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State of the Art
Brandyn D. Lau , Michael B. Streiff , Peter J. Pronovost , Elliott R. Haut
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Circulation. 2018; 137: 1278-1284
Brandyn D. Lau
Russell H. Morgan Department of Radiology and Radiological Science (B.D.L.) Division of Health Sciences Informatics (B.D.L.) Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.) Johns Hopkins University School of Medicine, Baltimore, MD. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.D.L., P.J.P., E.R.H.)
Michael B. Streiff
Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.) Department of Medicine (M.B.S.) Department of Pathology (M.B.S.)
Peter J. Pronovost
Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.) Department of Anesthesiology and Critical Care Medicine (P.J.P., E.R.H.) Johns Hopkins University School of Medicine, Baltimore, MD. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.D.L., P.J.P., E.R.H.)
Elliott R. Haut
Armstrong Institute for Patient Safety (B.D.L., M.B.S., P.J.P., E.R.H.) Department of Anesthesiology and Critical Care Medicine (P.J.P., E.R.H.) Department of Surgery (E.R.H.) Johns Hopkins University School of Medicine, Baltimore, MD. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (B.D.L., P.J.P., E.R.H.)

Abstract

Venous thromboembolism (VTE) is 1 of the most common causes of preventable harm for patients in hospitals. Consequently, the Joint Commission, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the United Kingdom Care Quality Commission, the Australian Commission on Safety and Quality in Health Care, the Maryland Health Services Cost Review Commission, and the American College of Surgeons have prioritized measuring and reporting VTE outcomes with the goal of reducing the incidence of and preventable harm from VTE. We developed a rubric for defect-free VTE prevention, graded each organizational VTE quality measure, and found that none of the current VTE-related quality measures adequately characterizes VTE prevention efforts or outcomes in hospitalized patients. Effective VTE prevention is multifactorial: clinicians must assess patients’ risk for VTE and prescribe therapy appropriate for each patient’s risk profile, patients must accept the prescribed therapy, and nurses must administer the therapy as prescribed. First, an ideal, defect-free VTE prevention process measure requires: (1) documentation of a standardized VTE risk assessment; (2) prescription of optimal, risk-appropriate VTE prophylaxis; and (3) administration of all risk-appropriate VTE prophylaxis as prescribed. Second, an ideal VTE outcome measure should define potentially preventable VTE as VTE that developed in patients who experienced any VTE prevention process failures.

Venous thromboembolism (VTE), comprised of deep venous thrombosis and pulmonary embolism (PE), affects as many as 600 000 in the United States annually. Furthermore, >100 000 patients die in the United States each year because of PE—more than the number of deaths from motor vehicle collisions, breast cancer, and AIDS combined. 1 Rates of VTE are even higher in Europe, where estimates range from 95 to 148 per 100 000. SHIRTS Shirts Sessun Sale Shop Offer Buy Cheap Collections Free Shipping Shop Offer eD5F55T
It is estimated that ≈50% of all new VTE events occur during or within 90 days of hospitalization or surgery 3 , 4 and that the majority are preventable if patients receive VTE prophylaxis. 5 , 6

Clinical microbiology tests of value in establishing an etiologic diagnosis of infections of the urinary tract are covered in this section, including specimens and laboratory procedures for the diagnosis of cystitis, pyelonephritis, prostatitis, epididymitis, and orchitis. Some special tests not available in smaller laboratories may be sent to a reference laboratory, but expect longer turnaround times for results.

Key points for the laboratory diagnosis of urinary tract infections (UTIs):

Urine should not sit at room temperature for more than 30 minutes. Hold at refrigerator temperatures if not cultured within 30 minutes, or use a urine transport device (boric acid or other preservative).

Reflexing to culture after a positive pyuria screen should be a locally approved policy.

The presence of 3 or more species of bacteria in a urine specimen usually indicates contamination at the time of collection, and interpretation is fraught with error.

Do not ask the laboratory to report “everything that grows” without first consulting with the laboratory and providing documentation for interpretive criteria for culture that is not in the laboratory procedure manual.

The IDSA guidelines for diagnosis and treatment of UTIs are published [ 182 , 183 ] as are American Society for Microbiology recommendations [ 184 ]. These provide diagnostic recommendations that are similar to those presented here ( Table 34 ). The differentiation of cystitis and pyelonephritis requires clinical information and physical findings as well as laboratory information, and from the laboratory perspective the spectrum of pathogens is similar for the 2 syndromes [ 185 ]. Culturing only urines that have tested positive for pyuria, either with a dipstick test for leukocyte esterase or other indicators of PMNs, may increase the likelihood of a positive culture, but occasionally samples yielding positive screening tests yield negative culture results and vice versa [ 186 ]. The Gram stain is not the appropriate method to detect PMNs in urine, but it can be ordered as an option for detection of high numbers of gram-negative rods when a patient is suspected of suffering from urosepsis. Because urine is so easily contaminated with commensal flora, specimens for culture of bacterial urinary tract pathogens should be collected with attention to minimizing contamination from the perineal and superficial mucosal microbiota [ 187 ]. Although some literature suggests that traditional skin cleansing in preparation for the collection of midstream or “clean catch” specimens is not of benefit, many laboratories find that such specimens obtained without skin cleansing routinely contain mixed flora and, if not stored properly and transported within 1 hour to the laboratory, yield high numbers of one or more potential pathogens on culture. Determining the true etiologic agent in such cultures is difficult, so skin cleansing is still recommended. The use of urine transport media in vacuum-fill tubes or refrigeration immediately after collection may decrease the proliferation of small numbers of contaminating organisms and increase the numbers of interpretable results. Straight or “in-and-out” catheterization of a properly prepared patient usually provides a less contaminated specimen. If mixed enteric bacteria in high numbers are recovered from a second, well-collected, straight-catheterized sample from the same patient, a enteric-urinary fistula should be considered. Laboratory actions should be based on decisions arrived at by dialogue between clinician and laboratory.

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Representing the Dead

Overview

An examination of how the dead were memorialised in late medieval French literature.

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October 2016 5 colour, 21 black and white illustrations 354 pages 23.4x15.6 cm Gallica ISBN: 9781843844365 Format: Hardback Outlet Store For Sale COATS amp; JACKETS Synthetic Down Jackets 313 Clearance Discount Cheap 2018 Newest Clearance Fake Cheap Discount v2MpagS
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Introduction: Representing the Dead Framing Identity: 'je suis' and 'cy gist' Identity and/as Echo: the and Dying to be told: storytelling and exemplarity 'selon le stile Jehan Bocace' Placing the Dead: Cemeteries, Hospitals and Temples Afterword: Illustrating the dead Coda: re-member me Appendix: Early Editions of the Bibliography
The concept of "epitaph fictions" announced in this study's subtitle thus introduces not simply a subgenre of metafiction, it also proposes a fresh and productive way of approaching the medieval literary treatment of death. RENAISSANCE QUARTERLY A lively and dazzling book, full to bursting with clever analyses, probing questions, vivid illustrations.and suggestive connections. MODERN LANGUAGE REVIEW

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