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    The course of disease was one year or less in 37 cases buy estradiol 2mg, 1-5 years in 71 cases order 2mg estradiol with amex, and more than five years in 21 cases generic 1mg estradiol amex. Sixty-one cases had enuresis on average one time per night, 43 cases had enuresis every other night, and 25 cases had enuresis three times per week. These 129 cases were randomly divided into three groups – a treatment group of 65, a comparison group #1 of 32, and a comparison group #2 also of 32. Treatment method: All members of the treatment group received scalp acupuncture at Zu Yun Gan Qu (Foot Motor Sensory Area) bilaterally. This point is located on the crown of the head one centimeter 146 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine anterior from the center on the midline. The point is three cen- timeters parallel to the midline anterior and posterior from this point. This area corresponds to the transverse line on the crown of the head found in standardized international scalp acupunc- ture. After a quick insertion below the skin, the needle was slowly moved to a depth of three centimeters transversely. The needle was stimu- lated at a rate of 200 times per minute, and this was performed every 3-5 minutes. The needles were retained for 5-10 minutes and were removed after the third time the needles were manipu- lated. This treatment was given every other day, and 10 treat- ments equaled one course. Ye Niao Dian (Enuresis Point) was needled bilaterally using a half inch, 30 gauge filiform needle. The needles were manipulated until the child felt distention and then the needles were retained for 30-45 minutes. This treatment was administered one time every other day, and 10 times equaled one course of treatment. All members of comparison group #2 were administered the fol- lowing Chinese medicinals: Sang Piao Xiao (Ootheca Mantidis) Yuan Zhi (Radix Polygalae) Shi Chang Pu (Rhizoma Acori Tatarinowii) Long Gu (Os Draconis) Fu Shen (Sclerotium Pararadicis Poriae Cocos) Ren Shen (Radix Ginseng) Dang Gui (Radix Angelicae Sinensis) vinegar mix-fried Gui Ban (Plastrum Testudinis) Three to 10 grams of each medicinal was used according to the age of the patient. One packet of these medicinals was decocted in water and administered per day, with 10 days equaling one course of treatment. Study outcomes: The following table shows the outcomes of these three groups. Chinese Research on the Treatment of Pediatric Enuresis 147 NO AMELIORATION NUMBER CURE (%) IMPROVEMENT IMPROVEMENT RATE OF CASES (%) (%) (%) Treatment 65 53 (81. From A Comparison Study & the Clinical Results of Treating Kidney Qi Insufficiency Pattern Enuresis with Moxibustion on Medicinal Cakes and Acupuncture by Jiang He-xin, Shang Hai Zhong Yi Yao Za Zhi (Shanghai Journal of Chinese Medicine & Medicinals), 1998, #5, p. These 220 patients were randomly divided into a moxibustion on medicinal cake group and an acupuncture group. The moxibustion on medicinal cake group consisted of 120 cases, 67 males and 53 females, with an average age of nine years old. The course of disease in this group ranged from four months to 10 years. The acupuncture group was comprised of 100 cases, 54 males and 46 females, with an average age of 8. The course of disease in this group ranged from five months to 11 years. Other signs and symptoms includ- ed a bright white facial complexion, devitalized essence spirit, a cold body and chilled limbs, a pale tongue with white fur, and a deep, slow, forceless pulse. Urine tests were normal in all cases, and x-ray showed no abnormalities. Children had to be more than three years old to be enrolled in this study. Treatment method: The medicinal cakes that were used on all members of the moxi- bustion on medicinal cakes group were made from unspecified amounts of: 148 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli) Rou Gui (Cortex Cinnamomi) Ding Xiang (Flos Caryophylli) These three medicinals were ground into powder.

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    For example purchase estradiol 1 mg free shipping, some infections cause hypoglycemia; • Adolescents may resist adhering to their prescribed others estradiol 1mg for sale, especially chronic infections purchase estradiol 2 mg overnight delivery, may cause hyper- treatment regimens, and effective management may be glycemia and insulin resistance and may precipitate ke- especially difficult during this developmental period. As a result, insulin requirements may vary Adolescents and young adults may delay, omit, or de- widely during illness episodes and should be based on crease dosage of insulin to fit in socially (eg, by eating blood glucose and urine ketone levels. Hypoglycemia more, sleeping in, or drinking alcohol) or to control their often develops in young children, partly because of weight. Omitting or decreasing insulin dosage may lead anorexia and smaller glycogen reserves. Also, adolescent • During illness, children are highly susceptible to dehy- females may develop eating disorders. When blood glucose values are above 250 mg/dL, diet Juvenile Diabetes Foundation International soda, unsweetened tea, and other fluids without sugar 120 Wall Street should be given. New York, NY 10005-4001 • For infants and toddlers who weigh less than 10 kg or 1-800-JDF-CURE require less than 5 units of insulin per day, a diluted in- 1-800-223-1138 sulin can be used because such small doses are hard to measure in a U-100 syringe. The most common dilution Type 2 Diabetes is U-10, and a diluent is available from insulin manu- facturers. Vials of diluted insulin should be clearly la- Type 2 diabetes is being increasingly identified in children. This trend is attributed mainly to obesity and inadequate ex- • Rotation of injection sites is important in infants and ercise because most children with type 2 are seriously over- young children because of the relatively small areas weight and have poor eating habits. In addition, most are 402 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM members of high-risk ethnic groups (eg, African American, Oral drugs. Sulfonylureas and their metabolites are ex- Native American, or Hispanic) and have relatives with dia- creted mainly by the kidneys; renal impairment may lead betes. These children are at high risk for development of seri- to accumulation and hypoglycemia. They should be used ous complications during early adulthood, such as myocardial cautiously, with close monitoring of renal function, in infarction during their fourth decade. Management involves clients with mild to moderate renal impairment, and are exercise, weight loss, and a more healthful diet. Alpha- glucosidase inhibitors are excreted by the kidneys and accumulate in clients with renal impairment. However, Use in Older Adults dosage reduction is not helpful because the drugs act locally, within the GI tract. Metformin requires assess- General precautions for safe and effective use of antidiabetic ment of renal function before starting and at least annu- drugs apply to older adults, including close monitoring of ally during long-term therapy. In addition, older adults may have im- initially if renal impairment is present; it should be paired vision or other problems that decrease their ability to stopped if renal impairment occurs during treatment. They but increments should be made cautiously in clients with also may have other disorders and may take other drugs that renal impairment or renal failure requiring hemodialysis. For example, renal insuf- ficiency may increase risks of adverse effects with antidiabetic drugs; treatment with thiazide diuretics, corticosteroids, estro- Use in Hepatic Impairment gens, and other drugs may cause hyperglycemia, thereby in- creasing dosage requirements for antidiabetic drugs. There may be higher blood levels of insulin in With oral sulfonylureas, drugs with a short duration of ac- clients with hepatic impairment because less insulin tion and inactive metabolites are considered safer, especially may be degraded. Careful monitoring of blood glucose with impaired liver or kidney function. Therapy usually should levels and insulin dosage reductions may be needed to start with a low dose, which is then increased or decreased prevent hypoglycemia. Sulfonylureas should be used cautiously and Few guidelines have been developed for the use of newer liver function should be monitored. Insulin analogs appear to lized in the liver and hepatic impairment may result in have some advantages over conventional insulin. Acarbose, higher serum drug levels and inadequate release of he- miglitol, and metformin may not be as useful in older adults patic glucose in response to hypoglycemia.

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    These drugs should not be used in clients with se- and may depress muscle strength cheap 1mg estradiol overnight delivery, muscle tone quality 1 mg estradiol, and root- vere cardiovascular disease or hyperthyroidism cheap estradiol 2mg visa. If excessive amounts are used (eg, in paracervi- rine should be no greater than 1:200,000 because of cal block), local anesthetics may cause fetal bradycar- the danger of producing vasoconstriction in uterine dia, increased movement, and expulsion of meconium blood vessels. Such vasoconstriction may cause de- before birth and marked depression after birth. Dosage creased placental circulation, decreased intensity of used for spinal anesthesia during labor is too small to uterine contractions, and prolonged labor. For spinal or epidural anesthesia, use only local anes- thetic solutions that have been specifically prepared for spinal anesthesia and are in single-dose containers. Topical Anesthesia Multiple-dose containers are not used because of the of Mucous Membranes risk of injecting contaminated solutions. Epinephrine is often added to local anesthetic solutions When used to anesthetize nasal, oral, pharyngeal, laryngeal, to prolong anesthetic effects. Such solutions require tracheal, bronchial, or urethral mucosa, local anesthetics special safety precautions, such as the following: should be given in the lowest effective dosage. This combination of drugs should not be used for well absorbed through mucous membranes and may cause nerve blocks in areas supplied by end arteries (fin- systemic adverse reactions. CLIENT TEACHING GUIDELINES Perioperative Medications ✔ When anticipating a surgical procedure and a general ✔ With preanesthetic, sedative-type medications, stay in anesthetic, be sure to inform health care providers about bed with the siderails up and use the call light if help is any herbal or other dietary supplements you take. You may fall or otherwise injure yourself if you American Society of Anesthesiologists recommends that get out of bed without assistance. Most of the com- alert from general anesthesia, sedation, or pain med- monly used herbal products (eg, echinacea, ephedra, fever- ication. Because few studies and little testing you will receive pain medication by injection (often intra- have been done, some products have unknown effects venously) for 2 or 3 days, then by mouth. CHAPTER 14 ANESTHETICS 229 CLIENT TEACHING GUIDELINES Topical Anesthetics ✔ Use the drug preparation only on the part of the body for ✔ With spray preparations, do not inhale vapors, spray near which it was prescribed. If the condition for which it is being used persists, report ✔ Use the drug only for the condition for which it was pre- the condition to the physician. For example, a local anesthetic prescribed to re- ✔ Inform dentists or other physicians if allergic to any local lieve itching may aggravate an open wound. Allergic reactions are rare, but if they ✔ Apply local anesthetics to clean areas. For the drugs to have occurred, another type of local anesthetic can usu- be effective, they must have direct contact with the af- ally be substituted safely. Use in Children Adverse effects include respiratory depression, hypo- tension, and pain with injection. Slow titration of dosage, Compared with adults, children are at greater risk of compli- a large-bore IV catheter, adding lidocaine, and slow cations (eg, laryngospasm, bronchospasm, aspiration) and drug injection into a rapidly flowing IV can minimize death from anesthesia. In addition, the formulation now contains to children should be knowledgeable about anesthetics and an antimicrobial agent, which should reduce risks of their effects in children. In general, infants and children have a higher anes- require anesthesia or sedation must be skilled in using the thetic requirement, relative to size and weight, than nursing process with children. Some agencies allow parents to be present during in- chodilation and does not irritate respiratory mucosa, duction of general anesthesia. This seems to reduce features that make it especially useful for children with anxiety for both parents and children. However, the drug dilates blood vessels in the of surgery and anesthesia, contraindications to a par- brain and increases intracranial pressure, so it may not ticular agent, the presence of client conditions that af- be indicated in clients who already have increased fect or preclude use of a particular drug, and the intracranial pressure or mass lesions. For short surgical also sensitize the myocardium to epinephrine, although procedures, intermediate-acting nondepolarizing agents children are less likely than adults to have ventricular (eg, atracurium, mivacurium) are commonly used. Sevoflurane, a newer agent, may have some advan- contraindicated for routine, elective surgery in children tages over halothane in pediatric anesthesia. This precaution stems from reports of a faster induction and emergence, does not stimulate several deaths associated with the use of succinylcholine the sympathetic nervous system or potentiate cardiac in children with previously undiagnosed skeletal mus- dysrhythmias, and produces a minimal increase in in- cle myopathy.

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    Unfortunately trusted estradiol 2 mg, the economic implications of both short- and long-term infrastructure investments under- mine these efforts discount estradiol 2mg without prescription. Working in an environment that embraces short-term financial gain (in the form of either the quarterly report to stockholders or the report to the chairman of the board) proven estradiol 2mg, physicians and hospital admin- istrators often face an outright disincentive to invest in an infrastructure that will improve compliance with best practices (Leatherman et al. Those same economic incentives may be effective in addressing vari- ation in healthcare by awarding financial bonuses to physicians and admin- istrators who meet quality targets or withholding bonuses from those who do not. This economic wake-up call makes it clear that future success within an organization is dependent on participating in quality improvement efforts, reducing undesirable variation in processes of care, and encourag- ing an environment conducive to quality research and improvement. The threshold for quality parameters is to meet or exceed 25 percent of the overall group performance from the previous year. Quality performance money is awarded at the group level, with 10 percent of the total performance fund pool awarded to the group staff (Ballard 2003). Case Study For the period of care from September 1999 to September 2002, BHCS measured its pneumococcal vaccine screening and administration per- formance for patients hospitalized with community-acquired pneumonia. At the Baylor-Irving Hospital, only 2 of 51 patients (4 percent) had med- ical record documentation that they received these processes of care, sub- stantially below the goal of 90 percent specified by the BHCS Best Care V ariation in Medical Practice and Implications for Quality 53 Committee (Ballard 2003). Initial assessments of this suboptimal per- formance showed superficial or incomplete medical history, lack of com- mitment to the screening process, and difficulty in obtaining accurate information from the admission source (e. Irving began a number of process improvement efforts designed to increase screening and vaccination rates, including improved physician and nurse education, improved history and immunization record assessment, and improved liaison with nursing homes. Screening levels improved sub- stantially, but the immunization rate did not. The hospital staff next iden- tified a physician champion and began developing a protocol and physician order set (a group of orders that relate to a specific health condition) that specifically included the pneumococcal vaccine. This proved time inten- sive, taking some ten months to approve and implement, and the delay hin- dered the rollout sufficiently to undermine its overall success. Physicians and nurses also disliked the presence of an additional step in the order process. Consequently, immunization rates improved somewhat but then dropped because of physician and nurse resistance to use of the order set. Additional physician-related interventions included multiple chart-based reminders and computer-generated forms that ordered vaccination prior to discharge. Despite these efforts, vaccination rates improved little, as the vaccination order was often overlooked or the patient was unwilling to delay hospital departure to await the vaccine. Although there has been some fluctuation, this action led to the sustained improvement of vac- cination rates at Irving. The screening and vaccination rate at Irving rose from 4 percent in January 2000 to 91 percent in June 2003. Although gaps in the data during 1999, 2000, and 2001 exist, a large jump in screening and vac- cination percentages occurred, from single digits to figures ranging from 70 percent to 100 percent. Applying a run chart for the period from June 2001 to June 2003 shows fewer than seven data points on one side of the 54 The Healthcare Quality Book weighted average, so Figure 3. This assignable variation tells us that the screening and vaccination protocols Irving implemented resulted in real improvements at one hos- pital. The difference in the rates at Irving and at other BHCS hospitals suggests that Irving is doing something different from the remaining BHCS hospitals, although this conclusion is largely intuitive and does not necessarily exclude random variation in accounting for this difference. Over time, these improvements can be measured to determine their broader success. Conclusion Contemporary industrial and commercial methods to improve quality, such as Six Sigma and ISO 9000, emphasize the need to minimize variation, if not eliminate it altogether. While certainly appropriate in a setting that requires the repetitive manufacturing of mass quantities of identical prod- ucts, these tools may unnecessarily mask variation in the healthcare envi- ronment and consequently obscure opportunities to change or improve essential processes of care. The keys to successful management—rather than elimination—of variation in pursuit of quality healthcare are to be able to 100 L L L L L NL NL L L L L L L L L L L L L L L L L L L L L L L FIGURE 3. V ariation in Medical Practice and Implications for Quality 57 FIGURE 3. Ultimately, variation tells us what is working and what is not and how far from optimal our healthcare processes really are.

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