A smart curtailment approach for reducing bat fatalities and curtailment time at wind energy facilities symptoms vitamin b deficiency purchase zofran 8mg on line. Assessment of avian use and mortality related to wind turbine operations: Altamont Pass treatment 12mm kidney stone discount zofran 8mg on line, Alameda and Contra Costa Counties medicine joji generic zofran 8mg on-line. Activity of tree bats at anthropogenic tall structures: implications for mortality of bats at wind turbines medicine gustav klimt best 4 mg zofran. Estimating bat and bird mortality occurring at wind energy turbines from covariates and carcass searches using mixture models medicine man 1992 buy zofran 8mg without prescription. Assessing impacts of windenergy development on nocturnally active birds and bats: a guidance document symptoms of colon cancer generic zofran 8mg otc. Hawaiian hoary bat (Lasiurus cinereus semotus) activity medications qid generic zofran 4mg otc, diet and prey availability at the Waihou Mitigation Area medications to treat bipolar disorder 8 mg zofran overnight delivery, Maui. Hawaiian hoary bat (Lasiurus cinereus semotus) activity, diet, and prey availability at the Waihou Mitigation Area, Maui. Evaluating a novel approach to optimize operational minimization to reduce bat fatalities at the Pinnacle Wind Farm, Mineral County, West Virginia, 2015. Using echolocation monitoring to model bat occupancy and inform mitigations at wind energy facilities. Mitigating the negative impacts of tall wind turbines on bats: Vertical activity profiles and relationships to wind speed. Total nightly bat visual (video) and acoustic detection events and respective detection rates (combined and adjusted for sampling effort for all four turbines). Additional supporting information (including detection events by turbine) are available as a U. Date 8/1/2018 8/2/2018 8/3/2018 8/4/2018 8/5/2018 8/6/2018 8/7/2018 8/8/2018 8/9/2018 8/10/2018 8/11/2018 8/12/2018 8/13/2018 8/14/2018 8/15/2018 8/16/2018 8/17/2018 8/18/2018 8/19/2018 8/20/2018 8/21/2018 8/22/2018 8/23/2018 Total visual detection events 1 13 5 2 1 10 8 1 0 2 0 0 3 15 2 11 6 0 5 10 0 0 1 Visual detection rate 0. Summary of the number of nightly visual (video) and acoustic bat detection events per turbine, detection rate (number of detection events per hour, calculated as the nightly total of events divided by sample duration at a turbine), and the nightly metrics of weather and turbine operation variables, including precipitation ("precip"; total in cm for a 24-hour midnight-to-midnight period centered on the day of the record), mean wind speed ("wind-mean"; calculated as the mean of 10-minute interval recordings), variability in wind speed ("wind-sd"; calculated as the standard deviation of 10-minute interval recordings), turbine blade movement ("rpm"; rotations per minute), and turbine starts ("rpm-starts"; calculated as the total of such events following one or more 10minute intervals at which the blade was motionless). All weather and turbine operation variables used in regression analysis were standardized and centered on the variable mean. Diagnostics demonstrated that the six top-ranked regression models (listed in Tables 5 and 6) met assumptions of uniformity (left panels) and did not exhibit zero inflation (right panels). Left panel shows model met assumptions of uniformity, and right panel displays model did not exhibit zero inflation. From the Commission Co-Chairs most americans feel that life in prison and jail does not affect them. When the emotional reaction to the awful headline fades, however, we are left only with the sinking feeling that prison is a problem with no solution. The temptation is always to look away, hoping the troubles inside the walls will not affect us. Every day judges send thousands of men and women to jail or prison, but the public knows very little about the conditions of confinement and whether they are punishing in ways that no judge or jury ever intended; marked by the experience of rape, gang violence, abuse by officers, infectious disease, and never-ending solitary confinement. Unless the experience of incarceration becomes real through the confinement of a loved one or through a family member who works day-to-day in a correctional facility, jails and prisons and the people inside them are far removed from our daily concerns. Americans share concerns about struggling schools, dangerous hospitals, and corrupt corporations. We now talk openly about domestic violence and child abuse because we know there are terrible consequences for our loved ones, our families, and our communities if we remain silent. Yet there is a shame and a stigma about incarceration that makes it very difficult to have honest, productive conversations about what we are doing and the results. Our inquiry and this report reveal both grave problems and also good work that fills us with hope. Katzenbach iii "The culture of our prisons virtually dictates the level of violence that you will have in them. Educate and Involve the Public "People are sentenced to prison as punishment, not for punishment. Measure Safety and Effectiveness Commission Witnesses Works Cited Acknowledgments v Preface A little more than one year ago, a diverse the kinds of productive activities that discourgroup of individuals-respected civic leaders, age violence and make rehabilitation possible, experienced corrections administrators, scholars, and a culture in many prisons and jails that pits advocates for the rights of prisoners, law en- staff against prisoners and management against forcement professionals, members of the reli- staff. It is simply not enough to be beting the available research and data is that the ter than we were. Arthur Wallenstein and Michael Ashe an admirable job, but steady decreases nationally talked about how providing high quality health in riots and homicides do not tell us about the care in the jails they run benefits the surroundmuch larger universe of less-than-deadly vio- ing communities. And beyond physical violence, there are Brown described his return to prison as a counother serious problems that put lives at risk and selor, helping to guide young prisoners away cause immeasurable suffering. Corrections Secretary For all of the hard work and achievements of Theodis Beck portrayed an officer corps in North corrections professionals-most of which the Carolina that is more diverse, better trained, and public does not hear about-there is still too more professional than ever before. Through tears, Pearl Beale told us her other forms of segregation, a desperate need for son Givon was stabbed nine times by another p r e fa c e prisoner in a crowded Washington, D. Garrett Cunningham recounted being raped by a Texas corrections officer twice his size and then disbelieved and left unprotected by the prison authorities in whom he confided. Some people would say these are just stories and would believe the ones that mirror their own views and experiences. Success stories are pitted against tragedies, statistics against anecdotes-as if one must choose between data and personal experiences that can reveal truths hidden in the numbers. Critics of the daily headlines are right when they claim that the most awful events in correctional facilities are unusual given the innumerable encounters that take place there every day, but that does not make them unimportant. Beyond the human loss, an awful event in a correctional facility can be a sign of underlying problems that may be frequent and widespread. They include current and past leaders of state and federal correctional systems and current and former prison wardens and jail administrators. We listened equally to labor, seeking to understand the day-to-day experience of working in prison and jail. We consulted with experts who monitor prisons, those who advocate for the rights of the incarcerated, and with current and former prisoners and their families. We took advice from scholars and researchers, religious leaders, and government officials responsible for making law and policy. We also sought out personal accounts about life behind bars, receiving more than a thousand letters, e-mails, and phone calls. Listening to all of them, we understood over time how the views they have in common far outnumber their disagreements. Drawing on that consensus, this report outlines four broad areas where change can and must occur: conditions of confinement that directly affect the safety, health, and well-being of prisoners and staff, the quality of and support for labor and leadership, oversight of and accountability for what happens behind bars, and the state of our knowledge and data. In each of these areas, we offer clear and bold recommendations that have the potential to change the very nature of incarceration in this country. It will require an investment of many dollars to achieve these recommendations, but those dollars will pay dividends for years to come. Readers looking for a report card on safety and abuse in all the prisons and jails across America will not find it in these pages. The Commission could not walk into every jail and prison, look around, ask questions, and review data. We had neither the time nor the resources for that kind of inquiry, and our work was never primarily about counting and grading. Sometimes the things we could not do loomed larger in our minds than what we were accomplishing. There are entire categories of facilities that we did not examine: juvenile detention centers and facilities housing people facing deportation, as well as facilities run by the military or by Indian tribes. We did not look specifically at differences between prisons run by government and those run by private companies, the impact of an aging prison population, and the consequences of placing juveniles in adult facilities. Women are the fastest-growing segment of the prison population and most of them are primary caregivers of children. We would like to have learned more about how issues of safety and abuse play out differently for women prisoners than they do for men. And finally, the significant differences between prisons and jails deserve much more attention than we have been able to give them. There are failing prisons and jails across this country, but the American public is also failing them. Congress and state legislatures have passed laws that dramatically increased prisoner populations without providing the funding or even the encouragement to confine individuals in safe and productive environments where they can be appropriately punished and, for the vast majority who are released, emerge better citizens than when they entered. With deep personal frustration and disappointment, former Mississippi Warden Donald Cabana told the Commission, "In an eight-year period, we doubled our prison population in the poorest state in America. We should be astonished by the size of the prisoner population, troubled by the disproportionate incarceration of African-Americans and Latinos, and saddened by the waste of human potential. It was beyond the scope of our inquiry, and indeed beyond our mission, to explore how states and the federal government might sensibly reduce prisoner populations. We incarcerate more people and at a higher rate than any other country in the world. This reliance bleeds correctional systems of the resources that could be used to rehabilitate rather than merely to punish and incapacitate; it crowds whole systems and sometimes individual facilities to the breaking point; and it exacerbates racial and ethnic tensions in America through its disproportionate impact on African-Americans and Latinos. Corrections managers are caught in the middle: They know that the number of people incarcerated cannot be an excuse for operating dangerous and abusive correctional facilities. Nor can the fact that some of those individuals have committed serious and violent crimes. Managers must overcome the real difficulty of creating safe and productive correctional environments when their systems must accommodate so very many people. Corrections administrators must have the resources and support to operate safe and effective prisons and jails. Better funding will not guarantee better results, but without it too many vital reforms will never be attempted. In correctional facilities around the country, there are stark differences and a dehumanizing disconnection between the people who are incarcerated and the men and women sworn to protect and supervise them. Those differences involve race, culture, class, gender, and the difference between rural and urban America. When we began our inquiry in March, 2005, it felt like the right time for the first national prison commission in three decades. Fifteen months later, as we complete our report, the need for reform feels even more urgent. Attorney for the Eastern District of Michigan (19942001) Ray Krone: Former prisoner who spent more vate practice who is frequently called to provide expert testimony in criminal and civil cases around the country about the lasting psychological damage of violence and abuse in prison Richard G. Luttrell: Sheriff of Shelby County (Memphis), Tennessee, and former warden at three federal prisons commissioners Gary D. Maynard: Director of the Iowa Department of Corrections and President-Elect of the American Correctional Association Marc H. Louis, Missouri; and a former attorney in the Civil Rights Division, Special Litigation Section, of the U. District Judge in the Western District of Texas, and former Director of the Federal Bureau of Investigation Association for the Advancement of Colored People, Washington Bureau Hilary O. When people live and work in facilities that are unsafe, unhealthy, unproductive, or inhumane, they carry the effects home with them. We must create safe and productive conditions of confinement not only because it is the right thing to do, but because it influences the safety, health, and prosperity of us all. Many of those who are incarcerated come from and return to poor African-American and Latino neighborhoods, and the stability of those communities has an effect on the health and safety of whole cities and states. If there was ever a time when the public consequences of confinement did not matter, that time is long gone. Some of the people confined in our jails and prisons have committed serious and violent crimes. We can legitimately deprive them of liberty, but we cannot allow anyone who is incarcerated to be victimized by other prisoners, abused by officers, or neglected by doctors. We must remember that our prisons and jails are part of the justice system, not apart from it. There are nearly 5,000 adult prisons and jails in the United States-no two exactly alike. To succeed, jail and prison administrators everywhere must confront prisoner rape, gang violence, the use of excessive force by officers, contagious diseases, a lack of reliable data, and a host of other problems. But there is no reason why health and safety should be limited to only some correctional facilities and no reason why even the best institutions cannot make a larger contribution to public safety and public health. The findings and recommendations outlined below, and explored in detail throughout the pages of this report, address the most pressing problems facing corrections today and the reforms that can and must occur. There is disturbing evidence of individual assaults and patterns of violence in some U. Corrections officers told the Commission about a near-constant fear of being assaulted. Former s u m m a ry o f f i n d i n g s a n d r e c o m m e n d at i o n s 11 prisoners recounted gang violence, rape, beatings by officers, and in one large jail, a pattern of illegal and humiliating strip-searches. Former Florida Warden Ron McAndrew described small groups of officers operating as "goon squads" to abuse prisoners and intimidate other staff. And in February, 2006, while the Commission was gathered in Los Angeles for a final hearing, more than a thousand prisoners were attacking each other in the Los Angeles County jails, days of violence that the press described as riots. At that hearing, California corrections Secretary Roderick Hickman told the Commission: "Quite frankly, no one denies that violence occurs in prisons and jails in this country. Every correctional facility can provide a safe environment for prisoners and staff. The culture of our prisons virtually dictates the level of violence that you will have in them. But because lawmakers have reduced funding for programming, prisoners today are largely inactive and unproductive. States and localities must comtional facilities and also to lower recidivism rates after release. A well-developed system to obprograms that are proven to reduce violence and to jectively classify prisoners by risk reduces violence among them. Use force and non-lethal weaponry only as a last is crucial because the unnecessary or excessive use of force and weapons resort. Former general counsel of use of weaponry to qualified staff, and eliminating the Texas prison system, Steve Martin, told the Commission that these the use of restraints except when necessary to preweapons are often used as a "first strike" response, before other tactics are vent serious injury to self or others. Make good use Finally, the ties with family and community that former prisoners depend of recording surveillance cameras to monitor the coron after release also promote safety during incarceration. Reexamsome facilities that does not welcome visitors-makes it hard to maintain ine where prisons are located and where prisoners those ties. There are even barriers to maintaining contact by phone when are assigned, encourage visitation, and implement the cost of receiving a collect call from someone in prison-much higher phone call reform. Data about deadly violence show decreasing rates nationally of homicide and suicide, but we do not have equally reliable data about the much larger universe of non-lethal violence. There are prisons and jails that are not collecting or reporting information about assaults: For example, Arkansas, North Dakota, and South Dakota each reported zero assaults among prisoners statewide in the year 2000. In-depth studies suggest that actual levels of violence among prisoners are at least five times higher than what even the best administrative records capture. Equally troubling, we have no national measures of non-lethal physical violence perpetrated by staff against prisoners, despite widespread agreement that excessive use of force happens. Chief statistician for the federal Bureau of Justice Statistics Allen Beck told the Commission, "I cannot measure well the level of assaults using administrative records as they exist today. Much of the public dismisses jails and prisons as sealed institutions, where what happens inside remains inside. In the context of disease and illness, which travel naturally from one environment to another, that view is clearly wrong. As a result of poverty, substance abuse, and years of poor health care, prisoners as a group are much less healthy than average Americans. Protecting public health and public safety, reducing human suffering, and limiting the financial cost of untreated illness depends on adequately funded, good quality correctional health care. They have to care for a sick population on shoestring budgets and with little support from community health-care providers and public health authorities. Joe Goldenson told the Commission, "There are facilities with four or five thousand people that only have two or three doctors. The public has yet to face the broad and long-term costs of these kinds of failures. Finding: Medical neglect and the spread of infectious disease are not inevitable; there are solutions to the health-care dilemmas facing corrections. Correctional facilities have a tremendous opportunity to provide health care to people in jail and prison that also protects the public health. Lawmakers must provide adequate funding, and health-care providers from the community must get involved. Together, they can recruit qualified and caring medical staff who are able to manage contagious and costly diseases. Proper screening and treatment of infectious diseases in correctional facilities makes a difference: Between 1992 and 1998, New York City reduced tuberculosis cases citywide by 59 percent, and drug-resistant cases by 91 percent, through this kind of partnership. Many short-term costsaving measures imposed by local, state, and federal legislatures have long-term negative consequences. To drive down the costs, legislators pressure corrections administrators to require prisoners to make co-payments for their medical care. While co-payments seem reasonable on the surface, they cost more in the long run by discouraging sick prisoners from seeking care early on, when treatment is less expensive and more effective and before disease spreads. Equally troubling, misguided federal law deprives correctional systems of desperately needed Medicaid and Medicare dollars to fund decent health care. Many people in prison and jail qualify for these federal benefits and lose them when they are incarcerated. Just like any other community healthcare provider, correctional agencies should be reimbursed for the cost of providing health services to people who are Medicaid and Medicare eligible. Finally, along with committing more funds to care for mentally ill prisoners, states and counties need to expand treatment in the community.
Please discuss your "9+3" status with your graduate adviser at the start of your program treatment thesaurus cheap zofran 4mg. Reading Specialist Certification Preparation Purpose of Program the Reading Department of East Stroudsburg University offers an online graduate program of study leading to the Pennsylvania Reading Specialist Certificate treatment of hemorrhoids cheap zofran 8mg free shipping. This certificate enables a teacher to provide reading instruction in kindergarten through grade 12 medications not to take during pregnancy cheap zofran 4 mg on line. The mission of the Reading Specialist Certificate Program is to create a diverse community of educators dedicated to continuously advancing the teaching of reading treatment 7th march bournemouth generic 4 mg zofran overnight delivery, emerging literacies medications for fibromyalgia zofran 4mg online, and research in an ever changing global society my medicine order zofran 4mg otc. A variety of methods for developing language and teaching reading to culturally and linguistically diverse learners are also emphasized medications hard on liver generic zofran 8mg without a prescription. Participants examine diverse approaches to reading symptoms stiff neck buy zofran 8mg cheap, engage in productive discussion, and explore the research knowledge base from which reading educators work. Graduate assistants do not teach classes, but they assist with research and complete projects assigned by professors. Responsibilities of the graduate assistant may include conducting research, assisting with preparing class materials, and proofreading. Graduate assistantships are awarded for the first year of full-time study, with the possibility of extension through the first summer. Prospective students should apply for a graduate assistantship at the time of original application to the program, using the application form provided by Graduate Studies or online. Reading as a thinking process, comprehension skill and strategy instruction, and the evaluation of instructional materials are emphasized in this course. There is a focus on formal and informal assessments and appropriate instructional techniques. Pre-service teachers become knowledgeable about literacy issues associated with specific content areas using a variety of types and levels of text. The creation of a Literacy Profile, which includes assessment results and diagnostic information serves as the basis for instructional practices. Among the topics to be addressed will be teaching reading through thematic units, the shared stages of reading and writing, literature-response methods, and developing reading strategies through a variety of literary genres. Emphasis is placed on topics such as coaching assessments, data collection and analysis, and matching students with appropriate instructional materials. It includes a research-based theoretical framework and practical ideas for teaching emergent literacy. Topics emphasized include motivation and engagement, phonemic awareness, phonics, fluency, vocabulary, reading comprehension, and assessments. Emphasis is placed on topics such as providing professional development on reading topics such as phonemic awareness, phonics, fluency, vocabulary, and comprehension, a major responsibility of literacy coaches. Designed to be taught in an interactive workshop format, Reading Colloquium emphasizes learning, application, and performance assessment. The candidates will (1) observe the reading supervisors in all phases of their work; (2) assist the Reading Supervisor as requested; and (3) assume responsibilities as the Reading Supervisor deems feasible. Special Education College of Education Department of Special Education and Rehabilitation Stroud Hall 570-422-3558 This program can be combined with the Supervisory certification, the Applied Behavior Analyst certification, or an individually devised program designed with assistance from an academic adviser. The individually designed program takes into account the work experience and professional goals of the candidate to tailor the course work to the needs of the student. Special Education Supervisory Certification 18 credits Program Purpose the Special Education Supervisory Certification Program is designed to prepare professionals to become special education leaders for programs in their schools, districts, intermediate units, or other related areas. This program is for teachers who want to qualify for Pennsylvania Supervisor of Special Education certification. Assignments in other geographical areas will be utilized by the department when deemed appropriate. Field experience supervision will be provided by the faculty of Special Education and Rehabilitation Distribution: Advanced. The course emphasizes research-validated literacy interventions and evidencebased instructional practices. It focuses on the components of reading and writing that pose challenges for students with disabilities. Designed to help them create school climates that celebrate diversity and meet the needs of students of different races, ethnicities, gender, and ability levels. The interaction enables them to review and to develop positive models for their particular schools that allow for exceptional and non-exceptional children to learn together, to respect each other, to know each other. Emphasis is on a case-by-case analysis of client or student needs, and development of appropriate projects for their training and rehabilitation. Attention will be given to conferencing, reporting, and instructing parents in the process of home training. Further attention will be given to directing parents toward community services and resources, developing school-initiated parent support groups. The use of consultation is reviewed at the pre-referral, referral, and mainstreaming level of service. The goals for this course include student competence in consultation concepts and skills in working with classroom teachers. Classroom management utilizing nonaversive behavior management techniques will be presented. This course will examine the principles of behavior in depth and focus on the use of these principles in applied settings with students and/or individuals with disabilities. The content of this course is determined by the Task List of the Behavior Analyst Certification Board. Additionally, appropriate and feasible research designs and techniques are discussed within the framework of current special education methods and procedures. Content for this course was determined by the Task List of the Behavior Analyst Certification Board and the Council for Exceptional Children Knowledge and Skill Statements. The content of this course was developed in accordance with the Task List of the Behavior Analyst Certification Board. Students will learn how the Behavior Analyst Certification Board Guidelines for Responsible Conduct will guide their practice, as well as specific guidelines for professionalism in representing the field of Applied Behavior Analysis. The student will review, assess, and discuss implications of new mandates for human services. An emphasis will be placed upon issues which are presently affecting (and will continue to shape) services to learners with exceptionalities, regular and special education professionals, and administrators. Objectives include an awareness of conceptual models and program activities toward ameliorating impact of maladaptive behaviors. This will include problems of programming for students with exceptionalities; different curriculum approaches and review of research implications. Emphasis is placed on consumer-driven technology selection and evaluation processes. Students will learn how to access assistive technology services as well as strategies for collaborating with experts in technology. Objectives include amelioration of effects of physical disabilities toward possible mainstreaming. Graduate students spend a minimum of 120 hours in an educational setting and meet regularly with their university supervisor to reflect upon their experiences, their professional development and strategies related to teaching and learning as well as opportunities for observation(s) in the field. This program requires an on-site internship of at least seven credit hours and the successful completion of the Sport Management Comprehensive Examination. In summary, the Master of Science in Sport Management prepares graduates to enter a complex, changing global world with competence and confidence. Student Learning Outcomes Students graduating from the Master of Science Degree program in Sport Management will be able to: 1. Illustrate knowledge of managerial principles required of sport managers in a contemporary sport setting. Utilize sport industry vernacular and professional oral and written communication skills when interacting in the workplace. Identify and describe best practices and research methods used by professionals in the sport industry. Demonstrate critical thinking skills to interpret issues confronting professionals in sport management. This body of knowledge typically includes undergraduate coursework or life experience contributing to a foundation of knowledge in the following areas: sport studies; health and physical education; and hotel and tourism. Sport Management College of Business and Management Department of Sport Management 210 Zimbar-Liljenstein Hall 570-422-3495 The Master of Science degree program in Sport Management prepares students for professional careers in the sport management industry. Buildings, grounds, and equipment, as well as maintenance of these facilities will be discussed. The course is designed to provide the student with knowledge of the planning and management of facilities for school physical education, athletic, and intramural/recreational programs. It will also give the student knowledge and understanding of the marketing considerations of various sport organizations. Legal issues involving personnel, facilities, equipment, transportation, medical aspects, liability and gender will be examined. Final graduation requirement Students are required to take a comprehensive exam based on the required coursework. Admissions Requirement and Deadlines Students will be admitted to the program based on demonstration of an academic record that fulfills the existing Graduate Studies criteria required for admission. Students applying for admission to the Master of Science degree program in Sport Management are strongly encouraged to apply by March 15 before the academic year in which they are seeking admission. Sport areas covered will be philosophy, pedagogy, physiology, medicine, and management. The course will emphasize practical issues related to planning, conducting, and interpreting research in sport management. Attention is directed to specific personnel tasks such as hiring, development and evaluation of sport staff, and personnel issues of current importance. The advantages and application of computers in sports programs will be emphasized. Opportunities for understanding and running existing computer programs will be provided. Content includes establishing a framework for public relations processes, communicative tools and techniques, and relationships with the media. This course is designed to acquaint the graduate student with the methods and materials of graduate study and scientific inquiry. This course is required for all students in the research or project program and it may be repeated with permission. Additional emphasis will centered around a presentation of analytic techniques specific to maximum realization of motor performance. Further research will be directed toward practical application of all research relevant to the gymnastic discipline. Additional emphasis centers on a critical review of the research relevant to the gymnastic discipline. Programs and Course Descriptions 113 Teaching the Developing Child College of Education Department of Early Childhood & Elementary Education Stroud Hall 209 570-422-3356 The 18 credits of the concentration and electives are selected by the graduate student (in collaboration with the graduate coordinator) from one of the focus areas available for in-depth study. Core courses present research-based concepts related to teaching and learning as well as introduce various tools of inquiry. Early Childhood and Elementary Education Faculty Graduate Coordinator: Craig Wilson, Ph. At the end of graduate course work, the master teacher candidate will be able to demonstrate reflective, collaborative, and creative teaching practice and professional leadership qualities. A student may have a maximum of six credits of workshop courses included in a plan of study. Through the core courses and individualized experiences, candidates are able to create a vision of themselves as reflective, synergistic decision makers. Candidates must submit all necessary documents required by the Graduate Studies Application, a Professional Goals Statement that reflects professional objectives for the program and two professional letters of recommendation. Full consideration will be given to those students who meet the application deadlines. Candidates will be selected and interviewed by the department chair and/or graduate coordinator. Please contact the department chair and/or graduate coordinator at 570-422-3356 for additional information. Student professionals in the program are assigned to schools as fulltime interns and in addition participate in group seminars, field trips, and a program of various assignments planned in cooperation with the program coordinator. Students will assess their philosophies in regard to classroom management practices and discipline models. The course will also examine the impact of internal and external variables on second language acquisition and development. Some topics include: the role of learning environment for language acquisition, explanations for different success among second language learners, variations in second language use, and the effect of classroom instruction in second language acquisition. Topics addressed include basic competencies of culturally and linguistically effective programs and instructional strategies appropriate for multi-cultural student populations. It introduces the origins and nature of language, examines the language systems, and how meaning is structured. In particular, the course will focus on the core areas of linguistics and interdisciplinary aspects. The core linguistics will include phonetics (the study of speech sounds), phonology (the sound system of languages), morphology (the internal structure of words), syntax (the sentence structure), and semantics (the study of word and sentence meanings). The interdisciplinary areas will incorporate language and sociolinguistics (language in social contexts meanings). The interdisciplinary areas will incorporate language and sociolinguistics (language in social contexts). Much of the course will include hands-on experience, discussion, and practical application of course topics. The students will be challenged to apply knowledge of the richness of contributions from our diverse linguistic and cultural society to your teaching field. The impact, application of the laws, and strategies for complying with them in the K-12 setting are major areas of focus. Students will explore the various ways in which issues of language intersect with issues of the law. It concerns itself with education in, through, and about the arts for aesthetic and motivational purposes. Students will work on individual projects which can be applied directly to their own teaching assignment. Although emphasis is placed on elementary education, many topics will apply to the K-12 classroom. Students are encouraged to investigate their own creative process and develop strategies for enriching teaching strategies. Literature representative of diverse cultural and ethnic groups will be explored, evaluated, and utilized. Dramatic behaviors, theatre skills, imagery ability, imagination, group skills, and the connection between imagination and action are actively explored. Students will participate in model lessons and then design and field test their own unit of instruction. Participants will experience a variety of hands-on activities and develop a set of activity-based materials for use in their own classrooms. There will also be opportunities to explore the use of emerging technologies such as microcomputer-based laboratories and interactive multimedia. Additional emphasis will be placed on standards-based teaching and the evaluation of mathematics programs. Students will have the opportunity to experience different styles in teaching and learning, how reflective teaching practice can become an integral part of the teaching process, and how teacher education reform occurs in different contexts through seminars and observations. The class will deal with exploring differences and similarities between cultures and philosophies. Students will create a wide assortment of books as they explore the unique relationship between visual and verbal literacies. Instructional strategies to connect, set up, integrate, document and evaluate BookArts in the classroom will be delineated. The course is designed to stimulate new thinking, to have participants experience activities that can be used with students, and to give participants confidence in creating personalized reading activities and materials for their own students. Participants will also utilize social studies learning strategies and develop activities consistent with current literature. Brain function and dominance will be reviewed in light of how these processes result in different student learning styles. The primary emphasis of the course will be on developing the skills necessary to work with student teachers using the clinical supervision model. Programs and Course Descriptions 117 Participants will become effective at accurately collecting data on classroom verbal interaction, teacher non-verbal behavior, questioning techniques, movement patterns, student involvement, student behavior, time allocation, classroom management, and teacher effectiveness. Cooperative learning provides the educators with a framework for maximizing student achievement through the use of critical thinking, problem solving skills, and teamwork. The course will introduce the educator to the fundamentals of control theory as it applies to cooperative learning, and will provide the educator with the opportunity to develop a teaching plan or implementing cooperative learning in the classroom. The course provides techniques for reducing classroom stress in both teachers and students. Emphasizes the skills and understanding necessary for the following: recognition of various forms of exceptionality in children; establishment of good interpersonal relationships; selection and adaptation of suitable curriculum materials, content, and methodology; and awareness of proper procedures in referring exceptional students for specialized help. This course must be repeated until "satisfactory" grade is earned; failure to design an acceptable proposal results in "no record" which carries no credit or penalty. Attention is given to the significant steps involved in compiling a research proposal. In compliance with the Graduate School policies, students are advised to complete this course early in their program. Emphasis is placed upon the kinds of problems that frequently confront the elementary school teacher in the normal teaching situation.
There are insufficient data to recommend either for or against the use of interferon beta for the treatment of early medicine joint pain cheap 4mg zofran with amex. Rationale Studies have shown no benefit of interferons in patients with other coronavirus infections medications for fibromyalgia purchase zofran 8mg with amex. In addition medicine xalatan zofran 8 mg online, interferons have significant toxicities that outweigh the potential for benefit symptoms 0f yeast infectiion in women best 8 mg zofran. However symptoms after conception cheap zofran 8mg visa, there is insufficient data to assess the potential benefit of interferon use during early disease versus the toxicity risks treatment concussion cheap zofran 8mg without a prescription. Additional detail is required to fully evaluate these findings and their implications medications prolonged qt buy zofran 8 mg low price. Of note treatment xanax withdrawal generic zofran 4mg overnight delivery, inhaled interferon beta-1a as used in this study is not commercially available in the United States. There was no difference in the primary outcome of time to clinical response between the interferon beta-1a group (n = 42) and the control group (n = 39), and there was no difference between the groups in overall length of hospital stay, length of intensive care unit stay, or duration of mechanical ventilation. The reported 28-day overall mortality was lower in the interferon beta-1a group; however, four patients in the interferon beta-1a group who died before receiving the fourth dose of interferon beta-1a were excluded from the analysis, which makes it difficult to interpret these results. In the combination antiviral therapy group, the treatment regimen differed by time from symptom onset to hospital admission. Patients in the control group received lopinavir/ritonavir alone regardless of the time from symptom onset to hospitalization. The antiviral and clinical effect was more pronounced in the patients hospitalized within 7 days of symptom onset, suggesting that interferon beta-1b with or without ribavirin was the critical component of the combination antiviral therapy. The study provides no information about the effect of interferon beta-1b when administered 7 days after symptom onset. The time to viral clearance in the upper respiratory tract and reduction in systemic inflammation was faster in the interferon alfa-2b groups than in the umifenovir only group. However, the results of this study are difficult to interpret because participants in the interferon alfa-2b with umifenovir group were substantially younger than those in the umifenovir only group (mean age of 40 years in the interferon alfa-2b with umifenovir group vs. The nebulized interferon alfa-2b formulation is not approved by the Food and Drug Administration for use in the United States. A randomized clinical trial that included 301 patients with acute respiratory distress syndrome10 found that intravenous interferon beta-1a had no benefit over placebo as measured by ventilator-free days over a 28-day period (median of 10. Adverse Effects the most frequent adverse effects of interferon alfa include flu-like symptoms, nausea, fatigue, weight loss, hematological toxicities, elevated transaminases, and psychiatric problems. Ribavirin and interferon therapy in patients infected with the Middle East respiratory syndrome coronavirus: an observational study. Ribavirin and interferon therapy for critically ill patients with Middle East respiratory syndrome: a multicenter observational study. Ribavirin and interferon alfa-2a for severe Middle East respiratory syndrome coronavirus infection: a retrospective cohort study. Effect of intravenous interferon beta-1a on death and days free from mechanical ventilation among patients with moderate to severe acute respiratory distress syndrome: a randomized clinical trial. Pregnancy outcomes in multiple sclerosis following subcutaneous interferon beta-1a therapy. Pregnancy outcomes from the global pharmacovigilance database on interferon beta-1b exposure. The association between exposure to interferon-beta during pregnancy and birth measurements in offspring of women with multiple sclerosis. The patients in both groups were all admitted to the same hospital in Paris, France. The historic controls were patients who fulfilled the same eligibility criteria and admitted to the hospital during the same period. As standard of care for both groups, some patients received hydroxychloroquine, azithromycin, or parenteral beta-lactam antibiotics. Clinical characteristics were similar between the groups, except that the cases had a lower mean body mass index than the controls (25. The primary outcome of admission to the intensive care unit for mechanical ventilation or death occurred among 13 case patients (25%) and 32 control patients (73%) (hazard ratio 0. However, within the first 2 days of follow up, in the control group, six patients (14%) had died and 19 patients (43%) had reached the composite primary outcome, which further limited intragroup comparisons and specifically analyses of time to event. Thromboembolic events occurred in 10 patients (19%) who received anakinra and in five control patients (11%). Patients in both the anakinra and control groups received hydroxychloroquine and lopinavir/ritonavir. However, the patients in the anakinra group were younger than those in the control group (median age 62 years vs. High-dose anakinra was discontinued in seven patients (24%) because of adverse events (four patients developed bacteremia and three patients had elevated liver enzymes); however, retrospective assessment showed that these events occurred with similar frequency in the control group. Adverse Effects Anakinra was not associated with any significant safety concerns when used in clinical trials for the treatment of sepsis. Drug Availability Procuring anakinra may be a challenge at some hospitals in the United States. Continuous intravenous anakinra infusion to calm the cytokine storm in macrophage activation syndrome. Recombinant human interleukin 1 receptor antagonist in the treatment of patients with sepsis syndrome. Initial evaluation of human recombinant interleukin-1 receptor antagonist in the treatment of sepsis syndrome: a randomized, open-label, placebo-controlled multicenter trial. The primary outcome for Phase 3 of the trial was change on a seven-point ordinal scale, and this phase was modified to focus on the dose of sarilumab 400 mg among the patients in the critically ill group. During the conduct of the trial, there were numerous amendments that increased the sample size and modified the dosing strategies being studied, and multiple interim analyses were performed. Ultimately, the trial findings to date do not support a clinical benefit of sarilumab for any of the disease severity subgroups or dosing strategies studied. Considerations in Pregnancy There are insufficient data to determine whether there is a drug-associated risk for major birth defects or miscarriage. Monoclonal antibodies are actively transported across the placenta as pregnancy progresses (with greatest transfer during the third trimester) and may affect immune responses in utero in the exposed fetus. The primary outcome was improved clinical status, which was measured using a seven-point ordinal scale to assess clinical status based on the need for intensive care and/or ventilator use and the requirement for supplemental oxygen over a 4-week period. At Week 4, mortality rates did not differ between the tocilizumab and placebo groups (19. The difference in median number of ventilator-free days between the tocilizumab and placebo groups did not reach statistical significance (22 days for tocilizumab group vs. The mean PaO2/FiO2 ratio of the patients increased between admission (152 +/- 53 mm Hg) and Day 7 of hospitalization (284 +/- 116 mm Hg). No details were provided regarding the rate of secondary infections after tocilizumab use. The authors report an association between earlier use of tocilizumab and reduced mortality; however, interpretation of this result is limited because the study results did not describe a comparison group or specify an a priori comparison. Adverse Effects the primary laboratory abnormalities reported with tocilizumab treatment are elevated liver enzyme levels that appear to be dose dependent. Adverse Effects the primary adverse effects reported for siltuximab have been related to rash. Monoclonal antibodies are transported across the placenta as pregnancy progresses (with greatest transfer during the third trimester) and may affect immune responses in utero in the exposed fetus. Drug Availability Procuring siltuximab may be a challenge at some hospitals in the United States. Macrophage activation syndrome in patients with systemic juvenile idiopathic arthritis under treatment with tocilizumab. Because both baricitinib and corticosteroids are potent immunosuppressants, there is potential for an additive risk of infection. Participants who received baricitinib had a shorter time to clinical recovery than those who received placebo (median recovery time of 7 vs. This treatment effect was most pronounced among those who required high-flow oxygen or non-invasive ventilation but were not on invasive mechanical ventilation. The difference in mortality between the treatment groups was not statistically significant. Adverse effects include infections (typically respiratory and urinary tract infections) and the reactivation of herpes viruses. Complete blood count with differential, liver function tests, and kidney function tests should be obtained in all patients before baricitinib is administered and during treatment as clinically indicated. Considering its immunosuppressive effects, all patients receiving baricitinib should also be monitored for new infections. The primary endpoint was time to recovery, which was defined as reaching Category 1 (not hospitalized, no limitations), Category 2 (not hospitalized, with limitations), or Category 3 (hospitalized, no active medical problems) on an eight-category ordinal scale within 28 days of treatment initiation. In the overall cohort, the median time to recovery was shorter in the baricitinib plus remdesivir arm (7 days) than in the placebo plus remdesivir arm (8 days) (rate ratio for recovery 1. In subgroup analyses according to disease severity, the difference in time to recovery was greatest among the participants who required high-flow oxygen or non-invasive ventilation (10 vs. However, the treatment effect within this subgroup should be interpreted with caution given the relatively small sample size. There was no evidence that the risk of serious adverse events or new infections was higher in the baricitinib arm than in the placebo arm (16% vs. There were no statistically significant differences between the baricitinib and placebo arms in the frequency of pulmonary embolism (5 vs. Preliminary results of this study suggest that baricitinib improves time to recovery in patients who require supplemental oxygen but not invasive mechanical ventilation. Treatment with ruxolitinib was associated with a nonsignificant reduction in the median time to clinical improvement (12 days for ruxolitinib vs. There was no difference between the groups in the median time to discharge (17 days for ruxolitinib vs. More patients in the ruxolitinib group than in the placebo group had radiographic improvement on computed tomography scans of the chest at Day 14 (90% for ruxolitinib vs. The use of ruxolitinib was not associated with an increased risk of adverse events or mortality (no deaths in the ruxolitinib arm vs. Limitations of this study include the small sample size, the exclusion of ventilated patients at study entry, and the concomitant use of antivirals and steroids by 70% of the patients. Considerations in Pregnancy Pregnancy registries provide some outcome data on tofacitinib used during pregnancy for other conditions. Among the 33 cases reported, pregnancy outcomes were similar to those among the general pregnant population. In animal studies, acalabrutinib and ibrutinib in doses exceeding the therapeutic human dose were associated with interference with embryofetal development. Comparison of baricitinib, upadacitinib, and tofacitinib mediated regulation of cytokine signaling in human leukocyte subpopulations. Effects of Janus kinase inhibitor tofacitinib on circulating serum amyloid A and interleukin-6 during treatment for rheumatoid arthritis. Pregnancy outcomes in the tofacitinib safety databases for rheumatoid arthritis and psoriasis. Outcomes of pregnancies with maternal/paternal exposure in the tofacitinib safety databases for ulcerative colitis. Review of Bruton tyrosine kinase inhibitors for the treatment of relapsed or refractory mantle cell lymphoma. A subgroup analysis that was limited to the critically ill patients suggested a mortality benefit at 28 days, which was no longer significant at 60 days. The results of this study are difficult to interpret because of important limitations in the study design. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Adverse Effects Monitoring Parameters Drug-Drug Interaction Potential Panel Recommendations, Comments, and Links to Clinical Trials Corticosteroids, continued Dexamethasone, continued · Peripheral edema · Myopathy (particularly if used with neuromuscular blocking agents) · When used during outbreaks of other novel coronavirus infections. The doses listed here are for approved indications or from reported experiences or clinical trials. Because both agents are potent immunosuppressants, there is a potential for an additive risk of infection. Corticosteroid therapy for critically ill patients with Middle East respiratory syndrome. The study further reported that in a subset of 395 mechanically ventilated patients, 29. The study had important limitations: it lacked details on patient characteristics, indications for anticoagulant initiation, and descriptions of other therapies that the patients received that may have influenced mortality. In addition, the authors did not discuss the potential impact of survival bias on the study results. Only the patients treated with therapeutic anticoagulation showed improvement in the ratio of arterial oxygen partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2). Two patients treated with therapeutic anticoagulation had minor bleeding, and two patients in each arm experienced thrombosis. Some guidelines note that intermediate dose anticoagulation can be considered for critically ill patients. Although data supporting this recommendation are limited, a retrospective study showed reduced mortality in patients who received prophylactic anticoagulation, particularly if the patient had a sepsis-induced coagulopathy score 4. Anticoagulation is routinely used to prevent arterial thromboembolism in patients with heart arrhythmias. Unblinded data and additional study outcomes, including the occurrence of thrombosis, are expected to be reported soon. The Food and Drug Administration approved the use of rivaroxaban 10 mg daily for 31 to 39 days in these patients. Special Considerations During Pregnancy and Lactation Because pregnancy is a hypercoagulable state, the risk of thromboembolism is greater in pregnant individuals than in nonpregnant individuals. Efficacy and safety of fondaparinux for the prevention of venous thromboembolism in older acute medical patients: randomised placebo controlled trial. Randomized, placebo-controlled trial of dalteparin for the prevention of venous thromboembolism in acutely ill medical patients. A comparison of enoxaparin with placebo for the prevention of venous thromboembolism in acutely ill medical patients. The Association of Non-University Affiliated Intensive Care Specialist Physicians of France. Trends in the incidence of venous thromboembolism during pregnancy or postpartum: a 30-year population-based study. Coronavirus disease 2019 infection among asymptomatic and symptomatic pregnant women: two weeks of confirmed presentations to an affiliated pair of New York City hospitals. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. The predictive value of D-dimer test for venous thromboembolism during puerperium: a prospective cohort study. Some clinicians advocate for the use of vitamin and mineral supplements to treat respiratory viral infections. Ongoing studies are evaluating the use of vitamin and mineral supplements for both the treatment and prevention of severe acute respiratory syndrome coronavirus 2 infection. The following sections describe the underlying rationale for using adjunctive therapies and summarize the existing clinical trial data. It is an antioxidant and free radical scavenger that has antiinflammatory properties, influences cellular immunity and vascular integrity, and serves as a cofactor in the generation of endogenous catecholamines. Two other trials found no differences in any physiologic or outcome measure between the treatment and placebo groups. Other Considerations It is important to note that high circulating concentrations of vitamin C may affect the accuracy of pointof-care glucometers. Hydrocortisone, vitamin C, and thiamine for the treatment of severe sepsis and septic shock: a retrospective before-after study. Combined vitamin C, hydrocortisone, and thiamine therapy for patients with severe pneumonia who were admitted to the intensive care unit: propensity score-based analysis of a beforeafter cohort study. Combined treatment with hydrocortisone, vitamin c, and thiamine for sepsis and septic shock: a randomized controlled trial. Combination therapy of vitamin C and thiamine for septic shock: a multicentre, double-blinded randomized, controlled study. Because the vitamin D receptor is expressed on immune cells such as B cells, T cells, and antigen-presenting cells, and because these cells can synthesize the active vitamin D metabolite, vitamin D also has the potential to modulate innate and adaptive immune responses. In observational studies, low vitamin D levels have been associated with an increased risk of community-acquired pneumonia in older adults3 and children. These trials will administer vitamin D alone or in combination with other agents to participants with and without vitamin D deficiency. Low serum 25-hydroxyvitamin D level and risk of upper respiratory tract infection in children and adolescents. The role of vitamin D in increasing circulating T regulatory cell numbers and modulating T regulatory cell phenotypes in patients with inflammatory disease or in healthy volunteers: a systematic review. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. The recommended dietary allowance for elemental zinc is 11 mg daily for men and 8 mg for nonpregnant women. Long-term zinc supplementation can cause copper deficiency with subsequent reversible hematologic defects. The primary endpoints were recovery within 28 days, the need for mechanical ventilation, and death. Interpretation A moderately sized randomized clinical trial failed to find a clinical benefit for the combination of zinc and hydroxychloroquine. Among the 46 patients who did not receive zinc, 32 patients (70%) received hydroxychloroquine. The primary outcome was days from hospital admission to in-hospital mortality, and the primary analysis explored the causal association between zinc therapy and survival.
However symptoms checklist zofran 8 mg for sale, this type of reaction characteristically produces a great quantity of heat that is released into the surrounding environment treatment 5th metatarsal fracture buy zofran 8mg with mastercard. To prevent this phenomena from becoming problematic symptoms 5th week of pregnancy order zofran 4 mg on-line, an oxygen analyzer is placed within the circle to measure the percentage of oxygen within the breathable air medicines generic 8mg zofran with amex. When the percent oxygen within the circle system decreases below a preset level symptoms insulin resistance 8 mg zofran fast delivery, the oxygen analyzer symptoms 5 weeks pregnant generic zofran 4mg mastercard, which is electronically coupled to a tank of high-pressure 100% oxygen (not air) within the unit symptoms jaw pain and headache purchase zofran 8mg without a prescription, releases a measured quantity of oxygen into the circle system through the second stage (low-pressure) reducing valve symptoms of appendicitis cheap zofran 8 mg with amex. The first stage high-pressure reducing regulator is directly attached to the outlet valve of the oxygen tank. Advantages of the closed-circuit (circle) system include a longer period of usage without refilling the oxygen tank, usually in the neighborhood of 4 hour, as opposed to a maximum usage of 1 hour with an open system employing compressed air. Disadvantages would include the heavy weight of the system, although the open circuit is also heavy, and the exothermic (heat producing) reaction that takes place between carbon dioxide and soda lime or other carbon dioxide-removing substances. Oxygen readily supports combustion which is an Personal Protective Equipment: Practical and Theoretical Considerations 555 obvious disadvantage, as well as the necessity of having to periodically change the carbon dioxidefiltering material. If changing the carbon dioxide-filtering material is ignored, carbon dioxide levels within the circle system will continue to increase. As levels of carbon dioxide increase initially a cerebral vasodilatory effect (dilatation of blood vessels within the brain, which increases pressure on the brain) will occur, the extent of which will be directly proportional to the level of carbon dioxide. This will be expressed clinically with the development of an increasingly severe headache. At levels of carbon dioxide of approximately 80 mmHg or above (3640 mmHg is considered normal), carbon dioxide will exert an anesthetic effect on the responder, and he may initially become light headed, dizzy, and may fall into a deep sleep from which arousal is difficult or impossible, depending on the levels of carbon dioxide within the circle system. A chemical reaction occurs within the filtering material when it becomes saturated with carbon dioxide and needs to be changed. The color of this material will undergo a color change, usually from white to blue. This water would then have to be drained from the system through a one-way valve mechanism. The exact composition of an air-purifying filter will be discussed later in this chapter. What is important is that the filter employed be able to remove the contaminant and in the concentrations present. Air is usually introduced into it by two one-way valves (one on each side) located inside the nosecup. Some respirators, especially those of British origin, lack the one-way valves, but strategically place the interconnection between inside and outside of the nosecup in a location that will not interfere with proper functioning of the nosecup. If this latter were to occur the temperature and humidity content of the air on the inside of the eye lens would be significantly greater than that on the outside of the eye lens, with resulting condensation of water vapor to liquid water on the inside of the eye lens, with the resulting obscuring of vision. It totally covers the head, has an opening for the facepiece of the respirator that is surrounded by an elasticized band to tightly secure the hood to the respirator facepiece, and additionally covers the shoulders and the upper chest (both front and rear aspects), and is secured by two straps that extend from the outside of the bottom of the rear aspect of the hood, with one strap extending under each axilla (armpit), and subsequently both straps attaching to the outside of the lower margin of the front aspect of the garment. If the task is performed in a sunny area, then radiant energy from the sun in the form of infrared rays provides additional heat accumulation within the ensemble. The following medications decrease blood flow to the skin: diuretics by producing fluid loss and dehydration with accompanying constriction of blood vessels, beta blockers by decreasing cardiac output, and alpha agonists by constricting blood vessels. Weight-loss medications have multiple effects, including increasing the rate of metabolism and hence heat production; and anticholinergic drugs decrease or prevent sweating thus decreasing or eliminating evaporative cooling. Consequences of heat stress would include reduced psychological functions including reduction in speed of thought, alertness, and reaction time. Resting body metabolism will produce heat energy equivalent to that produced by a 100 W light bulb, moderate work increases this to about 250 watts, whereas extreme work, such as running, increases this to approximately 1000 watts. The body attempts to dissipate heat production by increasing blood flow to the skin and increasing sweating. Cardiac output initially increases, but will fall as circulating volume decreases by sweating, and syncopal (fainting) episodes may result. When heat production exceeds heat dissipation, body temperature will begin and continue to rise. This method of cooling relies on the ability of the surrounding atmosphere to accept water vapor. Hence, the lower the humidity of the surrounding air, the more humidity it will accept, and the greater the degree of evaporative cooling that will occur. Air that is 100% saturated with water vapor will no longer accept additional moisture, and hence evaporative cooling comes to a halt. The latter normally constitutes the principal method by which body-generated heat is lost to the environment. If patients experience heat exhaustion they are still capable of sweating and controlling thermoregulation (temperature control of body). This less-severe diagnosis of heat exhaustion is a diagnosis of exclusion, whose symptoms include exhaustion, weakness, headache, fatigue, light-headedness, and dizziness. Signs of heat exhaustion may also include lethargic, depression, irritability, and confusion, elevated pulse rate, and orthostatic hypotension. Heat stroke is a true medical emergency, and serious medical consequences, including death, may result if external cooling of the body is not immediately instituted. Signs of heat stroke include delirium, disorientation, combativeness, seizures, collapse (fainting), low blood pressure, and a compensating weak, rapid pulse. Anatomical dead space (the volume of air in the respiratory tree that must be moved before fresh air can be admitted to the alveoli) is usually 1 cc per pound of body weight. Tidal volume and hence minute ventilation increase significantly to compensate for this added dead space. However, the increase in tidal volume and minute ventilation is usually not as great as the increase in dead space; consequently alveolar ventilation decreases slightly. Usually respiratory rate decreases slightly with initial respirator usage, although this will increase as the level of exercise increases, and the corresponding need for oxygen increases. Since cerebral blood vessel diameter is directly proportional to blood carbon dioxide concentration within the range of 2080 mmHg, cerebral blood vessels dilate; this may slightly increase intracranial pressure, and a headache often results. Air-purifying respirators increase expiratory resistance far less than atmosphere-supplied pressure-demand respirators. The latter maintains a significant positive pressure throughout the entire expiratory cycle. This in turn keeps more alveoli ventilated (opened) during expiration, which increases the oxygenation of the blood. This lowered cardiac output at worst could result in syncope (fainting), and at best a decreased endurance at increased levels of exercise. Negative-pressure air-purifying respirators (gas masks) increase inspiratory resistance to a far greater extent than expiratory resistance. With negative-pressure air-purifying respirators, as minute ventilation increases, inspiratory and expiratory resistances increase geometrically thus individuals may decrease their peak inspiratory and expiratory flow rates to decrease the resistance to air flow. Moreover, respirator users must increase their respiratory rate (Hodous, 1989) to meet the demands of increased minute ventilation. Personal Protective Equipment: Practical and Theoretical Considerations 559 airflow. Bronchospasm (narrowing of the bronchi) may result in hypoxia (decreased oxygen) and hypercarbia (increased carbon dioxide) in the blood. An increase in respiratory work, due to increased expiratory resistance as described above, will also increase cardiac work by a ripple down effect especially as work loads increase. In summary, the increased tidal volume, increased inspiratory and expiratory airway resistances (the magnitude of which vary depending on the type of respirator employed), increased anatomical dead space, as well as the initial decrease in respiratory rate, result in decreased alveolar ventilation, increased work of breathing, and decreased endurance at maximum work loads. Generally negative-pressure air-purifying respirators tend primarily to increase respiratory work that may then later have a ripple down effect to increase cardiac work in individuals with metabolic compromise. Atmosphere-supplied pressure-demand respirators generally increase cardiac work significantly due to the increased weight of the respiratory equipment. Additionally, increased respiratory work is generated by the increased muscular effort needed to continue breathing against the positive pressure created by the respirator during the entire expiratory cycle. Interestingly enough, a responder using a negative-pressure air-purifying respirator during a period of very heavy exercise will increase his maximal negative oral pressure during inspiration to about 1517 cm of water pressure. The maximum peak positive oral pressure generated during very heavy exercise with a respirator in the positive pressure mode. This process produces further dehydration while requiring additional energy utilization. Some respirators come equipped with a voicemitter to overcome this difficultly, and although this is an improvement, much is left to be desired. Heightened emotions in the form of anxiety, as well as a feeling of claustrophobia and isolation frequently occur. In addition to a decrease in visual fields, the sensation of touch is decreased, and smell and taste are also compromised. Individuals with decreased tear production, or an impaired blinking mechanism, may experience drying of the eyes under such conditions. Principal among these are rapid heat buildup secondary to increased metabolism, increased sweat production, loss of evaporative cooling, and rapid production of dehydration. All of these lead to the production of a metabolic environment that results in a decreased work endurance at maximal levels of exercise, heat cramps, heat exhaustion, and possibly heat stroke. Additionally, exposure to any extremely toxic or corrosive gases, liquids, or solids that may cause significant skin damage on exposure require Level A. Downgrading to a lower level of protection occurs as a threat analysis if the situation allows. This is the highest level of protection since it completely isolates its occupant from toxic vapor and liquid contamination from the outside. Through the use of one-way valves the suit exhausts expired air and yet maintains an extremely slight positive pressure inside the suit with reference to the surrounding environment. As previously stated, a pressure-demand respirator maintains a slightly positive pressure within the facepiece of the respirator (with reference to the surrounding atmospheric pressure) in every phase of both inspiration and expiration. In the case of a Level A ensemble the outside of the mask would actually be the inside of the Level A suit, which itself maintains a slightly positive pressure compared with the surrounding contaminated atmosphere through the use of a one-way valve mechanism. Another advantage of this type of respirator is that the air supply to the responder is totally independent of the surrounding atmospheric contaminated air. One should remember that the total dose of the toxic agent, and not the concentration in the atmosphere, affects physiological and pathological outcome. The ease of inspiration in pressure-demand (positive pressure throughout all of inspiration and expiration) mode allows only a minimal increase in inspiratory work compared with no respirator usage; however, the responder does expire against a positive pressure that would significantly increase respiratory work. Respiratory expiration when wearing Level A may produce a slight breeze within the suit that may have a very slight convective cooling effect. This may help to increase alveolar recruitment (keeping more alveoli open during the respiratory cycle) in the lungs, thus decreasing ventilation=perfusion abnormalities and raising arterial pa02, and consequently increasing blood oxygenation. Disadvantages would include the significant weight of the unit, usually 3040 pounds, thus carrying this weight would significantly increase cardiac work. These units are also bulky, have a limited air supply (3060 min), and require regular maintenance by qualified individuals. Failure of any of its many high-pressure components could result in catastrophic explosive traumatic injury. This lower form of dermal (skin) protection provides protection against liquid splash only. Environmental toxic vapors can come into contact with the skin when Level B is worn. Should a potential problem arise if toxic vapor were to come in contact with the skin, Level B should not be worn. Level B suits provide no skin protection from vapor exposure, nor any protection against continuous contact with liquids. The suit is therefore designed as splash resistant, that is, resistant to liquid splash, but not liquid proof because of the method of construction of seams and zippers. Unlike Level A zippers and seams, those in Level B suits would allow penetration of vapor and liquid. Clearly the space created between the suit and the facepiece of the respirator could be penetrated by vapors and liquids, unless measures are taken to prevent this. Devices such as a ``hood' (previously defined) and a respirator ``second skin' have been designed to deal with this problem. A photograph illustrating this lack of protective coverage of the chin area is included in the photographic section of this chapter. A third type of Level B suit is also made in the coverall configuration as discussed above, but is manufactured in two pieces (jacket and trousers) instead of one. Even though the level of respiratory protection has been downgraded from Level B, the degree of skin protection offered in Level C is the same as Level B, namely liquid splash protection only. There is no skin protection against vapor contact or continuous contact with liquid. The first type is identical to the coverall suit (impermeable material in either a one- or two-piece design) described for Level B. The second presentation of the Level C suit ensemble is usually a two-piece (although one-piece suits do exist) semipermeable activated carbonlined suit. The permeable, or more correctly, semipermeable suit is actually constructed in two layers. The outer layer is constructed of a 50% nylon per 50% cotton poplin rip-stop material that has been chemically treated with a heavy-duty water repellent. The inner layer consists of a nonwoven front laminated to activated carbon spheres bonded to a tri-cotton knit back. Civilian versions would be structurally identical to these chemicalprotective suits, although the coloring on the outside of the suit may be in various colors and patterns. The newer versions of the civilian suits followed the military lead and are now equipped with a built-in hood. Semipermeable suits would allow the outward passage of certain entities to a limited extent, such as body moisture and heat. Any suit containing activated carbon should not be exposed to becoming saturated with water or liquid, as this degrades the suit, compromises the activated * the pressure inside the facepiece is positive in pressure compared with that of the ambient air. Indeed the military does use this type of suit in decontamination procedures employing liquid decontaminating materials. Activated Carbon Activated carbon (sometimes referenced as activated charcoal) is a specially formulated carbon-based product. Materials used include various carbon-based products including coconut shells, various woods, coal, etc. These materials may be pretreated with acids, and then subjected to combustion at varying degrees of time, temperature, and additionally with pressurized steam. This process expands the porous nature of these materials, and tremendously increases the surface area for adsorption of toxic materials onto the surface of the activated carbon. In a typical chemical warfare filter in excess of 200 gram of activated carbon fill is used. As an example, using 950 m2 (the average of 500 and 1400 m2) and multiplying this by 200 gram (the minimum weight of activated carbon in the filter) the surface adsorptive area of the activated carbon in the filter would be at least 190,000 m2. Thus the minimal activated carbon adsorptive area of an average chemical warfare filter is greater than 35 times the size of a regulation football field. During the manufacturing process, activated carbon is also impregnated with salts of various inorganic metals. The exact composition of the impregnated metals varies according to the type of toxic materials that the activated carbon is designed to filter. This activated carbon is impregnated with the salts of silver, copper, zinc, molybdenum, as well as triethylene diamine. Generally speaking, removal of chemical contaminants by activated carbon is based on two things: (1) the vapor pressure of the toxic contaminant, and (2) its reaction chemistry. Activated carbon has difficulty in removing compounds with low molecular weight (Pope, 1996), as exemplified by carbon monoxide and ammonia, etc. Briefly, substances with vapor pressures below 10 mmHg are adsorbed onto the surface of the activated carbon, where they are usually held there by electrostatic forces and then slowly undergo degradation by hydrolysis. The impregnated salts of inorganic metals react chemically with toxic gases having higher vapor pressures, including chlorine, phosgene, cyanide, cyanogen chloride, as well as other acidic gases. The most difficult toxic materials for the filter to remove will be the contaminants that will be the limiting factor in the serviceable life of the filter. These agents will destroy the protective filter barrier the quickest, and they are the ``blood' or cyanide agents, that is, cyanogen chloride and hydrogen cyanide. Sarin is the most difficult nerve agent to be filtered by the activated carbon because it has the highest vapor pressure of all the nerve agents. Sulfur mustard was used as the vesicant representative, again the total filtering capacity was also 300,000 mg-min per m3. Phosgene was the representative of the lung damaging agent category, and the total filtering capacity was 120,000 mg-min per m3, whereas cyanide represented the blood agents and the total filtering capacity was only 80,000 mg-min per m3. Chlorine, phosgene, the cyanides (hydrogen cyanide and cyanogen chloride), and other acidic gaseous are removed by reaction chemistry of Personal Protective Equipment: Practical and Theoretical Considerations 565 their molecules with the impregnated salts of inorganic metals, rather than by adsorption onto the surface of the activated carbon (Morrison, unknown year). Hexavalent chromium has been implicated in causing cancer, and is therefore considered a hazardous material, and must be disposed of by employing a hazardous material waste disposal protocol. This type of carbon is contained in the older C2 and M17 military filters, since replaced by the C2A1 filter. A third compartment (closest to the outlet of the filter) contains another, much smaller P-100 filter whose purpose is to remove any activated carbon that may have become dislodged, thus preventing this from entering the facepiece of the respirator. Activated carbon, impregnated with the salts of inorganic metals, is contained in the filters of all air-purifying respirators, and also the inner lining of semipermeable protective suits. It is also present in selected glove and boot liners that are specially designed to adsorb toxic chemical agents. Conditions of Level C usage: For the safety of the responder, several conditions must be met before Level C may be employed. A second condition of Level C usage is that is cannot be used in an oxygen-deficient atmosphere, that is, one in which oxygen by volume is <19. Additionally, the toxic material must have good warning properties (irritating odor, tearing, choking, coughing, etc. Actually most modern respirators that have been properly maintained can deliver protection factors far in excess of these assigned protection factors. Personal Protective Equipment: Practical and Theoretical Considerations 567 2005).
Order zofran 8 mg visa. AIDS Important Symptoms and Treatment.
