogen into diseased tissue under ultrasound guidance. Brachytherapy, which is the implantation of radioactive seeds for the treatment of prostate cancer, is in benefit. Seeds are placed under ultrasound, fluoroscopic, and/or computed tomographic guidance. Transrectal ultrasound is in benefit for a number of indications, including but not limited to screening, diagnosis, cancer staging, and guidance of biopsy sampling and radioactive seed implantation. Interpretation: Prosthetic devices are those items used as a replacement or substitute for a missing body part. Benefits are available for, but not limited to the following devices and appliances: Artificial eyes Artificial limbs (including harnesses, stump socks, etc. These are in benefit for aphakic post-surgery members (when an intraocular lens is not implanted during surgery). Replacement of prosthetic devices is covered when the replacement is necessitated by surgery (such as a pacemaker replacement), growth of the member, accidental destruction of the device, or wear. Benefits will not be provided for dental appliances or hearing aids, or for replacement of covered cataract lenses unless a prescription change is required. Note: See related benefits Guidelines on Vision Screening/Routine Vision Care and Contact Lenses/Eyeglasses for additional information. Note: Little Company of Mary Hospital (Employer Group # B92749) has coverage for a cranial prosthesis (wig) in relation to the medical diagnosis of cancer or alopecia for up to $250. Generally, a provider who specialized in mastectomy products can also supply a cranial prosthesis. Interpretation: Pulmonary rehabilitation programs offer a structured approach to progressive increase in exercise tolerance for members with pulmonary disease. Chronic obstructive pulmonary disease is the prototypical condition for which pulmonary rehabilitation is typically recommended, although it may be appropriate for a range of moderate to severe pulmonary conditions. A typical course of pulmonary rehabilitation consists of a single course of 36 hours of medically-supervised therapy over a period of 6 weeks, although the degree of rehabilitative services and treatment modalities do vary. Facilities with pulmonary rehabilitation programs may at times use ancillary services, such as psychological or dietary services. They may also provide services to members who have non-pulmonary medical conditions. Benefits for ancillary services to these members, or services given in a pulmonary rehabilitation program to members without pulmonary disease, should not be billed as pulmonary rehabilitation.

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