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Editor's note: We acknowledge the concern expressed by Dr. Harris that a statement in the "Editor's Take" was interpretable as being unnecessarily pessimistic, whereas it was intended to provide a realistic caution regarding the limited application of the findings of this study.
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IDENTIFICATION OF ENDOTRACHEAL TUBE MALPOSITION USING COMPUTERIZED ANALYSIS OF BREATH SOUNDS AUTHORS: C. J. O'Connor, H. A. Mansy, R. A. Balk, R. H. Sandler; AFFILIATION: Rush Medical College, Chicago, IL. INTRODUCTION: Endotracheal tube ETT ; malpositioning may produce significant hypoxemia if placed in a bronchus or the esophagus. Current methods of correct ETT position rely primarily on detection of end-tidal CO2, but this modality may be unavailable in non-hospital emergency settings or low cardiac output states, and may not reliably detect endobronchial intubation. Auscultation of breath sounds can frequently be inaccurate. The purpose of this study is to quantify breath sounds using electronic stethoscopes placed over each hemithorax and epigastrum to detect ETT malposition. METHODS: Following Human Investigation Committee approval and informed consent, ventilation sounds were obtained in 15 healthy, nonobese subjects undergoing general surgery. While in the supine position, 2 electronic were placed at the bilateral axillary lines and a 3rd stethoscope placed over the epigastrium. Anesthesia was induced, intubation of the trachea performed with bronchoscopy, and the ETT positioned 3 cm above the carina, after which 3 tidal volume breaths of ~ 500 mL were given. Breath sounds were recorded with a digital recorder. A 2nd ETT was placed in the esophagus, the stomach emptied, the breathing circuit attached to this ETT, and a similar series of breaths given. The stomach was emptied, the ETT removed, and the tracheal ETT advanced fiberoptically into the right mainstem bronchus RMB ; . 3 breaths were administered, after which the ETT was withdrawn into the standard tracheal position. Acoustic signals were digitized and the energy in each acoustic signal was calculated as the mean squared amplitude of each sensor output. The acoustic energy ratios between the 3 positions were then calculated. Breath sound spectra were calculated using the Fast Fourier Transform for each 4096-point data segment after windowing with the Hanning window. Energy ratios for the 3 ETT locations were compared using the Wilcoxon signed-rank sum test. RESULTS: Total energy ratios accurately identified 13 15 esophageal intubations, although accuracy was poor for the RMB intubation where 10 15 were misclassified using total energy ratios. Accuracy was increased to 100% for all malpositions by using band-pass filtering during analysis of the acoustic signals p 0.001 ; Fig 1 and 2, showing epigastrium right chest E R ; and left right L R ; energy ratios, respectively ; . The 100% separation using energy ratios suggest a high sensitivity and specificity for detection of both esophageal and RMB intubation. DISCUSSION: These preliminary results suggest that this device, when incorporated into a simple 3-component electronic stethoscopetype device, may be an accurate, portable, and inexpensive mechanism to detect ETT malposition in situations where ETCO2 may be unavailable or unreliable. Further studies will determine the applicability of this device to a more diverse and heterogeneous group of patients. REFERENCES: 1 ieee eng med bio mag 16: 105-17; 1997 med bio eng comp 40: 526-32; 2002. The American Gastroenterological Association AGA ; is dedicated to the mission of advancing the science and practice of gastroenterology. Founded in 1897, the AGA is the oldest medical-specialty society in the United States. Comprised of two non-profit organizations -- the AGA and the AGA Institute -- our 14, 000 members include physicians and scientists who research, diagnose and treat disorders of the gastrointestinal tract and liver. The AGA, a 501 c6 ; organization, administers all membership and public policy activities, while the AGA Institute, a 501 c3 ; organization, runs the organization's practice, research and educational programs. On a monthly basis, the AGA Institute publishes two highly respected journals, Gastroenterology and Clinical Gastroenterology and Hematology. The organization' annual meeting is Digestive Disease Week, which is held each May and is the largest international gathering of physicians, researchers and academics in the fields of gastroenterology, hepatology, endoscopy and gastrointestinal surgery and toprol, because neurontin.
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Protein The right source of protein will help reduce a headache, while the wrong source may cause a headache. Red meats can lead to headaches through the aracadonic acid pathway due to the production of inflammatory prostaglandin's. Processed meats are sources of nitrates, sulfites, and other additives that are directly related to headaches. The best sources of protein are cold water fish, tofu, egg whites, and free range hens. Because hypoglycemia is commonly related to headaches, I have my patients eat these sources of protein three times a day to reduce glucose fluctuations. Carbohydrate Have your patients review their carbohydrate sources. Once they look at the glycemic index of various foods, they may be surprised at how much sugar they have been feeding their children. Hypoglycemia has a close relationship to headaches. You may be surprised to see that a baked potato has a glycemic index higher than that of table sugar. For a complete listing of the glycemic index and more information go to : mendosa gi . Essential Fatty Acids Fatty acids can play a major role in the development of childhood headaches. I recommend the elimination of all polyunsaturated vegetable oils, any form of trans-fatty acids margarine and partially hydrogenated vegetable oils ; from the child's diet. These substances promote the production of inflammatory prostaglandin's. Children should eat foods high in gamma-linolenic acid black current oil ; and omega-3 fatty acids salmon, oily fish, and flax oil ; . For cooking, use only use pure virgin oil. Vitamin and Mineral Deficiencies.

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The faith community plays a vital role in supporting families and nurturing the development of children, by integrating faith, access to care and health of the whole person. Health ministries, parish nurse programs, congregations and other faith-based organizations are getting actively involved in tending directly to the health concerns of their members and the large community. Faith organizations that sponsor community-based programs such as child care centers, food pantries and summer camps are becoming more attentive to the insistent problems children face. For this reason, WVCHIP finds it essential to collaborate with the faith community in an effort to educate and support families in obtaining health care coverage and promoting healthy lifestyles. In 2003-2004, WVCHIP scheduled meetings with pastors, parish nurses and lay leaders from the faith communities in Wood and Raleigh counties, two of the fifteen that have been targeted with higher numbers of uninsured children. WVCHIP used these meetings to discuss Program eligibility and solicit ideas from the faith community in reaching uninsured children in their respective congregations and counties. The following faith-based efforts were implemented in fiscal year 2004: Letters were sent to Pastors in Wood and Raleigh Counties offering assistance in promoting health and health care coverage options. A WVCHIP bulletin flyer was made available to use by all congregations in West Virginia. Workshops in two targeted counties were conducted to assist interested local congregations implement a health ministry. Created and distributed a WVCHIP Outreach Manual targeted to faith-based initiatives.

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Prevention and treatment of osteoporosis Prevention and treatment of osteoporosis consists of non-pharmacologic and pharmacologic therapy 66 ; . From prevention to treatment of established disease, the goal is to intervene as early as possible to ensure saving of bone mass and to preserve structural integrity of the skeleton, thus preventing fragility fractures. Non-pharmacologic Measures The results of large prospective RCTs, carried out over the last 10 yr, have helped guide our therapeutic options, which include non-pharmacologic approaches that should be recommended for all patients, they include: diet, exercise, and cessation of smoking. In addition, affected patients should avoid, if possible, drugs that increase bone loss, such as glucocorticoids. Since most fractures happen as a result of falls, attention to reducing the risk of falls seems important. Diet Adequate calories, calcium and vitamin D through diet or supplements, taken together, are essential adjuncts to osteoporosis prevention and treatment 10 ; . Calcium supplementation alone provides small beneficial effects on bone mineral density throughout postmenopausal life and might slightly reduce fracture rates 67 ; . A meta-analysis concluded that vitamin D reduced the risk of hip fracture by 26% and non-vertebral fracture by 23% in a dose-dependent manner in individuals with vitamin D deficiency 68 ; . However, Calcium and vitamin D should not be used as the sole treatment of osteoporosis. Macronutrients- protein, fatty acids, dietary fiber The effect of essential fatty acids or dietary fiber on BMD or fracture risk is uncertain. Protein intake may be an important component of the diet, particularly in women who already have osteoporotic fractures. Increasing protein intake among those who have inadequate dietary protein has a positive effect on the risk of hip fracture in men and women 69 ; . Diet-related lifestyle factors- coffee, tea and salt Heavy caffeine ingestion more than 4 cups coffee day ; is significantly associated with hip fracture in men and women 70 ; , but this effect is not seen with tea 12 ; . The effects of so5 and valtrex.

Dr. Patrick Antonelli has written an article in the first issue of the Clinical Practice Bulletin that explains the purpose of the Clinical Practice Committee and the content that will be in this newsletter. Although quality medical care is one of their focuses, there is much more that just quality issues inside both bulletins. Eventually, the Clinical Practice Bulletin may spin-off and become a stand-alone publication. For now, look for the insert with important information about clinical practice issues. The Drugs & Therapy Bulletin is affiliated with the Pharmacy and Therapeutics P&T ; Committee. Like the Clinical Practice Committee, the P&T Committee is a medical staff committee. The.

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By the committee for nurses to administer Vecuronium Bromide, it should be noted that it is not approved for administration by paramedics. Aminophylline was then presented in a request for approval for inter-facility transport. Dr. Baker made a motion that it be approved as requested See attached ; . The motion was seconded by Dr. Bonnin. The motion passed. Dr. Gerard abstained. Mr. Smith then presented some questions surrounding paramedic course administration. One question was who was the physician in charge of the paramedic course. Although the local medical control physicians must provide medical control for a paramedic student the course medical director should be responsible for the paramedic students during the course, especially the clinicals. Mr. Warren said that there is a written policy in the Low Country region that says the student has 10 days to get a new medical control physician if the present medical control physician withdraws support. He said that the regional medical director is the director of all courses for the region. The Committee agreed by consensus that the regional medical director is in charge of all advanced life support training activities within the region. They agreed that the regional medical director could appoint a designee, but that the regional medical director is still ultimately responsible. They agreed that the director of such a course must also have attended a medical control physician's workshop. Dr. DesChamps requested that Dr. Sorrell, Doug Warren, and Al Smith develop a proposal policy to resolve the questions and problems regarding the acceptance and rejection of students. Policies will be developed regarding the removal of a student from a course, and the conditions for acceptance into a course. Dr. Norcross suggested that the committee needs a legal opinion on personnel issues for paramedic courses for the regions. Which personnel are responsible for the students in paramedic courses? Is it the medical director who sends the EMT to the course or is it the regional medical director? Mr. Warren suggested that the state office of EMS establish a registry for Paramedics and other EMTs that contains information on the removal, reprimand or other limitations placed on an EMT as the result of misconduct, inappropriate procedures, etc. Dr. Norcross next presented the idea of allowing patients with chest tubes in place to be transported within the state. Dr. Gerard suggested that there is a need for state protocols and training for field procedures. He suggested that a short one page protocol be developed for each procedure. He suggested that protocols should be in place to provide procedures that might be necessary in situations of, for example, ibuprofen. From July of 1997 through June of 1999 Forest caused an AWP of $19.18 to be reported for Levothroid .15 mg NDC 00456-0325-01 ; . During that same period, the product was available from wholesalers for $8.65. Forest specifically marketed the product based on spread, noting it would generate a profit per unit of $8.23 based on reimbursement at AWP-12% ; , versus the profit per unit of only $0.08 for the competing product Synthroid. 466. Illinois and Kentucky allege that in 2000 the Forest Labs drug Tlazac and tobradex.
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