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  • Associate Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences
  • Clinical Pharmacy Specialist—Internal Medicine, Indiana University Health Methodist Hospital, Indianapolis, Indiana

The community and the university are mutually dependent on each other economically in treatment 2 cefuroxime 250 mg without prescription. Numerous local businesses serve the university and local merchants depend upon business from staff and students medicine 6 year quality cefuroxime 250 mg. Immediate impacts from university closure would be the loss of jobs and local sales medicine x stanford order cefuroxime 250mg. Their vulnerability depends upon characteristics such as size medications john frew generic cefuroxime 250mg visa, age, building materials and construction quality. Other vulnerability factors include building value, historic value, building contents, occupancy, and whether or not hazardous materials are stored in them. Figure 3-2 presents an aerial view of the campus identifying buildings by name and number. Building characteristic information was compiled from the State of Montana Commercial Property Schedule and Property Appraisals from the Risk Management and Tort Defense Division, and was verified by campus personnel. Combining the type of structure and the year it was designed yields a risk variable known as the design level. The level is noted as low, medium or high and it relates directly to the specific building code used during the design process. Structures designed to the most current code are in the high category while structures designed before 1941 fall into the low category. Buildings designed after 1941, but before the adoption of the most recent code, land in the medium group. Buildings constructed of concrete or reinforced steel have a better chance of withstanding a disaster than those constructed of unreinforced masonry or wood. Buildings constructed with unreinforced masonry are at greatest risk to damages from earthquakes and those constructed from wood frame construction are at greatest risk to fire. Buildings constructed from unreinforced masonry or wood are at a greater risk to damage during an explosion compared to those constructed of concrete or reinforced steel. Storage Container #2 Chemistry Biochemistry Building Chemistry Stores Cobleigh Hall Cooley Laboratory Creative Arts Complex - Cheever Hall Creative Arts Complex - Haynes Hall Creative Arts Complex-Howard Hall Culbertson Hall Danforth Chapel Engineering Physical Sciences Building Facilities Chemical Storage 11 Faculty Court 13 Faculty Court 15 Faculty Court 21 Faculty Court 22 Faculty Court 23 Faculty Court 24 Faculty Court 25 Faculty Court Facilities Heat Plant Generator Building Gaines Hall Hamilton Hall Heating (Physical) Plant Herrick Hall Huffman Building N Y N Y N N Y N N Y N N N N N Y N N N N N N N N N N Y N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N Partial Y N N Partial Y N N N N Y N Y Y N N N N N Y N Y Y Y Y Y Y Y Y N Y N Y N Y 13 H H H L H H H H H H M M M L L H H L L L M L L L L L H H H H M 1954 2010 2008 2007 2008 2008 2007 2009 1970 1960/2012 1974 1974 1974 1955 1952 1996 2010 1999 1999 1996 1957 1957 1957 1957 1957 1922 1961/2010 1910 1923 1926 1969 Year Built Name 41,622 40,634 3,693 14,300 198 198 90,037 756 94,262 38,143 60,500 44,600 31,216 48,639 1,560 151,388 619 2,220 2,220 2,084 1,043 1,043 1,043 1,043 1,043 719 96,993 28,013 11,616 41,286 8,843 Square Feet No. Apartments (64 Units in 11 44 Buildings) 48 Family Housing Office Building 49 Fox Street House (23 Units In 23 Buildings) 51 Gallatin Hall 52 Glacier Court 3 Bdrm (42 Units In 42 Buildings) 53 Gopher Street House (7 Units In 7 Buildings) 55 Grant Chamberlain (144 Units In 6 Buildings) 57 Hannon Residence Hall (166 Units In 1 Buildings) 58 Hapner Residence Hall (168 Units In 1 Buildings) 62 Indoor Tennis Facility Tetra Tech Inc. N N Y Y Y Y Y Y N N N N N N N N N Y N N N Yes N N N Y Y N N N N N N N N N N N N N N N N N N Y N N N No N N N N N N N N N N N N N N Partial N N N N N N N N Y N N N No N N N N N N 15 L L L L L L L L L L L L L L L L L L L M L Low L L L L L L 1957 2009 1935 1935 1935 1935 1935 1935 1998, 2011 1973, 2011 1997 1987 2011 2011 2012 1973 1976 1958 1968 1968 1957, 1964 2013 1957, 1964 1957, 1964 1975 1955 1959 2003 Year Built Name 1,043 6,972 6,866 6,937 7,381 7,488 7,009 6,989 61,394 60,980 4,800 3,217 240 1,161 840 80,845 42,424 184,452 48,192 2,709 15,548 29,990 28,392 4,732 122,850 90,748 95,524 29,183 Square Feet No. Garfield Street House (2 Units In 2 Buildings) West Julia Martin Drive Apartments (64 Units In 8 Buildings) Y N N N Y N N N N Y N N M M L L 1939 1957 1957, 1964 1971 Year Built Name 191,407 22,213 1,352 54,880 Square Feet No. Building Value - based on values reported by the university to the State of Montana Risk and Tort Management Division. The division puts a four percent increase on the value to ensure it is insured at market value. Figure 3-5 shows Building Values Content Value - based on values reported by the university to the state of Montana Risk and Tort Management Division. Economic damages associated with building content include but are not limited to books, technical instruments, research equipment, art, specimens, and furniture. Hazardous material risk was ranked as low, medium, and high by campus personnel based on the volume and type of materials stored where: Low indicates no or very few chemicals such as cleaning supplies, Medium indicates moderate amount of chemicals such as maintenance chemicals or a photo lab or art studio, and High indicates very toxic chemicals usually found in science laboratories or central power stations. The majority of graduate and family housing facilities do not have fire sprinkler systems except for the Nelson Story and Peter Koch Towers. All campus buildings have fire alarm systems and evacuation maps showing a primary and secondary route to exit. Community critical facilities considered in this report are those that provide services the campus cannot provide during an emergency event, as described below. The Bozeman Fire Department staffs two frontline fire engines and relies on off-duty personnel to staff a reserve engine when on-duty resources are committed to emergency calls. Determining the location, condition and vulnerability of utilities and communications systems necessary for the campus to function is an important step in mitigation of potential damages and overall risk from hazards. Five percent of the total electrical and 50 percent of data and communications are run through the tunnel system. Steam and condensate, compressed air, domestic water and irrigation water are also run through the tunnels. Fire alarms and emergency sirens cannot be heard in the tunnels making them a vulnerable location in the event of a disaster. Steam from the plant either goes through pipes in the underground tunnels or is dispersed through buried piping.

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We failed to medicine world order cefuroxime 250mg online thread the catheter even after two attempts We decided to treatment zinc overdose 250mg cefuroxime mastercard pass a lumbar catheter instead shakira medicine discount cefuroxime 250 mg on line. Same needle was introduced in L4-5 space using loss of resistance to symptoms prostate cancer discount 500mg cefuroxime mastercard air technique. When the air was pushed in, we could see an obvious and evident bulge with air leak in the sacral hiatus region (Figure-1) probably due to air escaping through the hiatal opening in the subcutaneous tissue. The surgery was uneventful and post operatively epidural infusion of low dose bupivacaine with opioids was given for three days and then the catheter was removed. In children, small anatomical structures and catheter insertion under general anesthesia poses difficulty to identify epidural space. Figure 1: Showing sacral bulge after loss of resistance Various complications associated with the use of air for the loss of resistance technique are pneumocephalus, spinal cord and nerve root compression, retroperitoneal air, subcutaneous emphysema, venous air embolism and inadequate analgesia and paresthesia. The technique described by us utilizes two puncture sites and may have potential to decrease the amount of air retained in the space, hence probably reducing the air related complications. Misconnected epidural infusion into A major cause for these erroneous connections is the central line: A perfect recipe for disaster incorporation of the Luer lock, which permits the linking of functionally dissimilar tubes. Other causes Dear Editor, include the use of tubes or catheters for unintended Based on the severity of the sickness, patients may have purposes (intravenous extension tubing for epidurals, several tubes and lines connecting them to devices for irrigation, drains, and central lines, or to extend enteral delivery of various drugs or nutrition through different feeding tubes), positioning of functionally dissimilar routes. After shifting the patient to the post anesthesia care unit, various lines and tubings were attached by the onduty nurse. At the time of hand-over, it was discovered that the extension tubing for connecting the syringe containing the epidural solution (50 ml solution of 0. Through this connection, the epidural solution had been running intravenously for the past three hours at the rate of 5 ml/hr. The patient was monitored for any signs of toxicity and a close watch was kept on the vitals of the patient. The Sentinel Event Alert, issued by Joint Commission in 2006, had cited different tubing and catheter misconnections, leading to eight deaths and one permanent loss of function. Moreover, the extension tubing, which was not primed with the epidural solution, would have accommodated some amount of the drug. Ropivacaine itself provided a degree of safety due to its lesser central nervous system and cardiovascular system effects in humans, as compared to bupivacaine. Rechecking and tracing of tubings to their origin, as a part of hand over process, saved the day for us. We would also like to voice our support for the recommendations of equipment design solution. This Focused Cold Therapy technology is meant to induce a kind-of hibernation of nerves, blocking their signaling ability and therefore reducing pain. The device was approved in Europe and Canada for temporary wrinkle reduction. The device aims to make intubation safer (less broken teeth/ busted lips from the laryngoscope), cheaper, and simpler. A sensing plate with an integrated piezo-electric sensor is easily placed under the mattress so the patient remains comfortable and enjoys complete freedom of movement. Antipsychotic agents can cause rigidity and hyperthermia (neuroleptic malignant syndrome). Hypertension and tachycardia may occur due to ganglionic stimulation (nicotinic action). Dialysis does not help in reducing the severity of symptoms as confirmatory change in acetylcholine receptors have ensued following irreversible binding of receptors with acetylcholine esterase. Acitvated charcoal has a low affinity for binding cyanide, though the usual doses of 60­100 g are adequate to bind typically ingested lethal doses (100­200 mg), so is recommended in cases of cyanide ingestion. Nitrites induce methemoglobinemia which binds cyanide but also may induce hypotension and may raise methemoglobin to dangerous levels. Q 1: Which of the following statement is correct in terms of asthma characteristic or prevalence?

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Home Health ValueBased Purchasing this is a fiveyear model which ties a portion of home health agency payment to symptoms after flu shot cheap cefuroxime 250mg overnight delivery quality medications zocor 250 mg cefuroxime with visa. Participation in this model is required for home health agencies providing services in nine randomly selected states: Massachusetts medicine in ukraine generic cefuroxime 250mg mastercard, Maryland treatment degenerative disc disease cheap 250 mg cefuroxime amex, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee. The goal of the model is to incentivize providers to offer improved care, which may result in reduced hospital admissions and skilled nursing facility stays during or immediately following home health care. Payments for an individual home health agency could increase or decrease by as much as 3 percent in 2018 and by as much as 8 percent in 2022. Initiatives Focused on Prevention Accountable Health Communities Model the Accountable Health Communities model will address critical gaps between clinical care and communitybased services. The Innovation Center will award up to 44 5year cooperative agreements to eligible organizations responsible for developing 122 Centers for Medicare & Medicaid Services referral networks of community service providers for Medicare and Medicaid beneficiaries to address their healthrelated social needs. Applications will be due by the end of March 2016 and the Innovation Center anticipates announcing awards in the fall of 2016. Million Hearts Cardiovascular Disease Risk Reduction Model Heart attacks and strokes are a leading cause of death and disability for Americans. The Million Hearts model proposes an entirely new way of lowering those risks across the population. Currently, providers are paid to meet specific blood pressure or cholesterol or other targets in their patients. Many of the biggest drivers of health and health care costs are beyond the scope of health care alone. The Accountable Health Communities Model will provide up to $157 million over five years to "bridge organizations" to screen Medicare and Medicaid beneficiaries for social needs during a primary care experience and help them connect with and/or navigate the appropriate communitybased services. The model will test three different approaches to addressing health-related social needs and linking clinical and community services: 1. Creating awareness by referring patients to community services; Providing assistance including navigation services; and Aligning community partners around the needs of Medicare and Medicaid beneficiaries. Through this model, health care providers will work with Medicare beneficiaries to calculate their individual risk for a heart attack or stroke in the next 10 years based on their comprehensive profile of age, risk factors, blood tests, and behavioral factors. Patients will be shown various approaches to reduce risks-for example, stopping smoking, reducing blood pressure, or taking statins or aspirin. Providers will be paid for how much they reduce absolute risk for their highrisk patients. Initiatives to Innovate Health Plans under Medicare Part D Enhanced Medication Therapy Management Model this model will test strategies to improve medication use among Medicare beneficiaries enrolled in Part D. Medication therapy management, when implemented effectively, can improve health care and outcomes for patients and has the potential to lower overall health care costs. Announced in September 2015, the model will begin in 2017 with a fiveyear performance period. Medicare Advantage ValueBased Insurance Design Model this model will test whether giving Medicare Advantage plans flexibility to offer targeted extra supplemental benefits or reduced cost sharing to enrollees who have specified chronic conditions can lead to higher quality, reduced utilization of avoidable highcost care, and lower costs for plans, beneficiaries, and the Medicare program. The model focuses on Medicare Advantage enrollees with the chronic conditions of diabetes, congestive heart failure, chronic obstructive pulmonary disease, past stroke, hypertension, coronary artery disease, and mood disorders. The model will begin January 2017 and run for five years in Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. The Innovation Center has worked with experts Centers for Medicare & Medicaid Services 123 at the Centers for Disease Control and Prevention, National Institutes of Health, Administration for Children and Families, and the Health Resources and Services Administration to identify the goals and shape the direction of Strong Start. Initiatives Supporting MedicareMedicaid Enrollees More than 10 million Americans are dually enrolled in the Medicare and Medicaid programs. Section 2602 of the Affordable Care Act established the Federal Coordinated Health Care Office, also known as the MedicareMedicaid Coordination Office, to promote access to care, improve the overall beneficiary experience, and coordinate services for MedicareMedicaid enrollees. States participating in the initiative have designed models to improve quality and achieve savings using either a capitated payment system or the current feeforservice structure. New York has two capitated models, with one focused specifically on serving beneficiaries with intellectual and developmental disabilities.

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The more criminalized and stigmatized men who have sex with men are in a given country medications prescribed for depression buy 250 mg cefuroxime, the larger this line item should be medicine 93 discount cefuroxime 250mg with visa. Clinical Services Lab tests and associated equipment and supplies Drugs for diseases managed Hazardous waste containers Secure and appropriate storage for drugs and diagnostics Medical supplies (gloves symptoms 6 days post iui generic cefuroxime 250mg amex, alcohols swabs medications i can take while pregnant buy cheap cefuroxime 500mg on line, bandaids, swabs) Hepatitis B vaccination for clinical providers Quality assurance/quality control contract for laboratory Liability insurance Refrigerator Registration fees/licence fees Training for infection control Secure storage for clinic records 217 6 Programme Management the implementing team is likely to include both community members and non-community members. Staff who are not men who have sex with men should be sensitive to the context of identity, discrimination, violence and other problems faced by men who have sex with men. They should also be able to discuss such topics as sex and service delivery needs in a nonjudgemental manner. Given the overarching goal of progression and community empowerment for men who have sex with men, staff should be prepared to learn from the men who have sex with men as well as serve as mentors to the process. Although staff are hired for a specific role in the programme and will have a job description, they need to be flexible to adapt to new situations on the ground and incorporate new approaches. Capacity-building of human resources is an important aspect of any programme but is particularly important in programmes with men who have sex with men, where the intent is to progressively increase their involvement in decision-making and ownership of the programme. This involves increasing the number of men who have sex with men in staff management positions as well as field staff. From rolling out services to improving coverage and quality During this stage of implementation the focus is on ensuring coverage of the community with services (outreach, education, prevention drugs and commodities, referral to appropriate services etc) and improving quality. This roll-out stage is a continuous process in which management at all levels reviews progress against targets and adjusts strategies and tactics, as necessary. Mid-course corrections are made where necessary, based on new data, new approaches or environmental or structural changes that affect programming. The intensity and quality of coverage increase as staff become more skilled in their positions. It is during this phase that flexibility and continuous programme learning are extremely valuable. A strong monitoring system with regular reviews is essential to the successful roll-out of services. It also signals to funders and the government whether programming is being implemented successfully, with fidelity to programme design and coverage goals. Aiming toward systems improvement, social norm change and increased sustainability the overall aim of the programme is: (1) to provide services and products to reduce risk of transmission and decrease mortality, (2) to promote an enabling environment to reduce vulnerability and increase access to and use of services, and (3) to empower men who have sex with men to participate and progressively build their capacity to implement the programme. This latter aim will make the programme more effective and potentially more sustainable. The ideal characteristics of such a programme include the following: Men who have sex with men lead in implementing outreach, distributing condoms and lubricant and facilitating effective clinical referrals. As skills and interest develop in the community they should fill management positions in the implementing organization. Programme implementation in this stage is a matter of strengthening systems, addressing structural barriers and empowering communities while simultaneously providing and measuring services. Some of the earlier intensive programme activities may be reduced as social norms regarding safer sex and clinical service use change and respectful services are increased. From expanding scope to adding services Once the infrastructure, community engagement and coverage with core services have been established and the programme is functioning well, additional services needed or requested by the community can be added. Periodic meetings should be scheduled to review data at every level, from community outreach workers and the staff of implementing organizations to the state/provincial level and central management. Visits by supervision staff to the field also provide qualitative information on implementation to help interpret data and find solutions. As an example, a supervision and programme review system used by a large project in India is depicted in Figure 6. Community committee meetings and regular supervision meetings between community outreach workers and their supervisors/managers are two ways in which qualitative as well as quantitative data about the programme may be gathered. This is an important part of the community empowerment process described in Chapter 1. The capacity-strengthening system needs to address the varying needs of implementing organizations to achieve comprehensive, high-quality programming for men who have sex with men. Staff capacity may be strengthened through regular classroom training, field exposure, supervision/mentoring and interactive problem-solving sessions. Ideally, training materials should be adapted or developed centrally to maintain quality of training and consistency with the minimum standards specified by the programme, and should be based on an assessment of the capacity-building needs. Staff who are not men who have sex with men: Training goals should be developed with input from the community and can include: acquainting the staff with the specifics of the project.

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