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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

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In cattle with lungs notoriously prone to fungus vulva 15mg butenafine visa this as a lesion fungus yeast mold cheap butenafine online visa, one should be able to fungus eating animal example buy butenafine mastercard find the cause of the dyspnea that led to antifungal nail gel buy butenafine line the lesion’s development. Histologically, the hamartoma was a mass of dilated, cuboidal cell lined bronchioles. The liver is coarsely nodular from chronic passive congestion as the intrapleural mass restricted blood flow out of the liver. Some call this redundant amount of tissue, in a normal location, a fetal tumor while others consider it a developmental defect,, Many are associated with vessels of the genitalia such as the vascular hamartomas of the ovary, etc. Markedly dilated lumina of the abnor­ mal bronchioles lined by cuboidal epithelium and thickened stroma make up the major mass of this hamartoma which filled 90% of the thoracic cavity and caused chronic passive congestion of the liver. Such a lesion is usually caused by anaphylaxis or a suddenly decompensated heart lesion as by an anomaly or Zenker’s degeneration in white muscle disease. This pig died from the serum leaking into the alveoli and airways (pulmonary edema) where it was mixed to a froth to prevent air flow. This problem is to be differentiated from the more common terminal edema as a result of euthanasia in which there is tracheal froth and alveolar edema, but not interlobular edema as seen here. On closer examination, the left apical and cardiac lobes are slightly shrunken and firmer than the remaining lung (swine enzootic pneumonia). A tan lung may also be seen in cases of chronic blood destructive diseases as equine infectious anemia in horses. The ventral portion of these lobes appear relatively less pigmented because of the terminal emphysema in these lobes. Histologically, the black pigment, in this case coal dust, is in macrophages scattered ifi the tissue. Draining lymph nodes get progressively darker as the phagocytes continue to clear the lung. The massive number of red foci are foci of acute pneumonia or petechiae caused by acute Salmonellosis. Several septicemic type organisms can cause this and a culture is necessary to determine which one. The red periphery is the inflammatory peripheral zone surrounding the small central core of purulent debris (abscess). Most of the lobules are swollen, probably from emphysema resulting from the edema and the subsequent froth production blocking the airways and air outflow. The pulmonic lesion itself usually does not involve a significant area of lung, but its nature of being embolic suggests that a more serious problem exists such as a vegetative endocarditis which is the source of the emboli. The right heart, or vessels leading to it as the jugular veins, and the caudal vena cava over a liver abscess, especially in the cow, are likely areas to search for the source of the emboli. At an earlier stage in this lesion or elsewhere in this lung, the vessel in which the lesion began would be seen and thus make one sure it was embolic in nature. One of many organisms could cause this lesion, but a hemolytic Staphylococcus spp. Several fibrous adhesions have been broken down and appear as tags on the surface of the right lung. Different from single particle or dust inhalation, this case is suspected of being the result of fluid inhalation. Many organisms washed down from the mouth or throat could be the isolated agents if cultured. A history compatible with inhalation, such as recent worming by drenching, would be of benefit in making such a diagnosis. One can not rule out a secondary infection with gangrenous organisms superimposed on a preexisting less severe pneumonia. In many chronically damaged tissues as in “end stage” renal, hepatic or pulmonic lesions, one can not always be sure of the initial cause or pathogenesis. Such a lesion usually has a locally extensive distribution and many different organisms are capable of causing this reaction with Pasteurella spp. There is a marked thickening of visceral pleura and interlobular septae with con­ nective tissue. Surgical removal of the causative lung lesion if possible usually causes some remission of the bone reaction. When this left pleural cavity was opened, the collapsed lung was covered by a foul smelling, thick milky fluid with pieces of debris in it (pyothorax, em­ pyema). When the purulent debris was washed from the lungs, an adhesion was found between the left cardiac and the cranial ventral left dia­ phragmatic lobe. Histological examination revealed the presence of a chronic purulent focus of pneu­ monia surrounding a piece of plant material in a small airway near the surface. This awn type foreign body was subsequently identified as a terminal twig of an ornamehtal cedar tree. The spines all going one way make iKdifficult for an animal to cough this up naturally and also enhances its travels within tissues. It is surrounded by purulent debris in an airway with just a small area of epithelium over a few glands. With such “one way” spines on plant materials, they are difficult to remove spontaneously by coughing. Materials of this sort are a common cause of foreign body pneumonia and subsequent empyema in cats and other species. They consist histologically of isf y * large numbers of macrophages and some giant cells containing clear vacuoles. Fibrin strands are present over the affected tissues and also gives this type of pneumonia the name fibrinous pneumonia. Al­ though this was in a pig, the lesion is similar in other species with fibrinous pneumonia. Edema, fibrin and cellular debris are present in the alveoli and the stroma is thickened by con­ gestion. Such a lesion is quite common, and often associated with pasteurella and hemophilus pneu­ monia. The underlying lung is congested and has some hemorrhage and neutrophils in the alveoli. These pneumonic lesions are not diagnostically significant as many organisms may result in similar lesions in their early stages. The lack of any acute inflammatory changes as edema, fibrin or hemorrhage and the depressed, firm character similar to all the lesions suggest it is nonprogressive and is probably resolv­ ing. The right ventricle is enlarged and when opened the wall was noted to be both dilated and slightly thickened from hypertrophy (cor pulmonale). This thickening is the response to the increased work load of pushing blood through the pneu­ monic lung. It is surprising more hearts are not similarly affected when one considers the number of animal lungs with chronic pneumonia. In most areas, but especially about the major airways, the alveoli are slightly to entirely collapsed (atelectasis). The remaining three fourths of the left lung is inflated with emphysema except for a crease in the lung tissue above the cardiac lobe. This should be considered a case of resolving bronchopneumonia as we cannot be sure of its original cause even if we culture it. Several pink areas are scat­ tered among these affected lobes and may re­ present unaffected lobes or surface emphysema over pneumonic areas. The bulging appearance of the remaining lung is from failure of normal collapse as terminal edema developed and was mixed to a froth with air. This prevented the nor­ mal collapse that occurs via elastic recoil action with death. This locally extensive pneumonia was at one time considered to be caused by a virus. There are others who consider that mycoplasma may not be the final answer to this problem. The junctional zone between the grey affected lobes and the more normal lung is dark and homogeneous and is firm like the anterior (cranial) lobes. Three large lym­ phoid follicles and one smaller one are developing near the bronchiole.

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Bent dryer hoses can cause lint to antifungal body lotion order butenafine cheap online catch in dryers antifungal quinoline order butenafine 15mg with amex, scalds for young children (2) fungus yellow nails generic 15mg butenafine amex. Disconnected dryer hoses greater than 120°F takes less than thirty seconds to antifungal diaper rash purchase butenafine 15mg overnight delivery burn will vent lint, dust, and particles indoors, which may cause the skin (2). No Centers should have a mechanical washing machine and child should simultaneously share a crib, bed, or bedding dryer on site or should contract with a laundry service. Facilities should ensure that toddler beds Where laundry equipment is used in a large or small family are in compliance with the current U. Bed linens used under children Droplet transmission occurs when droplets containing mi on cots, cribs, futons, and playpens should be tight-ftting. When pads are used, they should be enclosed in washable covers and should be long enough so the child’s head or Because respiratory infections are transmitted by large feet do not rest off the pad. Mats and cots should be made droplets of respiratory secretions, a minimum distance of with a waterproof material that can be easily washed and three feet should be maintained between cots, cribs, sleep sanitized. Plastic bags or loose plastic material should never ing bags, beds, mats, or pads used for resting or sleeping be used as a covering. A space of three feet between cribs, cots, sleeping bags, beds, mats, or pads will also provide access by the staff to No child should sleep on a bare, uncovered surface. If the facility uses screens to sonally appropriate covering, such as sheets, sleep gar separate the children, their use must not hinder observation ments, or blankets that are suffcient to maintain adequate of children by staff or access to children in an emergency. Pillows, blankets, and sleep posi Lice infestation, scabies, and ringworm are among the most tioners should not be used with infants. These diseases by toddlers and older children, pillows should have remov are transmitted by direct person-to-person contact. Ring able cases that can be laundered, be assigned to a child, worm is transmitted by the sharing of personal articles such and used by that child only while s/he is enrolled in the as combs, brushes, towels, clothing, and bedding. Each child’s pillow, blanket, sheet, and any special ing the sharing of personal articles helps prevent the spread sleep item should be stored separately from those of other of these diseases. The use of tight-ftting bed linens prevents suffocation and Pads and sleeping bags should not be placed directly on strangling. Adult bed sheets can become loose and en any foor that is cooler than 65°F when children are resting. Cribs, cots, sleeping bags, beds, mats, or pads in/on which From time to time, children drool, spit up, or spread other children are sleeping should be placed at least three feet body fuids on their sleeping surfaces. If the room used for sleeping cannot accommodate terproof, nonabsorbent rest equipment enables the staff to three feet of spacing between children, it is recommended wash and sanitize the sleeping surfaces. Plastic bags may for caregivers/teachers to space children as far as possible not be used to cover rest and sleep surfaces/equipment from one another and/or alternate children head to feet. If unoccupied sleep the end caps require constant replacement and the cots are equipment is used to separate sleeping children, the ar a cutting/pinching hazard when end caps are not in place. In small family child care homes, the caregiver/teacher should consider the home to Caregivers/teachers should never use strings to hang any be a business during child care hours and is expected to object, such as a mobile, or a toy or a diaper bag, on or abide by regulatory expectations that may not apply outside near the crib where a child could become caught in it and of child care hours. Caregivers/teachers may ask parents/guardians to provide Crib mattresses should ft snugly and be made specifcally bedding that will be sent home for washing at least weekly for the size crib in which they are placed. Chapter 5: Facilities 252 Caring for Our Children: National Health and Safety Performance Standards rest periods. This positioning may be benefcial in reducing mattress to the top of the crib rail should be twenty inches transmission of infectious agents as well. The crib should not have corner post extensions (over the use of solid crib ends as barriers between sleeping chil one-sixteenth inch). The crib should have no cutout open dren can serve as a barrier if they are three feet away from ings in the head board or footboard structure in which a each other (2). Red book: 2009 report of the Committee on Infectious of his/her crib, the child should be moved to a bed. Ages and stages: A ing various fabric, mesh, or other strong coverings over the parent’s guide to safe sleep. This crib should be used for Facilities should check each crib before its purchase and evacuation in the event of fre or other emergency. When it is determined that a crib is no facility meet these standards to protect children and prevent longer safe for use in the facility, it should be dismantled injuries or death (1-3). As of June 28, 2011 all cribs being manufactured, Staff should only use cribs for sleep purposes and should sold or leased must meet the new stringent requirements. No child Effective December 28, 2012 all cribs being used in early of any age should be placed in a crib for a time-out or for care and education facilities including family child care disciplinary reasons. For the most cur or mobile enough to reach crib latches or potentially climb rent information about these new standards please go to out of a crib, they should be transitioned to a different sleep. More infants die every year in incidents involving cribs than Each crib should be identifed by brand, type, and/or prod with any other nursery product (4). Children have become uct number and relevant product information should be kept trapped or have strangled because their head or neck on fle (with the same identifcation information) as long as became caught in a gap between slats that was too wide or the crib is used or stored in the facility. Staff should inspect each crib before each use to ensure An infant can suffocate if its head or body becomes wedged that hardware is tightened and that there are not any safety between the mattress and the crib sides (6). If a screw or bolt cannot be tightened securely, or there are missing or broken screws, bolts, or mattress sup Corner posts present a potential for clothing entanglement port hangers, the crib should not be used. Asphyxial crib deaths from wedg ing the head or neck in parts of the crib and hanging by a Safety standards document that cribs used in facilities necklace or clothing over a corner post have been well should be made of wood, metal, or plastic. The minimum height from the top of the Turning a crib into a cage (covering over the crib) is not a 253 Chapter 5: Facilities Caring for Our Children: National Health and Safety Performance Standards safe solution for the problems caused by children climbing 6. Portable cribs are designed so they they should be three feet apart and staff placing or removing may be folded or collapsed, with or without disassembly. Infants more fexibility for programs that vary the number of infants who are able to sit, pull themselves up, etc. Consumers can who fall from several feet or more can have an intracranial call 1-800-506-4636 or visit the Window Covering Safety hemorrhage. In addition, requiring staff safety specifcation for non-full-size baby cribs/play yards. Safe that is suspected to be related to the use of stackable cribs and sound for baby: A guide to juvenile product safety, use, and should be reported to the U. Red book: 2009 report of the Committee on Infectious area within a room for the temporary or ongoing care of a Diseases, 153. This room or area may Child-sized futons should be used only if they meet the fol be used for other purposes when it is not needed for the lowing requirements: separation and care of a child or if the uses do not confict. It is d) Meet all other standards on sleep and rest areas best practice for toilet and lavatory facilities to be readily (Section 5. Supervision provide rapid access in the event of vomiting or diarrhea to is necessary to maintain adequate spacing of futons and avoid contaminating the environment. Handwashing sinks ensure that bedding is not shared, thereby reducing trans should be stationed in each room not only to provide the mission of infectious diseases and keeping children out of opportunity to maintain cleanliness but also to permit the traffc areas. For speech therapy, working with the child in a quiet articles such as combs, towels, clothing, and bedding (1). Caregivers/teachers should Providing space so personal items may be stored separately attempt to incorporate therapeutic principles into the child’s helps prevent the spread of disease. The facility should provide separate storage areas for each child’s and staff member’s personal articles and clothing. Providing separate storage areas reduces fre load dry when they are stored and not touching. Lice infestation, scabies, and Family Child Care Home ringworm are common infectious diseases in child care. Policy statement: Firearm-related injuries fres started by children playing with lighters. Outcomes in children and young playing with candles or near candles is one of the biggest adults who are hospitalized for frearms-related injuries. Gun storage closet or under a bed when faced with fre, leading to fatali practices and risk of youth suicide and unintentional frearm injuries. When children leave the facility risk are printed on diaper-pail bags, dry-cleaning bags, and for a walk or to be transported, a designated staff member so forth. If present in a d) Non-glass, non-mercury thermometer to measure a small or large family child care home, these items must be child’s temperature; unloaded, equipped with child protective devices, and kept e) Bandage tape; under lock and key with the ammunition locked separately f) Sterile gauze pads; 257 Chapter 5: Facilities Caring for Our Children: National Health and Safety Performance Standards g) Flexible roller gauze; care program (1). Contact the local poison center at 1-800 h) Triangular bandages; 222-1222 for instructions if needed.

The following upper limits of normal are used in New Zealand:* Age 3-12 years: 0 antifungal leaves purchase butenafine once a day. A small proportion had more severe conduction abnormalities antifungal azoles purchase generic butenafine line, which were sometimes found in the absence of valvular regurgitation fungus jet fuel generic butenafine 15 mg free shipping. A positive culture without supportive antibody elevation may be carriage in up to antifungal powder with miconazole nitrate 2 buy generic butenafine 15mg on-line 50% of cases. The upper limit of normal approach attempts to determine a raised titre over and above this background, and therefore select out those children who have had a recent streptococcal infection. Lower levels may be acceptable in the very young or those over the age of 15 years. A four-fold (two-tube) rise or fall in antibody titres after 10-14 days would also be diagnostic. If the initial titre is below the upper limit of normal, testing should be repeated 10 to 14 days later (Grade D). Other Less Common Clinical Features these include epistaxis, abdominal pain, rheumatic pneumonia (pulmonary infiltrates in patients with acute carditis), mild elevations of plasma transaminase levels and microscopic haematuria, pyuria or proteinuria. As there is no differentiation of the colour-Doppler findings of acute carditis and that of chronic rheumatic valve regurgitation we recommend the same criteria for defining the acute phase and the chronic phase. The proportion of children with physiological valve regurgitation in a New Zealand population was 15%103 and this proportion increases in later decades100 If the aetiology of aortic or mitral regurgitation on Doppler echocardiography is not clear, the following features support a diagnosis of rheumatic valve damage: Both mitral and aortic valves have pathological regurgitation the mitral regurgitant jet is directed posteriorly, as excessive leaflet motion of the tip of anterior mitral valve leaflet (often referred to as prolapse) is the commonest mechanism of mitral regurgitation. If valvulitis is not found at presentation, it may appear within two weeks,71 or occasionally within one month72 but no longer. Thus only 20% of cases in the New Zealand setting have no evidence of carditis in this Auckland series. This is a rare scenario and is recognised in about two to three children per year in New Zealand. Lesch-Nyhan, hyperalanaemia, ataxia, telangiectasia Antiphospholipid antibody 23 * Includes septic arthritis. These patients are said not to be at risk of carditis, and therefore do not require secondary prophylaxis. Patients so diagnosed should receive secondary prophylaxis for at least 5 years (Grade D). Other investigations may be appropriate depending on the clinical picture and potential differential diagnoses. Neuroimaging is seldom necessary and should be reserved for cases who have an atypical presentation such as hemichorea. Hospitalisation is recommended to ensure correct diagnosis for this potentially chronic disease with long term consequences. This ensures that all investigations are performed and, if necessary, observations completed for a period prior to commencing treatment to confirm the diagnosis. Severe arthritis may not be completely controlled 26 with short course or prn ibuprofen but then respond to naproxen the most experience and published evidence for the management of arthritis is with salicylates. Fever alone, or fever with mild arthralgia or arthritis, may not require naproxen or salicylates, but can instead be treated with paracetamol. Carditis/Heart Failure Priorities in the management of carditis/heart failure are detailed in Table 14. Rarely, valve leaflet or chordae tendinae rupture leads to severe regurgitation into a noncompliant left atrium resulting in acute pulmonary oedema. This condition is often mis-diagnosed as pneumonia as the pulmonary venous congestion is often unilateral. Four such patients presenting within a two year period are described by Anderson et al with all cases achieving valve repair rather than replacement in this life threatening clinical scenario. Surgery is then deferred until the acute phase reactants have normalised as the surgeons can achieve more durable repairs when the early active valve inflammation has reduced. This is supported by a recent report based on 81 cases aged 3-19 years from the Greenlane and Starship Children’s Hospital experience. Not only was there lower morbidity (less endocarditis, no thromboembolism) for repairs but the need for reoperation was not increased compared to the mitral valve replacement group102 * the use of glucocorticoids and other anti-inflammatory medications in rheumatic carditis has been studied in two meta-analyses117,118 All of these studies of glucocorticoids were performed more than 40 years ago, and did not use drugs in common use today. Glucocorticoids may be considered for those with heart failure in whom acute cardiac surgery is not indicated (Grade D). This recommendation is not supported by evidence, but is made because many clinicians believe that 27 glucocorticoids may lead to more rapid resolution of cardiac compromise, and even be life-saving in severe acute carditis. If glucocorticoids are used, the drug of choice is oral prednisone or prednisolone (1 2mg/kg/day, to a maximum of 80mg once daily or in divided doses). If a week or less of treatment is required, the medication can be ceased when heart failure is controlled, and inflammatory markers are improving. For longer courses (usually no more than 3 weeks is required), the dose may be decreased by 20-25% each week. Treatment should be given in addition to the other anti-failure treatments outlined below. As glucocorticoids will control joint pain and fever, salicylates can usually be discontinued, or the dose reduced, during glucocorticoid administration. Salicylates may need to be recommenced after glucocorticoids are discontinued to avoid rebound joint symptoms or fever 4. Sydenham’s Chorea Priorities in the management of Sydenham’s chorea are detailed in Table 15. Table 15: Priorities in the Management of Chorea Priorities in the Management of Chorea Sydenham’s chorea is self-limited. Sometimes hospitalisation is useful to reduce the stress that families face in dealing with abnormal movements and emotional lability Because chorea is benign and self-limiting, and anti-chorea medications are potentially toxic, treatment should only be considered if the movements interfere substantially with normal activities, place the person at risk of injury or are extremely distressing to the patient, family and friends Valproic acid* and carbamazepine† are now preferred to haloperidol, which was previously considered the first-line medical treatment for chorea. A response may not be seen for 1-2 weeks, and successful medication may only reduce, but not eliminate, the symptoms. Medication should be continued for 2-4 weeks after chorea has subsided and then gradually withdrawn. Recurrences of chorea are usually mild and can be managed conservatively but, in severe recurrences, the medication can be re-started if necessary Aspirin and glucocorticoid therapy do not have a significant effect on rheumatic chorea81 Corticosteroids can be considered for severe or refractory cases of chorea. Case series140,141,142,143 and one larger retrospective analysis144 lend some support. One double blind randomised controlled trial (n=22 who received prednisone, and n=15 placebo) found a significant reduction in symptom intensity after one week and a significantly shorter time to complete remission of symptoms. Rarely carbemazapine can cause orofacial dyskinesia, oculomotor disturbances, speech disorders. Max 6mg/kg daily, not to exceed 80mg daily 12-18 years: 20-40mg daily (increase to 80-120mg daily in resistant oedema) Slow intravenous injection in children: 1 month-12 years: 0. Bed Rest In the pre-penicillin era, prolonged bed rest in those with rheumatic carditis was associated with shorter duration of carditis, fewer relapses and less cardiomegaly. Those with milder or no carditis should only remain in bed as long as necessary to manage other symptoms, such as joint pain (Grade D). Where echocardiography is freely available, echo can reassure there is no cardiac deterioration with mobilisation. Observation and General Hospital Care Guidelines for general in-hospital care are provided in Table 18 (Grade D). Table 19: Discharge Planning and Long Term Preventive Measures Clinical Follow-Up All patients should receive regular review and outpatient follow-up initiated prior to discharge the frequency and duration of review is dependent on the individual clinical needs and local capacity and should become more frequent in the event of symptom onset, symptomatic deterioration or a change in clinical findings Mild and moderate cases are followed up by paediatric and internal medicine services, severe cases jointly with cardiology. There is logic in maintaining less severe patients in the paediatric services as they will be discharged at age 21. This may include district nurses, public health nurses, medical officer of health and other public health staff A community nurse and/or community health worker for the area where the case resides should also do a ward and/or family visit if possible before discharge Patient and Family Education Offer the patient and their family education on rheumatic fever: At the time of diagnosis, it is essential that the disease process be explained to the patient and their family in a culturally appropriate way, using available educational materials and interactive discussion. If patients come from remote communities or other settings with limited access to high quality medical care, it is advisable to discuss discharge timing with the person, family and the local primary health care team (particularly Maori or Pacific health providers where possible). In some patients, it may be advisable to prolong the hospital stay until recovery is well advanced. Advice on Discharge All patients should have a good understanding of the cause of rheumatic fever and the need to have sore throats treated early for themselves as well as in other family members. Patients and their families should understand the reason for secondary prophylaxis and the consequences of missing a benzathine penicillin injection.

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Log books fungus xylaria buy generic butenafine 15 mg on line, recipe sheets antifungal cream for lips butenafine 15mg overnight delivery, batch sheets Identification of vessels antifungal wash for dogs buy butenafine on line amex, lines fungus gnats mosquito dunks discount butenafine 15mg on-line, valves etc. Intershift communication and records System for reporting and follow-up of Plant defects Process deviations Hazardous occurrences (‘near misses’) Accidents: minor/major injury and/or material loss Warnings, notices Notices relating to specific hazards Notices relating to temporary hazards (and their subsequent removal) (See also permit-to-work systems and operating procedures) Alarms; emergency communications Control of contractors Familiarization with plant hazards, rules and safety practices, security Clear delineation of work, responsibilities and handover (See also maintenance, permit-to-work systems, personal protection, site restrictions, access, modifications, personal hygiene etc. Scheduled maintenance of key plant items Use of job cards/log book to identify tasks precisely Permit-to-work systems Flame cutting/welding (or soldering, brazing etc. Other unusual/non-routine situations Provision for trained persons to be present/on call. All maintenance on equipment used with chemicals should be properly planned following a risk assessment, and recorded. Maintenance operations, particularly those which are non-routine, require a sound system of work with strict administrative procedures. A permit-to-work should be used wherever the method by which a job is done is likely to be critical to the safety of the workers involved, nearby workers, or the public; it is required whenever the safeguards provided in normal operations are no longer available. The system has written instructions to explain how it operates and to which jobs it is applicable. This must be issued by a responsible person and the recipient must be trained in the system and how to perform the work. Examples include: • Entry into confined spaces where there is likely to be a danger from toxic or flammable gases, ingress or presence of liquids, free-flowing solids, or oxygen deficiency or enrichment, etc. Enrichment of a room atmosphere >25% creates a hazardous situation: enrichment in a confined space is particularly dangerous. Isolate plant or section Remove sludge and/or concerned deposits if present Check no source of ingress Clean inside surfaces by of dangerous material. Specify: Protective clothing if needed Second man outside Rescue equipment Reviving apparatus Emergency back-up Issue permit-to-work certificate Specify time limit, cancellation in emergency Work finished inside time limit Work not finished inside time limit Warn personnel Refer back to supervisor for renewal Return permit for cancellation or new permit Return to service Re-check plant status. Requirements No entry without a specific permit-to-work authorizing the work; entry without a permit is forbidden except for rescue purposes Strict compliance with all instructions on the permit. Such vessels, although apparently ‘empty’, may have residue in the bottom and/or in seams and crevices. It must then be inspected internally; mirrors and torches can be used for this but any lights must be flameproof or intrinsically safe. An explosimeter can be used to check for vapour but will not detect solid residues or involatile liquid. Do not: – Attempt to drive off liquid using a naked flame; – Assume that a vessel is clean without inspecting it; – Rely upon blowing through with air or water washing; – Use chlorinated solvents to remove residues. Where this is impractical, checks on its containment and inerting are necessary, together with environmental monitoring to ensure that atmospheric levels are well below the lower explosive limit (Figure 13. Other situations for which permits-to-work are required include: • Maintenance of apparatus used for microbiology. Thus operating personnel are responsible for ensuring that an area or plant item is isolated and free of danger; at the end of the work, maintenance staff are responsible for ensuring that any hazard that may have been introduced during their work has been removed and the plant etc. Details of isolation: (2) the above item of plant is not isolated from every (dangerous) source of steam, gas, fume, liquid, solids, motive power, heat and electricity. Part 1 records conditions and steps required; Part 2 authorizes work and specifies precautions. This type of certificate may be designed to cover work on roofs, in storage bunkers and on plant containing gas, fume, steam or corrosive, poisonous or radioactive materials; welding and burning in potentially hazardous areas; work being carried out where there is a risk of fire, explosion, electric shock, flooding or high pressure. It is not considered appropriate for work on electrical equipment operating at >650 V. Only one permit relating to one piece of equipment should be allowed at any one time. Best practice is for only one person to have authority to issue permits for a specific area. Does each permit clearly identify the work to be done and the hazards associated with it Does each permit state the precautions which have been taken and those needed while the work is in progress. Is there a system of clear cross-referencing when two or more jobs subject to permits may affect each other Does each permit have a hand-back procedure which incorporates statements that the maintenance work has finished and that the plant has been returned to production staff in a safe condition Is the permit form clearly laid out, avoiding statements or questions which could be misleading or ambiguous, but being sufficiently flexible for use in ‘unusual’ circumstances, however rare Pressure systems the safety of pressure systems in Great Britain is controlled by the Pressure System Safety Regulations 2000. All steam systems with a pressure vessel used at work are covered, irrespective of pressure. Advice may be sought from any competent person when deciding what vessels and parts of the pipework need to be included. Here the safe operating units are basically the upper limits of pressure and temperature for which the plant was designed to be operated safely. Emergency procedures Emergencies include controllable events leading to safe shutdown of the plant and uncontrollable emergencies. However, most detailed planning tends to relate to major incidents, or those which might affect the public or neighbouring sites. It should provide simple and logical procedures for effective direction and coordination of an emergency incident in a way which • safeguards personnel including rescuers, fire-fighters, etc. An inherent part of planning is to ensure that all personnel fully understand their own role, and appreciate the roles of others, in dealing with an emergency. In some situations it will be important to recover records, equipment and samples for subsequent investigation. Warnings A primary consideration is the method of warning that an emergency has occurred. On a small site an emergency is likely to affect the complete site; hence a common warning system is required. A minor incident is one capable of being dealt with fairly effectively and quickly by personnel on the spot using the emergency equipment. The situation can be dealt with by the workforce, possibly including a Works Fire Brigade, fairly rapidly. A Category 1 incident is one requiring additional resources, but which can be dealt with by the site operator and internal fire brigade. Some thought needs, however, to be given as to whether, and when, the public emergency services should be notified. If the total site forces are fully occupied dealing with a protracted incident, back-up resources may be needed to guard against a second incident. The emergency services should be informed immediately of the magnitude of the incident and the specific location. The response from the emergency services will again need to be predetermined by pre-planning. Pre-planning may therefore include preparation of a ‘call-in’ list with the proviso that 90% of personnel will respond when called. Responsibilities and pre-planning Each person in the emergency team should understand clearly, and be well-practised in, the function that they have to perform. The priorities are: 1R escueofpersonnel,w hereappropriate;assessm entofw hethertherearecasualtiesorw hether people may be missing and should be searched for. Insom esituationsprovisionisobviouslynecessaryfor wardens or properly equipped rescuers to search areas to ensure evacuation is complete. Accounting for staff can be difficult; hence the advantage of site logging-in procedures. Instructions should be posted, stating • Where personnel should go, by which route/alternative routes in an emergency. If there is a flammable hazard on site, radios may need to be intrinsically safe or flameproof. Training and exercises Every part of an emergency plan has to be understood by all personnel involved, including the emergency services. Detailed instructions therefore have to be issued to all those who will act to control, or mitigate the effects of, a major incident. Everyone on site needs to understand the plan and the procedures in it; this includes: • Familiarity with the different alarms.

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Clinical Implications of • Hire counselors and administrators and appoint board members from the Culturally Competent diverse populations that the program Treatment serves fungus gnat infestation generic butenafine 15mg on-line. These 2006f) antifungal questions butenafine 15 mg without prescription, provides more information about services may be necessary for some clients assessing program needs fungus gnats plant damage buy 15 mg butenafine visa. Some clients left families Experienced providers report that this and friends behind when they came to fungus yellow foamy cheap 15 mg butenafine otc the approach works well with clients from United States. Helping these clients build many cultures and is the preferred support systems is critical. All • Use a motivational framework for treat materials should be sympathetic to the cul ment, which seems to work well with cli ture of clients being served. Basic principles 188 Chapter 10 of respect and collaboration are the basis education, economic status, and labor force of a motivational approach, and these participation. Mexican of minorities benefit from mutual-help Americans are the materials should be programs to the same extent as do Whites largest subgroup, (Tonigan 2003). These descriptions character Two-thirds of the Hispanic/Latino people ize entire groups. As a geographic distribution, rates of substance group, they are the most urbanized ethnic use) and include generalized cultural char population in the country. This erty rates for Hispanics/Latinos are high type of cultural overview is only a starting compared with those of Whites, by the third point for understanding an individual. Appendix 10-A (page 197) contains Celebrations and religious ceremonies are an annotated list of resources on cultural an important part of the culture, and use competence in general, as well as resources of alcohol is expected and accepted in these listed by population group. In the interest include free publications available from gov of family cohesion and harmony, traditional ernment agencies—in particular the Center Hispanic/Latino families tend not to discuss for Substance Abuse Treatment and the or confront the alcohol problems of family Center for Substance Abuse Prevention—and members. Among Hispanics/Latinos with a describe population-specific treatment guide perceived need for treatment of substance lines and strategies. Studies show that Hispanics/ Hispanics/Latinos include individuals Latinos with substance use disorders receive from North, Central, and South America, less care and often must delay treatment, as well as the Caribbean. De La Rosa and White’s (2001) review include American Indians, Spanish-speaking of the role social support systems play in Caucasians, and people from Africa. The have had distinctly different experiences 2000 Substance Abuse and Mental Health from U. Five percent of of African-Americans are foreign born; many Alaska Natives live on Hispanics reported have grown up in countries with majority use of illicit sub Black populations ruled by governments con stances, with the sisting of mostly Black Africans. Only 9 percent Cubans (Office of of African-American youth reported alco Applied Studies 2001). Hispanics/Latinos hol use, compared with at least 16 percent accounted for 9 percent of admissions to of White, Hispanic/Latino, and Native substance abuse treatment in 2000 (Office of American youth (Office of Applied Studies Applied Studies 2002). Six percent of African-Americans Spanish-language treatment groups are help reported use of illicit substances, compared ful for recently arrived Hispanic/Latino with 6 percent of Whites and 5 percent of immigrants. Programs in areas with a large Hispanics/Latinos (Office of Applied Studies population of foreign-born Hispanics/ 2001). African-Americans accounted for 24 Latinos should consider setting up such percent of admissions to substance abuse groups, using Spanish-speaking counselors. Among African-Americans with a per parts of the country, especially in urban ceived need for substance abuse treatment, areas. Islanders Currently only 20 percent of American Asian Americans and Pacific Islanders Indians and Alaska Natives live on res are the fastest growing minority group in ervations or trust lands, where they have the United States, making up more than 4 access to treatment from the Indian Health percent of the U. They account for (Center for Substance Abuse Prevention more than one-quarter of the U. The vast majority live in cent of Native Americans reported alcohol metropolitan areas (Reeves and Bennett use. Thirteen percent of Native Americans 2003); more than half live in three States: reported use of illicit substances (Office of California, New York, and Hawaii (Mok et al. Nearly 9 out of 10 Asian Americans 12 to 17, the use of illicit substances was either are foreign born or have at least one most prevalent among Native Americans—22 foreign-born parent (U. Asian Americans represent many Native Americans begin using substances distinct groups and have extremely diverse at higher rates and at a younger age than cultures, histories, and religions. Native Pacific Islanders are peoples indigenous to Americans accounted for 3 percent of admis thousands of islands in the Pacific Ocean. Fifty-eight three-quarters of all Native-American admis percent of these individuals reside in Hawaii sions for substance use are due to alcohol. One study found that rates for alco tural, linguistic, and psychological variations hol dependence among Native Americans that exist among the many ethnic subgroups were higher than the U. Thirty percent of men in cultur orders, seeking help, and use of treatment ally distinct tribes from the Northern Plains services (U. Department of Health and and the Southwest were alcohol dependent, Human Services 2001). Three percent ment toward using Native healing traditions of Asian Americans and Pacific Islanders and healers for the treatment of substance reported use of illicit substances (Office of use disorders. As a group Asian unique to each tribe or cultural group and is Americans and Pacific Islanders have the based on that culture’s traditional ceremo lowest rate of illicit substance use, but nies and practices. However, these new treatment use illicit substances at much greater rates protocols require clients to take multiple than Chinese (1 percent) and Asian Indians medications on a complicated regimen. In with men and people who inject drugs; these Hispanic culture, matters of sexual orienta groups together account for nearly four-fifths tion tend not to be discussed openly. Minorities selves targets of discrimination within their have a much higher incidence of infection minority culture and of racism in the general than does the general population. Among individuals are more likely to use alcohol 13 to 19-year-olds, females accounted for and drugs, more likely to continue heavy more than 60 percent of new cases (Centers drinking into later life, and less likely to for Disease Control and Prevention 2002). They also are more likely to have African-American and Hispanic/Latino used many drugs, including such drugs as women. Although they represent less than a Ecstasy, ketamine (“Special K”), amyl nitrite quarter of U. Persons With Physical and the development of new medications—and Cognitive Disabilities combinations of medications—has had a Nearly one-sixth of all Americans (53 mil significant effect on the length and qual lion) have a disability that limits their ity of life for many people who live with 192 Chapter 10 functioning. More than 30 percent of those tan population with disabilities live below the poverty line increased 10. But economic base and those with skills tend to be underemployed ethnic diversity of with disabilities is an or unemployed. The combination of depres these populations, sion, pain, vocational difficulties, and not just their isola emerging field functional limitations places people with tion, are critical physical disabilities at increased risk of sub factors. Many community-based treat farm workers across the South, and Native ment programs do not currently meet the Americans on reservations. Experienced clinicians report monalities: low population density, limited that an appreciable number of individuals access to goods and services, and consid with substance use disorders have unrecog erable familiarity with other community nized learning disabilities that can impede members. People who have the also share broad characteristics that affect same disability may have differing function treatment. Culture brokering is a treatment resistance to participating in group work approach that was developed to mediate because in small communities “everyone between the culture of a foreign-born person knows everyone else” and the health care culture of the United • A sense of strong individuality and pri States. This model helps rehabilitation pro vacy, sometimes coupled with difficulty in viders understand the role that culture plays expressing emotions in shaping the perception of disabilities • A culturally embedded suspicion of treat and treatment (Jezewski and Sotnik 2001). Among adults older than age 25, the rate of alcohol use is lower in rural areas than in metropolitan areas. But rates of heavy alco Rural Populations hol use among youth ages 12 to 17 in rural areas are almost double those seen in met In 2000, nearly 20 percent of the U. However, in drug, or mental disorder in the previous one study, urban residents received month (Urban Institute et al. Three substance abuse treatment at more than quarters of people who are homeless and double the rate of their rural counterparts need substance abuse treatment do not (Metsch and McCoy 1999). For 50 per attribute this disparity to the relative unavail cent of people who are homeless and ability and unacceptability of substance abuse admitted to treatment, alcohol is the primary treatment in rural areas of the United States substance of abuse, followed by opioids (18 (Metsch and McCoy 1999). Twenty three percent of people who are homeless Homeless Populations and in treatment have co-occurring disor Approximately 600,000 Americans are home ders, compared with 20 percent who are not less on any given night. Homeless populations include groups will assist providers in treating people who of people who are are homeless: • Transient.

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