Elizabeth A. Shaughnessy, MD, PhD

• Associate Professor
• Department of Surgery
• University of Cincinnati
• Surgeon
• University Hospital
• Cincinnati, Ohio

Therefore the committee made 7 recommendations based on their knowledge and expertise prehypertension fatigue buy genuine zestoretic. Women with gestational 8 thrombocytopenia are generally considered at low risk of bleeding complications during birth 9 whereas women with immune thrombocytopenic purpura are regarded as high risk wide pulse pressure in young adults discount zestoretic 17.5mg on-line. So the 10 committee recommended significant changes to the birth plan only if the woman had immune 11 thrombocytopenic purpura prehypertension meaning in hindi discount zestoretic 17.5 mg with amex, or gestational thrombocytopenia with a low platelet count hypertension va disability rating buy genuine zestoretic online. Conversely, 14 a woman with immune thrombocytopenic purpura may have a normal platelet count and a 15 baby with a low platelet count and high risk of bleeding. In other words, for women with 16 immune thrombocytopenic purpura the bleeding risk of the woman does not correspond to 17 the bleeding risk of the baby. Consequently if the woman has immune thrombocytopenic 18 purpura, it is safest to treat the baby as being at high risk of bleeding, and modify the birth 19 plan to reduce the bleeding risk to the baby wherever possible, for example, by not carrying 20 out any fetal blood sampling. Gestational thrombocytopenia therefore only puts the woman at risk of 23 bleeding, and not her baby. The committees discussion of the evidence4 Interpreting the evidence5 the outcomes that matter most6 7 Maternal and neonatal outcomes were prioritised for the review because a bleed in either the 8 woman or the baby can have serious consequences for that person. The 17 quality of each study was assessed using the Joanna Briggs Institute appraisal checklist for 18 case series and none of the studies was considered to have reported comprehensively. In one study (Boehlen 2000), although the sample size was 22 786, the study authors did not report clearly on the inclusion criteria for cases. In another 23 study (Payne 1997), although most of the information was reported (apart from the lack of 24 information on the above 3 points), the sample size was 55. The committees view was 31 that it is important to exclude other serious pregnancy-related thrombocytopenia such as pre 32 eclampsia or antiphospholipid syndrome. For example, the woman should be referred to a maternity unit that can 40 offer high dependency care. The committee justified the strong recommendation as there 41 was a risk of maternal death if the woman bled without adequate clinical support. The committee recommended monitoring 3 the womans platelet count to identify whether her condition is changing (for example, in 4 response to treatment of the condition. The committee explained that monitoring the 5 womans platelet count at 36 weeks of gestation is part of standard clinical practice, and that 6 the recommendation is weak because starting at 36 weeks of gestation is based on clinical 7 consensus rather than evidence. Thirty-six 10 weeks was selected because this is almost term and, therefore, the beginning of the period 11 when labour is likely to start. The platelet count threshold of 50 x 109/l was selected as the 12 threshold on the basis of clinical consensus as being the lowest count at which an 13 anaesthetist would usually consider regional analgesia. The committee discussed the use of 14 steroids or intravenous immunoglobulin to increase the platelet count. Because of lack of 15 evidence there was uncertainty about its effectiveness in preventing adverse outcomes, 16 however, the committee recommended considering steroids or intravenous immunoglobulin 17 for women with a platelet count less than 50 x 109/l to increase the count before admission 18 for birth. They 22 suggested that the intrapartum care should be modified according to the platelet count as 23 detailed below. It was also noted by the committee that the bleeding risk of the woman does 24 not correspond to the bleeding risk of the baby as it is possible that the woman with a normal 25 platelet count could have a baby with a low platelet count with a high risk of bleeding. For 26 example, if the woman is known to have immune thrombocytopenic purpura before birth, she 27 might have received treatment during pregnancy to increase the platelet counts and thus, the 28 platelet count of the woman could not be a reliable indicator of the bleeding risk of the baby. Therefore, they decided to make a separate 34 recommendation for the neonatal management of babies born to these women. The 35 committee explained that using ventouse or fetal blood sampling in labour can expose babies 36 to a high risk of bleeding and thus, these procedures should be avoided for babies of women 37 with bleeding disorders. The committee justified the strong recommendations on the grounds 38 that if the baby has a low platelet count then a bleed could be fatal, and there are other ways 39 of achieving the same outcome without exposing the baby to the same risks. The committee 40 also recommended being aware of the risks involved in using fetal scalp electrodes, mid 41 cavity forceps or rotational forceps. The committee could not make strong recommendations 42 here as the link between these procedures and bleeding risk was less clear and available 43 substitutes not always clinically appropriate. The committee added that caesarean section 44 may not protect the baby from bleeding; the common misconception that caesarean section 45 would protect the baby in this way which might lead to a woman agreeing to a surgical 46 procedure unnecessarily. For these situations, the 18 committee used their clinical experience to suggest the following guidelines to follow based 19 on platelet count alone while considering regional analgesia or anaesthesia. They suggested 20 on the basis of their experience a 3-tier cut-off system where risk was: known to be high; 21 known to be low; and unknown. They discussed how different clinicians might choose to 22 manage in different ways: 23 Platelet count >80 x 109/l 24 In the experience of the committee, a woman with a platelet count above 80 x 109/l would not 25 need her birth plan to be modified in the absence of any other risk factors. Thus, the 26 committee suggested to treat the woman as healthy when considering regional analgesia or 27 anaesthesia. The committee explained how a woman with immune thrombocytopenic 28 purpura with a high platelet count could still possibly have a baby with a low platelet count 29 and so platelet count was no guide in determining risk for these babies, but a woman with 30 gestational thrombocytopenia and a high platelet count was also likely to have a baby with a 31 high platelet count, and therefore the risk to the baby would be minimal. The womans 35 history, preferences and the level of expertise of the anaesthetist should be considered 36 before deciding whether or not to use regional analgesia or anaesthesia. The committee 37 explained that the balance of benefits and risks would shift somewhere between a platelet 38 count of 50 and 80 x 109/l, but that in the absence of evidence they were unsure where that 39 would be. However the committee explained that the changes in management required to 40 avoid bleeding risk in the baby were relatively minor and that it would be prudent to assume 41 the baby was at risk of bleeding even at relatively high platelet counts. However, in the case 42 of gestational thrombocytopenia, the bleeding risk in the baby was assumed to be normal 43 because only the woman is at risk of bleeding as women with gestational thrombocytopenia 44 do not have an alloantibody that affects the fetal platelet count. Babies of women 5 with gestational thrombocytopenia were assumed to have normal bleeding risk because they 6 do not have an alloantibody that affects the fetal platelet count and so only the woman is at 7 risk of bleeding. The committee explained that regional anaesthesia and analgesia could still 8 be considered under certain rare circumstances, for example, for a woman who was otherwise 9 healthy and well and where the anaesthetist was experienced in caring for women with low 10 platelet counts. However, the committee agreed that in general regional anaesthesia and 11 analgesia should be avoided in this group. The committee considered that no significant changes to the birth plan would be 18 required if the woman had gestational thrombocytopenia. For women with immune 19 thrombocytopenic purpura, both the woman and the baby can have a high risk of bleeding and 20 therefore the committee reasoned that it would be cost effective to modify the birth plan to 21 minimise the risks. The committee was generally of the view that the cost of the 22 recommendations was minor in comparison to the potential harms from not following the 23 recommendations. Therefore they recognised that the recommendation 27 could lead to more women requiring high dependency care. However, they thought this might 28 be offset by women at lower risk not being referred to such units. They agreed that it was not possible 34 to consider every possible bleeding disorder in this guideline. They identified gestational 35 thrombocytopenia and immune thrombocytopenic purpura as relatively common bleeding 36 disorders in pregnancy and for which there might be evidence available to guide 37 recommendations. The committee was aware that limiting the review to these bleeding 38 disorders might result in there being little evidence to interpret with regard to platelet function. However, gestational 3 thrombocytopenia is generally considered to be a low-risk condition and so the committee 4 agreed it would be unlikely to have a significant impact on practice. A research 5 recommendation on immune thrombocytopenic purpura would be probably be less relevant, 6 as it would be difficult to design a clinical trial based on clinical equipoise. Consequently the 7 committee did not make any research recommendations related to management of bleeding 8 disorders in pregnancy. Introduction7 8 the aim of this review is to determine how the third stage of labour should be managed for 9 women who are at increased risk of postpartum haemorrhage because of haemostatic 10 disorders. Clinical evidence7 Included studies8 9 Three retrospective cohort studies and 1 case series study were included in this review (see 10 Summary of clinical studies included in the evidence review. One study compared tranexamic acid 16 to no tranexamic acid in women haemostatic disorders (76% with von Willebrands disease, 17 18% haemophilia A carriers) (Hawke 2015. In this study, the women received antenatal 21 treatment such as steroids, intravenous immunoglobulin, or both, and the clinical outcomes 22 are reported descriptively according to treatment received. No evidence was identified for other population groups 3 specified in the protocol. No evidence was identified comparing additional obstetric 4 interventions with haemostatic therapy to additional obstetric interventions without additional 5 haemostatic therapy (comparison 2. Excluded studies7 8 Studies not included in this review with reasons for their exclusions are provided in appendix 9 D.

Their behaviors and/or symptoms can be adequately addressed through alternative methods prehypertension blood pressure symptoms zestoretic 17.5 mg otc. Functional and measurable progress toward treatment goals is not occurring (majority of goals are not being met hypertension 130100 order 17.5 mg zestoretic visa, there is not significant progress on behaviors and/or symptoms that prevent them from adequately participating in home hypertension jnc 8 ppt discount generic zestoretic uk, school hypertension and exercise order zestoretic 17.5 mg with visa, or community activities, and/or no longer present a safety risk to self or others), improvement is not durable over time, and generalizable outside the treatment setting, and there is no reasonable expectation of further progress d. However, more complex cases, or cases in which a complete functional analysis is needed, may require up to 15-20 hours for the initial assessment and treatment planning. As noted in the 2014 Agency for Healthcare Research and Quality update on A Review of Research of Therapies for Children with Autism Spectrum Disorder, early intervention programs. These services can include direct services to member/identified patient and/or parents by program manager/lead behavioral therapist and/or therapy assistants/behavioral technicians/paraprofessionals, supervision, and the development of a six-month progress report. Progress towards parent goals (how parents have been active participants in the treatment, what percentage of parent goals have been passed, and progress towards transferring interventions with the patient to the parents) c. For goals that have not been met, describe reason for not meeting goals, how goals are being adjusted, and how interventions are being revised to meet goals d. Any new goals that have been identified (if new goals are identified, include baseline and targeted performance. New goals should be geared towards progress or transition to less intensive interventions. How the patient is progressing towards discharge and/or plans for discharging from care and/or reducing intensity of intervention based on patient progress and/or the implementation of less intensive behavioral interventions f. A brief description of what was done during the past six months to coordinate treatment with school and/or health care providers. Every 12 months, developmental assessment should be re-administered to assess whether patient continues to be making functional and measurable progress. More than one program manager/lead behavioral therapist for a member/identified patient at any one time. Activities and therapy modalities that do not constitute application of applied behavioral analysis techniques for treatment of autism. Taking the member/identified patient to appointments or activities outside of the home (e. Assisting the member/identified patient with academic work or functioning as a tutor, educational or other aide for the member/identified patient in school Kaiser Permanente Cooperative. Be a licensed health provider under Title 18, Revised Code of Washington, including but not limited to: speech therapist, occupational therapist, psychologist, pediatrician, neurologist, psychiatrist, mental health counselor, social worker; and 2. Be credentialed and contracted by the Plan; or ii)Be employed by a Healthcare Delivery Organization that meets All of the following requirements: 1. Be a hospital, mental health facility, home health agency or in-home agency licensed to provide home health services, or other mental health agency licensed by the Washington Department of Health; or a community mental health agency or home health agency licensed by the Washington Department of Social and Health Services; and 2. Clinical supervision for unlicensed staff providing services must be provided by a lead behavioral therapist as indicated above. Patients may experience rest pain, ulceration, claudication, hospitalizations, and even amputation of limb. In addition, the procedure is time consuming and this might contribute to its low use in busy healthcare centers (Davies et al. Back to Top Date Sent: 3/24/2020 27 these criteria do not imply or guarantee approval. These encompass devices using oscillometric technology and plethysmographic-based technology. When the pressure of the upper occlusion chamber has exceeded arterial systolic pressure, the distal detection chamber detects a gradual decrease in limb volume as a result of blood redistribution in the absence of arterial blood inflow. As the pressure in the occlusion chamber is then incrementally reduced and reaches systolic pressure, arterial blood flow to the limb is restored, which is detected as a volume increase in the lower chamber. The pressure in the upper occlusion chamber at the point when this lower chamber volume increase occurs, is taken as the limb arterial systolic pressure? (Davies & Williams, 2016. It uses air plethysmography technology to perform these assessments (Millen et al. The Dopplex ability provides fast and easy measurements with a printout of results from integrated software package. The Dopplex ability system includes Dopplex ability automatic machine, one box of disposable sleeves, four pieces set of standard 8? The Dopplex ability is intended for wound care for arterial disease before deciding on compression bandaging. The use of Ankle-Brachial Index device using plethysmographic method for the diagnosis of peripheral artery disease does not meet the Kaiser Permanente Medical Technology Assessment Criteria. Back to Top Date Sent: 3/24/2020 28 these criteria do not imply or guarantee approval. Back to Top Date Sent: 3/24/2020 29 these criteria do not imply or guarantee approval. Background Articular hyaline cartilage is a highly specialized connective tissue that covers the surface of bone in synovial joints. It is a 2-4mm thick hyaline cartilage that provides smooth low friction movement and shock absorption. Unlike most tissues, articular cartilage does not have blood vessels, nerves, or lymphatics. The articular cartilage is prone to damage from acute high energy trauma and from repetitive shear and torsional forces applied to the surface. Lesions to the articular cartilage are often associated with pain and compromised 1998 Kaiser Foundation Health Plan of Washington. Back to Top Date Sent: 3/24/2020 30 these criteria do not imply or guarantee approval. Criteria | Codes | Revision History joint function and may lead to the development and progression of osteoarthritis. The damaged cartilage has very limited capacity for self-repair due to its avascular and hypocellular nature. Surgery has thus been the standard approach for repairing articular cartilage damage. Surgical techniques intended for restoring the articular surface are classified into 3 categories: 1. Reparative, which includes marrow stimulation such as microfracture; drilling; and abrasion arthroplasty, and 2. Investigators suggest that microfracture surgeries is more effective than reconstructive surgeries for the repair of smaller cartilage defects (<100mm2) while reconstructive surgeries are more effective for larger defects (>100mm2) (Crawford 2012, Perera 2012, Negrin 2013, Mundi 2015, Li 2015. Currently, marrow stimulation through microfracture is the standard first-line surgical treatment for articular cartilage lesions of the knee. It is a single-stage arthroscopic procedure that involves penetrating the subchondral bone plate after removing the damaged hyaline cartilage. Bleeding from the subchondral bone forms a clot that attracts bone marrow cells to migrate into the cartilage defect and create a ?super clot? that eventually matures into a firm repair tissue consisting of a combination of fibrous and hyaline-like cartilage. The technique is minimally invasive, technically simple, and is associated with low morbidity. However, the repair is composed of fibrocartilaginous tissue, which is mechanically inferior to the native hyaline cartilage; it has less ability to withstand shock and shearing forces leading to deterioration in function over time. In addition, the bone marrow stem cells and growth factors are released into the joint rather than being contained in the site of the defect. Some researchers suggest that microfracture is more effective in reducing pain and improving joiny function when performed for new injuries, small focal injuries, and in younger individuals with lower body mass index (Crawford 2012, Negrin 2013, Lee 2014, Mundi 2015. It is a surgical technique that uses osteochondral grafts taken from the lighter-load bearing areas of the patient?s own joint to fill the focal defects. There is a concern however, with the donor site morbidity, and thus the technique may not recommend for lesions larger than 400mm2 (Li 2015, Mundi 2015. First, a cartilage biopsy is harvested from healthy cartilage of the affected knee during an arthroscopic biopsy procedure. The specimen of live articular cartilage is sent to a cell expansion laboratory for chondrocyte culture. The cells are separated from the cartilage under a strictly controlled environment, and then multiplied using a cell-culture technique for 3-6 weeks. The cultured chondrocytes are then implanted into the cartilage defect in an open arthrotomy procedure.

Sarcoidosis is a multisystem granulomatous disease of unknown origin that occurs most commonly in young adults blood pressure medication green pill cheap zestoretic 17.5 mg with amex. A sarcoidosis-like pulmonary disease has been clearly asso ciated with beryllium exposure blood pressure chart english purchase zestoretic without a prescription. Alzheimer disease is a very heterogeneous disorder that is characterized by dementia due to plaque formation heart attack 3d order zestoretic with a mastercard, with a central amyloid core blood pressure medication and breastfeeding order zestoretic discount, in frontal and temporal lobes. Nevertheless, secondary immune responses to , for instance, amyloid-ȕ peptides may contribute to the pathogenesis of the disease, but this has not been validated. Atherosclerosis is a chronic inflammation of the arterial vessel wall resulting in plaque formation that eventually may cause cardio vascular events, such as myocardial infarction or cerebral vascular accidents. Atherosclerotic plaques also contain some T cells that are con sidered to be autoreactive, although the respective autoantigens have not yet been identified. These T cells are probably not involved in the plaque formation as such, but they may cause plaque instability, rupture, and subsequent clinical events. The incidence of a disease is the number of new diagnoses that occur in a population in a given time period. The prevalence is the number of people who have the disease and so is determined by the incidence and duration of the illness. The criteria used to define a disease, methods used to identify people with a specific condition, study area, as well as secular changes in rates can contribute to the variability in rates for a specific disease that may be seen among studies. A recent review of epidemiological studies covering 24 specific autoimmune diseases estimated that approximately 3% of the population in the United States suffers from an autoimmune disease (Jacobson et al. This estimate is likely to be low, as for many diseases our knowledge of basic epidemiology is quite limited or based on studies conducted 30 or more years ago, and some diseases (e. A revised estimate of the prevalence of autoimmune diseases presented in a recent report of the United States National Institutes of Health (2000) is 5–8%. Many specific autoimmune diseases are relatively rare, with an estimated incidence of less than 5 per 100 000 persons per year or an estimated prevalence of less than 20 per 100 000 (Table 7. Diabetes mellitus type 1 rates are for children and adolescents (age <20 years); all other rates are for adult populations. Two autoimmune diseases, diabetes mellitus type 1 and myocarditis, are most commonly seen in children and adolescents. Addison disease, multiple sclerosis, and vitiligo occur most often in young adults (and teenagers, in the case of vitiligo) (Table 7. The autoimmune thyroid diseases, lupus, systemic sclerosis, and rheumatoid arthritis usually occur in late reproductive and early-postmenopausal years, while some other diseases (e. Almost all autoimmune diseases that occur in adults dispropor tionately affect women. However, there is considerable variability in the extent of female predominance and no clear relation between degree of female predominance and type of disease or age at onset (Table 7. More than 85% of patients with Sjögren syndrome, systemic lupus erythematosus, systemic sclerosis, the autoimmune thyroid diseases, and primary biliary cirrhosis are female, compared with 65–75% of patients with rheumatoid arthritis and multiple sclerosis. The extent to which ethnic, racial, or geographic variability in disease incidence or severity occurs has been well characterized for only the few autoimmune diseases that have been the subject of numerous epidemiological studies. In diabetes mellitus type 1, multiple sclerosis, and hyperthyroidism, rates are higher among whites than among minority groups (Kurtzke et al. African Americans and other minority groups in the United States, Canada, and the United Kingdom are at higher risk of systemic lupus erythe matosus compared with whites (Hopkinson et al. Severity of these diseases is worse in these groups, too, with increased disease activity, increased organ 90 Epidemiology damage (particularly renal involvement), and higher mortality risks (Laing et al. Thus, it may permit the detection of genes or environmental factors that can inform preventive action. Co-morbidity can be observed at a number of levels, including the individual, the household, the family (genetically related), and population levels. Animal models suggest that both genetic and environmental factors are important in co-morbidity, and of particular interest is the way in which environmental factors can modify genetic suscep tibility. In both cases, early immune stimulation leads to lower incidence of diabetes, showing how genetic susceptibility to multiple autoimmune disorders may be disguised by environmental factors. Data pertaining to co-morbidity of autoimmune diseases in humans are surprisingly sparse. Few studies are population-based, and few are of sufficient size to address potentially important bio logical associations, given the relative rarity of many diseases (Scofield, 1996. A recent unpublished review of co-morbidity of rheumatoid arthritis, diabetes mellitus type 1, multiple sclerosis, Crohn disease, and autoimmune thyroid disease found evidence of an increased incidence of autoimmune thyroid disease in patients with rheumatoid arthritis and in autoimmune diabetes (E. Studies in this area are also few and most of a small size, which makes control of con founding difficult. One study of the household showed that those living with subjects suffering from systemic lupus erythematosus were more likely to have related autoantibodies (DeHoratius et al. The study was not able to fully distinguish between a genetic and environmental relationship, but it raises many intriguing ques tions. These studies are most feasible for the autoantibodies associated with the most common autoimmune diseases: diabetes mellitus type 1, autoim mune thyroid disease, and rheumatoid arthritis. Important issues with respect to interpreting these types of studies include the type of test used and definition of a positive result. Approximately 5% of high-risk groups (defined on the basis of family history or genetic susceptibility) have two or more of these antibodies, compared with 0. The presence of diabetes-related autoantibodies is strongly associated with subsequent risk of developing disease. The prevalence of antithyroglobulin and antithyroid peroxidase antibodies (formerly called antimicrosomal antibodies) increases with age, and the antibodies are more common among women than among men (Hawkins et al. In the recent population based sample in the United States, approximately 18% of people ages 12–80 who were not taking thyroid medications and did not report a history of thyroid disease or goitre had one or both of these antibodies. In the cross-sectional analysis of the full population (including those with thyroid disease), antithyroid peroxidase antibodies, but not antithyroglobulin antibodies, were highly predictive of hypothyroidism and hyperthyroidism (defined on the basis of thyroid stimulating hormone and thyroxine [T4] levels. The predictive ability of antithyroid peroxidase antibodies for the subsequent development of hypothyroidism was also seen in a longitudinal study in the United Kingdom (Vanderpump et al. In the Pima Indians, a population with an extremely high incidence of rheumatoid arthritis, the prevalence of rheumatoid factor is higher in females than in males (Enzer et al. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies have been shown to be predictive of the development of rheumatoid arthritis (del Puente et al. Several large studies of antinuclear antibodies in the general population have been conducted using blood donors (Fritzler et al. Similar estimates were seen in these studies, with a prevalence of approx imately 25–30% at a titre of 1:40 and 3–4% at a titre of 1:320. The prevalence of antinuclear antibodies is lower in children than in adults, but is fairly constant through the reproductive years. There are limited, and somewhat conflicting, data comparing prevalence of high-titre antinuclear antibodies by sex (Craig et al. None of these studies was able to provide data pertaining to ethnic differences in the prevalence of antinuclear antibodies. We do not currently have data pertaining to the predictive ability of antinuclear antibodies with respect to development of lupus. A complex relation is seen between dietary iodine and prevalence of antithyroid antibodies, with increased prevalence reported in relation to iodine deficiency and to excess intake. Smoking history has been associated with the prevalence of rheumatoid factor in several studies (Regius et al. These studies reported an increased prevalence of rheumatoid factor among smokers. A similar association was also seen between smoking and antinuclear antibodies in one study (Regius et al. With respect to thyroid antibodies, however, smoking was associated with a decreased prevalence of antithyroid peroxidase antibodies in a study of 759 women in the Netherlands (Strieder et al. Anti-glutamic acid decarbox ylase antibodies were also found at an increased prevalence among these workers (Langer et al. There are also other studies on pesticide immunotoxicity following exposure to the pesticide mancozeb (Colosio et al. Both of these studies suggest a slight immuno stimulatory effect exerted by mancozeb. Small studies examining pentachlorophenol (McConnachie & Zahalsky, 1991; Colosio et al.

While defibrillation may restore a normal rhythm blood pressure chart 14 year old buy zestoretic toronto, there remains a high risk of recurrence blood pressure chart sheet buy generic zestoretic on line. When the driver has a history of arrhythmia or uses an anti-arrhythmia device hypertension jama zestoretic 17.5mg fast delivery, you arrhythmia blog discount generic zestoretic uk, as a medical examiner, should consider the following:. The management of the underlying disease is not effective enough for the driver to meet cardiovascular qualification requirements. To review the Implantable Defibrillator Recommendation Table, see Appendix D of this handbook. When assessing the risk for sudden, unexpected incapacitation in a driver with a pacemaker, the underlying disease responsible for the pacemaker indication must be considered. Currently, pacemakers and the lead systems are reliable and durable over the long term. Waiting period Minimum 1 month post-pacemaker implantation if underlying disease is:. Page 86 of 260 Minimum 3 months post-pacemaker implantation if underlying disease is:. Treatment by catheter ablation is usually curative and allows drug therapy to be withdrawn. Anticoagulant therapy decreases the risk of peripheral embolization in individuals with risk factors for stroke. See the Supraventricular Tachycardias Recommendation Table for diagnosis-specific recommendations. Waiting period Minimum 1 month anticoagulated adequately and diagnosis is atrial fibrillation. Minimum 1 month post-isthmus ablation and diagnosis is atrial flutter Minimum 1 month asymptomatic/treated asymptomatic and diagnosis is:. A driver could have a benign underlying medical problem with an excellent prognosis but still not be medically qualified as a commercial driver. For example, if a benign supraventricular arrhythmia causes syncope, the driver cannot be medically certified until the problem has been corrected. Ventricular Arrhythmias Ventricular arrhythmias are categorized as ventricular fibrillation and ventricular tachycardia and are responsible for the majority of instances of cardiac sudden death. Most cases are caused by coronary heart disease, but can also occur in people with hearts that are structurally normal. See the Ventricular Arrhythmias Recommendation Table in Appendix D of this handbook for diagnosis specific recommendations. Monitoring/Testing Have annual evaluation by a cardiovascular specialist who understands the functions and demands of commercial driving. See the Ventricular Arrhythmias Recommendation Table for diagnosis-specific recommendations. Cardiovascular Tests Detection of an undiagnosed heart or vascular finding during a physical examination may indicate the need for further testing and examination to adequately assess medical fitness for duty. Diagnostic-specific testing may be required to detect the presence and/or severity of cardiovascular diseases. The additional testing may be ordered by the medical examiner, primary care physician, cardiologist, or cardiovascular surgeon. When requesting additional evaluation from a specialist, the specialist must understand the role and function of a driver; therefore, it is helpful if you include a description of the role of the driver and a copy of the applicable medical standard(s) and guidelines with the request. Exercise Tolerance Test the exercise tolerance test is the most common test used to evaluate workload capacity and detect cardiac abnormalities. These activities include sitting, slow walking, and lifting light objects of no more than 10 pounds. Overall requirements for commercial drivers along with the specific requirements in the job description should be deciding factors in the certification process. Coronary Heart Diseases and Treatments As a medical examiner, it is your decision whether the nature and severity of the condition of the driver will result in gradual or sudden incapacitation. Page 91 of 260 Sudden death occurs when an individual goes from a usual state of health to death within 1 hour. The incidence of crashes caused by sudden death is relatively low, primarily because of the length of time between the onset of the cardiovascular event and the incapacitation of the driver. Emphasize that the driver may have only a short time following the onset of symptoms to safely stop the vehicle and call for medical assistance. Decision Maximum certification period 1 year Recommend to certify if: the driver: Page 92 of 260. The presence of this condition usually implies that at least one coronary artery has hemodynamically significant narrowing. When evaluating the driver with angina, you should distinguish between stable and unstable angina. The presence of unstable angina may be a precursor to a cardiovascular episode known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure. Recommend not to certify if: the driver has had unstable angina within 3 months of examination. Evaluation from a cardiovascular specialist who understands the functions and demands of commercial driving. Decision Maximum certification 1 year Recommend to certify if: As the medical examiner, you believe that the nature and severity of the medical condition of the driver does not endanger the health and safety of the driver and the public. In the setting of an uncomplicated, elective procedure to treat stable angina, the post-procedure waiting period is 1 week. The waiting period allows for a small threat caused by acute complications at the vascular access site. Clearance from a cardiovascular specialist who understands the functions and demands of commercial driving. Typical angina symptoms should prompt evaluation with a stress imaging study or repeat angiography. Congenital Heart Disease Heart failure and sudden death are the major causes of death among individuals with congenital heart disease. Due to the complexity of these problems, the Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Drivers recommend that the driver has regular, ongoing follow up by a cardiologist knowledgeable in adult congenital heart disease. Advances in surgical and medical management are expected to result in an increased number of individuals with congenital heart disease seeking driver certification. Ebstein anomaly is included in the handbook because it is a condition you are likely to encounter in the clinical setting. Ebstein Anomaly Ebstein anomaly is a congenital downward displacement of the tricuspid valve. Adults with a mild form of Ebstein anomaly can remain asymptomatic throughout their lives. Monitoring/Testing Annual cardiovascular re-evaluation should include echocardiography and evaluation by a cardiologist knowledgeable in adult congenital heart disease and who understands the functions and demands of commercial driving. To review the Congenital Heart Disease Recommendation Table, see Appendix D of this handbook. Page 100 of 260 Heart Transplantation Although the number of heart transplant recipients is relatively small, some recipients may wish to be commercial motor vehicle drivers. The major medical concerns for certification of a commercial driver heart recipient are transplant rejection and post-transplant atherosclerosis. Decision Maximum certification period 6 months Recommend to certify if: the driver:. Recommend not to certify if: As the medical examiner, you believe that the nature and severity of the medical condition endangers the health and safety of the driver and the public. Monitoring/Testing Monitoring the driver with a heart transplant should include re-evaluation and recertification every 6 months by a cardiovascular specialist who:. To review the Heart Transplantation Recommendation Table, see Appendix D of this handbook. Page 101 of 260 Myocardial Disease Myocardial diseases are often progressive and require long-term follow-up. Even so, improved diagnostic testing and treatment can increase the number of drivers with myocardial disease who seek commercial motor vehicle driver certification. Hypertrophic Cardiomyopathy Hypertrophic cardiomyopathy is a complex disease characterized by marked morphologic, genetic, and prognostic heterogeneity. Some individuals experience a benign and stable clinical course, while in others the disease is characterized by progressive symptoms. For some individuals, sudden death is the first definitive manifestation of the disease.

When a permit has been ordered correction blood pressure 10 cheap 17.5 mg zestoretic mastercard, removal or abatement of the dangerous or detrimental revoked by the Commissioner blood pressure chart toddler buy zestoretic 17.5 mg with visa, and the Commissioner fnds that the condition(s) circumstances resulting in revocation show that the permittee or other (2) the Commissioner may require any permittee that persons exercising management and control are unable or unwilling consistently fails to correct imminent or repeat blood pressure homeostasis cheap zestoretic express, serious violations to operate a program in compliance with this Code arrhythmia on ultrasound 17.5 mg zestoretic, an application to prepare a corrective action plan in which factors contributing to for a new permit will not be accepted for at least fve years from the violations are analyzed and a plan is created to address and correct date revoked from either the permittee or from any individual person violations When, in the opinion of the Commissioner, a permittee exercising management and control of the program that had its permit is unable or unwilling to write or implement a corrective action revoked plan that adequately protects the health and safety of children, the Commissioner shall provide the permittee with an opportunity to show (Amended City Record 9/20/2016, eff 10/20/2016; amended City Record cause at a hearing why its permit should not be suspended or revoked 9/20/2017, eff 10/10/2017; amended City Record June 12, 2018, eff July 12, 2018) (b) Operating without a permit. Prior to initial admission one staff person trained to administer such epinephrine to a school, or within 90 days after admission for children who are either auto-injector shall be on-site in the school-based program at homeless, as defned by section 11434a of chapter 119 of title 42 of the all times children are present the epinephrine auto-injector United States code, or in foster care, all children shall receive a complete training must include: age appropriate medical examination, including but not limited to a history, physical examination, developmental assessment, nutritional (A) How to recognize signs and symptoms of severe allergic evaluation, lead poisoning screening, and, if indicated, screening tests for reactions, including anaphylaxis; dental health, tuberculosis, vision, and anemia (B) Recommended dosage for adults and children; (2) Immunizations. Written policies and (6) Within 24 hours following any emergency administration of procedures for managing health and other emergencies shall be included an epinephrine auto-injector, the person in charge of a school in the written health and safety plan Persons in charge of a school based program or designee shall contact the Department to shall provide notice of the location and contact telephone numbers of report the incident the school to local hospitals, police precincts, fre houses and emergency transport services and information about emergency policies and (7) Each epinephrine auto-injector shall be disposed of in procedures shall be provided to parents Emergency procedures and accordance with applicable law emergency telephone contact numbers (for Police, Fire Department, Poison Control Center, Child Abuse Hotline, and the Department of ([c]d) First aid supplies. A frst aid kit, completely stocked for Health and Mental Hygiene) shall be conspicuously posted in each emergency treatment of cuts and burns, shall be provided by the person classroom or area used by children in charge of a school and shall be easily accessible for use the frst aid (b) Necessary emergency medical care. When a child is injured, or kit shall be kept out of reach of children and inspected periodically becomes ill under such circumstances that [immediate] emergency ([d]e) Incident [L]log [of childrens illnesses, and accidents]. For the purposes of Section 4(a), employees 1) who were in active pay status before May 1, 2005, and 2) who are affected by the a. Employees who return to active status from an approved leave of (iii) Effective February 7, 2014, employees shall receive a general absence increase of 1 00% ii. Employees in active status (whether full or part-time) appointed (iv) Effective February 7, 2015, employees shall receive a general to permanent status from a civil service list, or to a new title increase of 1 50% (regardless of jurisdictional class or civil service status) without a (v) Effective February 7, 2016, employees shall receive a general break in service of more than 31 days increase of 2 50% iii. Employees who were laid off or terminated for economic reasons (vi) Effective February 7, 2017, employees shall receive a general who are appointed from a recall/preferred list or who were subject increase of 3 00% to involuntary redeployment (vii)Parttime per annum, per session, hourly paid and per diem iv. Provisional employees who were terminated due to a civil service employees (including seasonal appointees) and employees list who are appointed from a civil service list within one year of whose normal work year is less than a full calendar year such termination shall receive the increases provided in Sections 3(A)(a)(i) v. Permanent employees who resign and are reinstated or who are through 3(A)(a)(vi) on the basis of computations heretofore appointed from a civil service list within one year of such utilized by the parties for all such Employees resignation b. The general increases provided for in Section 3(A) shall be vi Employees (regardless of jurisdictional class or civil service calculated as follows: status) who resign and return within 31 days of such resignation (i) the general increase in Section 3(A)(a)(i) shall be based upon vii. The First Deputy Commissioner of Labor Relations may, after for each paid working day, which amount shall not notifcation to the affected union(s), exempt certain hard to recruit exceed $1,287 85 per annum titles from the provisions of subsection 4(a) ii Effective February 7, 2017, the contribution shall be Section 5. For the purpose of this Section 9 excluded from paid working days effective as of such date for the title formerly occupied shall be applied are all scheduled days off, all days in non-pay status, and all paid Section 6. A person permanently employed by the Employer who is appointed (1) maternity/child care leave; or promoted on a permanent, provisional, or temporary basis in (2) military leave; accordance with the Rules and Regulations of the New York City Personnel Director or, where the Rules and Regulations of the New (3) unpaid time while on jury duty; York City Personnel Director are not applicable to a public employer, (4) unpaid leave for union business, pursuant to such other Rules or Regulations as are applicable to the public Executive Order 75; employer, without a break in service to any of the following title(s) from another title in the direct line of promotion or from another title in the (5) unpaid leave pending workers compensation Career and Salary Plan, the minimum rate of which is exceeded by at determination; least 8 percent by the minimum rate of the title to which appointed or promoted, shall receive upon the date of such appointment or (6) unpaid leave while on workers compensation option promotion either the minimum basic salary for the title to which such 2; appointment or promotion is made, or the salary received or receivable (7) approved unpaid time off due to illness or in the lower title plus the specifed advancement increase, whichever is exhaustion of paid sick leave; greater: (8) approved unpaid time off due to family illness; and Advancement Increase Effective: 8/7/10 (9) other pre-approved leaves without pay; Title iii time while on absence without leave; Senior Automotive Service Worker $845 iv time while on unapproved leave without pay; or Section 8. Annuity Fund shall not become part of the basic salary rate and shall not pensionable a. A claimed assignment of employees to duties substantially shall be sent to the agency head the Commissioner of Labor different from those stated in their job specifcations; Relations or the Commissioners designee shall review all appeals d. Collective Bargaining that said case be submitted to the the term transfer shall mean the reassigning of an employee from expedited procedure the party receiving such request one geographic location to another For purposes of the Article, shall have ten business days from the receipt of the the parties shall defne geographic location as it applies to the request to raise any objections thereto Department of Sanitation, the Police Department and the Fire Department (4) No case shall be submitted to the expedited arbitration process without the mutual agreement of the parties Section 2. With the exception of temporary transfers, all vacancies that the (3) the Arbitrator shall not be precluded from attempting Employer has decided to fll shall be posted on a department bulletin to assist the parties in settling a particular case board fve (5) working days in advance of the effective date prior to (4) A decision will be issued by the Arbitrator within two flling except when such vacancies are to be flled in an emergency weeks It will not be necessary in the Award to recount (With respect to the Department of Sanitation, the posting period as any of the facts presented However, a brief explanation set forth in this Section, shall be for ten (10) working days and shall of the Arbitrators rationale may be included Bench apply to transfers between zones only) decisions may also be issued by the Arbitrator Section 6. A dispute concerning the application or interpretation of the terms All employee work areas shall be properly ventilated in order to of this economic collective bargaining agreement shall be subject to prevent the collection of noxious, explosive or other dangerous fumes the Grievance Procedure of this Agreement Except for the foregoing, the terms of this collective bargaining agreement represent the entire Section 8. Platelets are what makes blood clot and they stomach are needed to help you stop bleeding and bruising after an injury. If you do not have enough platelets in your blood, you are likely to bruise very spleen easily or may be unable to stop bleeding if you cut yourself. White blood cells in your blood and your spleen (an organ in your abdomen) are part of your immune system. One of their actions is to produce antibodies which help your body to fght infections. If you develop an autoimmune condition, your immune system can become overactive and the white blood cells will start to destroy things they shouldnt, such as your own platelets. This is usually referred to by doctors just using the frst three numbers, such as 150 or 400. You are unlikely to get bleeding symptoms unless your platelet count is below 20 or even 10. If you needed to have an operation this would be safe as long as your platelet count is more than 50. These work by stopping your immune system from destroying your platelets, by reducing the level of antibodies in your bloodstream. However, steroids can have side effects, especially if you need repeated courses of treatment or have to take them for a long time. Some side effects are related to stopping the white cells working properly; this can increase your chance of getting infections, as the white cells will also be less able to fght off bacteria and viruses. Steroids also have other side effects, such as thinning of the bones (osteoporosis), stomach ulcers and high blood sugar levels (diabetes. They can change your facial appearance and cause thinning and bruising of the skin. People feel they want to eat more while they are on steroids and often put on weight. If you are taking steroids it is very important that you do not stop them without advice from your doctor, as your body starts to rely on them. They may need to be cut down slowly so that your body has time to adjust, otherwise you might experience weakness and fatigue. If you are worried about possible side effects, please discuss your treatment with your doctor before making any changes to your medication. If this happens, your doctor will want to make sure there is no other reason for your low platelet count; this may involve some extra blood tests (including checking for infections if this hasnt already been done) or a bone marrow test. In the other 7 people the platelet count will drop again and more treatment may be needed. However, it is important that we discuss with you what treatment may be given if your platelet count falls further, you have bleeding symptoms, or you need an operation. There are different treatments available and it is important you understand a bit about them, so that you and your doctor can decide which would be most appropriate. It is a human blood product, which means that the antibodies have been collected from numerous blood donors. It is generally given before surgery, or if you have signifcant bleeding symptoms and your platelet count needs to be increased urgently. There is also a small risk of developing a rare complication called aseptic meningitis. This will be carried out during an operation under general anaesthetic (where you are made to be asleep. The operation can usually be done laparoscopically (using very small cuts to carry out keyhole surgery), which means you should recover more quickly. You will usually be in hospital for a couple of days, although it can take six weeks to fully recover from the operation. Sometimes the operation needs to be carried out using open surgery (a larger cut. Your surgeon will discuss this with you if they think you are likely to need this type of operation. For every three people who have the operation, two will not need further treatment. Unfortunately it is diffcult to predict whether you will be cured by this operation. Your doctor may ask you to have a special scan to look at your spleen, which can help them to decide whether a splenectomy will work for you. The test can sometimes show whether your spleen is the main place that your platelets are being destroyed, but it cannot completely predict whether you will be cured by the surgery. If 500 people have the operation by keyhole surgery, 1 may die because of the operation, either at the time of surgery or from complications happening afterwards. You may be at more at risk of complications from surgery if you have other medical conditions, are very overweight, or if it is not possible to increase your platelet count before the operation. To reduce the risk of long term infection you will need to have vaccinations (immunisations or jabs) before having surgery. After the surgery you may need to take long-term low dose antibiotics to help prevent infection, or you may be given a packet of antibiotics to keep at home in case you become unwell. This is because some of the white cells which would normally help your body to fght infection would have been made in your spleen. You must seek medical advice quickly if you develop symptoms of an infection and you should carry a card to say that you have had your spleen removed in case you are in an accident. Like steroids, it stops the immune system destroying platelets, but it has fewer side effects than steroids. It is a manufactured antibody (developed by a medicines company) which affects the white blood cells.

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