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Catherine Johnson, PhD, FNP-BC, PNP-BC

• Chair of Advanced Practice, School of Nursing, Duquesne University, Pittsburgh, Pennsylvania

https://pure.hud.ac.uk/en/persons/catherine-johnson

Reclaimed water can recharge an aquifer and be recovered as a potable water supply gastritis bile reflux diet purchase 250 mg clarithromycin, which is regulated by the Department of Health gastritis ginger order 250 mg clarithromycin otc. Significant coordination is needed to assure public health and environmental protection without redundancy gastritis diet mercola generic 250 mg clarithromycin. Increasing the use of reclaimed water could address this issue and assist with meeting existing and expected water demands gastritis diet in spanish cheap clarithromycin 500 mg buy online. King County is constructing a new wastewater treatment facility designed to produce Class A reclaimed water using a membrane bioreactor (King County Reclaimed Water Division). As part of the process to expand the reclaimed water program, a study was conducted to identify potential users for reclaimed water. End uses including industry, landscape irrigation, ecological enhancement, plant nursery, and truck farm irrigation were identified. Prior research and regulations in Washington State have established the safety and efficacy of reclaimed water for these end uses. In Washington, reclaimed water is regulated according to the Reclaimed Water Reuse Act of 1992, and is monitored by the Washington State Departments of Ecology and Health. Treatment requirements are dictated by the required effluent quality which is designated by the Class of reclaimed water, ranging from A­D, with A requiring the most stringent level of treatment and D requiring the least (Stensel, 2006). However, to both gain customer confidence and illustrate that local soil and reclaimed water characteristics are suitable for the end uses identified, King County partnered with the University of Washington to conduct research on the safety and efficacy of Class A reclaimed water. Here, the public concerns have bene centered on pathogens, potential for heavy metal accumulation, and changes in flavor as a result of using reclaimed water. Reclaimed Water for Edible Crops the University of Washington conducted both a greenhouse study (Figure 1) and a field trial to demonstrate the low potential for pathogen transfer (as indicated by presence of bacteria indicator species) and metal uptake from reclaimed water to garden vegetables. Lettuce, carrots and strawberries were included in the study, as each of these are commonly grown by local farmers and each presents potential risk pathways to test the contaminants of concern. Figure 1 Greenhouse trial of Class A reclaimed water (Photo credit: Dana Devin Clarke) Lettuce is known for high uptake of heavy metals and has been used as an indicator crop for metal availability (Brown et al. The edible portion of carrots is grown directly in soil and so may be more susceptible to pathogen contamination. Strawberries are often consumed without washing, also making them likely candidates for pathogen transfer. Case Studies During the greenhouse and field studies, reclaimed water source samples were collected weekly; crop and soil samples were collected at the end of the study when plants were ready for harvest. Soils, water samples and washed and unwashed edible portions of plant tissue were analyzed for bacterial indicators (total coliforms, fecal coliforms, and E. Bacteria tests were either negative or below the regulatory limit of 2 cfu/100 mL. In general, metal uptake for plants grown using reclaimed water was similar to that for those grown with tap water. Public Outreach Results of both studies reflect the quality of the source water, with respect to bacterial indicators and metal concentrations. It could be argued that these studies were superfluous based on the analysis of the reclaimed water. However, public perception and understanding of reclaimed water is an essential component in the development of a beneficial use program. The first luncheon was limited to staff within the King County Wastewater Treatment division and featured presentations on the edible crops and ornamental plant research. Guests were served a main course and desert that included crops from the greenhouse study (Figure 3). Brown presenting study data at luncheon (Photo credit: Jo Sullivan) Figure 2 Metal concentrations in lettuce from field trial In the greenhouse study, there were also no differences in bacterial indicators between the tap water irrigated crops or the reclaimed water irrigated crops for both washed and unwashed samples. Total coliforms were the only bacteria detected and they were only detected in the tap water control. In the field trial, total coliform counts were higher for all vegetables grown using reclaimed water in comparison to the tap water. This was likely due to increased contact with soil and coliform bacteria in the soil.

Recommendation no more likely to be opposed [in a European opposition proceeding] than other patents gastritis symptoms wiki 250 mg clarithromycin sale, other things being equal gastritis sweating discount clarithromycin 500 mg with mastercard. Kunin 7/10 at 133 (foreign experience revealed pre-grant opposition as "a form of applicant harassment") gastritis diet 911 cheap clarithromycin 500 mg visa. Post-grant review offers greater value to challengers and a more thorough probing of the issues than inter partes reexamination gastritis diet ������ buy generic clarithromycin 500 mg on line, with less opportunity for delay and harassment than pre-grant opposition. Similarly, the Federal Trade Commission conducts certain adjudicatory proceedings under a time schedule specified by regulation. Commentators have expressed uncertainty as to whether existing examination/reexamination procedures would constitute the "relatively formal administrative procedure[s]" that would trigger Chevron deference under Mead. Duffy 7/10 at 123 (cautioning that judicial "tweak[ing]" of deference standard may not greatly affect Federal Circuit practices). Considerable testimony indicated that with the advent of the Federal Circuit, patents typically have become easier to get, but more difficult to infringe, i. The studies also revealed a second relationship that may better account for any self-selection bias in the nature of cases filed: in the 1989-96 period, district court determinations of patent invalidity were reversed 23% of the time, but district court determinations of validity were reversed only 10% of the time. The data suggest that the courts, particularly at the appellate level, may have grown more willing over the years to find patents valid. One further study, focused just on appellate rulings pre- and post-formation of the Federal Circuit, again showed a higher percentage of invalidity determinations during the earlier period (56% versus 49%), but the difference was not statistically significant. In contrast, with regard to infringement, the data suggests that the Federal Circuit has not been supportive of patentees. See Myrick 3/19 at 46 (stating that in 2000 "[p]atent owners won only 12 decisions in the literal infringement area, while accused infringers won 47" and that under the doctrine of equivalents "patentees won five, while accused infringers won 44), citing Paul M. Levin 2/6 at 102-03 (discussing obviousness); Duffy 7/10 at 184 (discussing written description and doctrine of equivalents); Taylor 7/11 at 137 (discussing written description); American Bar Association Section of Intellectual Property Law, Statement of Robert P. Taylor on Behalf of Section of Intellectual Property Law American Bar Association on Competition and Intellectual Property Law and Policy In the Knowledge-Based Economy (7/11/02) 8 (discussing written description), at. Thus, with regard to validity, data showed that 54% of final, published district court and appellate decisions during the 1989-96 period found patents valid, compared to only about 42% and 34%, at the district court and court of appeals levels, respectively, during the 1953- 179 25 overall picture cannot simply be portrayed as pro-patent. The evidentiary burdens that govern this process are the focus of the next section. Presumption of Validity/Clear and Convincing Evidence the Hearings focused attention on the significance attached in litigation to the issuance of a patent. First, the Patent Act creates a presumption of validity applicable when a patent is challenged in federal court: "A patent shall be presumed valid. Panelists generally attributed the clear and convincing evidence standard to the Federal Circuit. Duffy, Nonobviousness: the Economics and Legal Process of the Doctrine (7/10/02) (slides) at 17, at. Some called for eliminating the presumption of validity, 192 at least in cases involving new, material prior art. Ellis 7/11 at 119-20; see also Sung 2/8 (Patent Session) at 141-42 (noting possible in terrorem effect of presumption of validity and clear and convincing evidence standard against challenging invalid patents). Ellis 7/11 at 118-19; Kirschner 2/26 at 289-90; Weinstein 2/27 at 533; Kesan 10/25 at 146; cf. Langenfeld 2/20 at 17 (deference to issued patents presumes high accuracy in examination process); Linck 4/9 at 67-68 (time pressures limit what practicably can be expected from examinations). One panelist suggested that the presumption might be retained, but with a delayed effective date. Dickinson 10/25 at 91 (analogizing to incontestability of certain trademarks after five years). But see Kushan 10/25 at 143 (unfair to withhold presumption of validity from a patent whose validity was never even questioned). To the extent that the clear and convincing evidence standard distorts the litigation process, as some of the panelists indicate, it is a matter for particular concern. Litigation is a mechanism for focusing enhanced attention on those patents that are most likely to hold commercial significance and for weeding out from this group those patents that should not have been granted.

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For many people gastritis diet ppt generic clarithromycin 500 mg, the mental image that forms when they hear they have been assigned to a group features some of their worst experiences or a quick Chapter 18 Group Presentations Task roles emphasizing organization focus on script development-cohesive language gastritis emedicine 500 mg clarithromycin purchase with mastercard, transitions gastritis with erosion 250 mg clarithromycin visa, and consistent graphics gastritis diet ���������� clarithromycin 250 mg order free shipping. Therefore, the group must plan on how they will identify and close gaps in content and support material. Finally, task roles at the level of delivery necessitates that the group communicate about assumptions, such as every individual is familiar with presentation software like PowerPoint or every individual is a regular user of the videosharing website YouTube. Other logistical challenges associated with delivery include planning the introduction of the group, where to stand, and equipment set up. Relationships within a group must be built and maintained simply because they are composed of individuals with different personalities, work styles, expertise, and availability. Your job as a group is to determine the best communication strategies for this speaking group. The strategies should support and enhance learning about and working with the differences. Although time restraints may limit the sophistication and quantity of your strategies, a communication plan for interaction roles should not be skipped. The best place to start is by selecting a group leader with the most appropriate leadership style to help the group maintain credibility within the group, among the audience, in the assignment and its assessment, and during the delivery. Thus, all group members should be aware of three small-group leadership styles - highly directive, participatory, and negligent (Brilhart, Galanes & Adams, 2001). A highly directive leadership style is where a leader uses an authoritarian method of dealing with group members. The participatory leadership style centers around a designated leader who offers guidance, suggestions, listening, and concern for members while also showing concern for completing the task. A negligent (or laissez-faire) leadership style is characterized by a leader who offers little guidance or direction. The group leader may guide the communication planning by first initiating a conversation about what communication media are accessible to group members. Some group members may not have access to a smartphone, text capability or all social networking sites such as Twitter, LinkedIn, and Facebook; and may not have consistent access to email or the Internet. For example, it is not uncommon for a student in a class to have Internet access only during open lab or library hours. Finally, keep in mind that some individual schedules or userstyles do not allow them to check email at the same daily frequency or dictate the same response style. All members should be careful not to criticize, judge or insult nonusers, limited users, and even overusers of technology. The gathering of contact information may be accomplished within the context of this conversation. The group leader can facilitate communication about member experience in the areas of presentation planning, organization, and delivery (see Table 18. Keep the focus on yourself by asking: What is my knowledge related to the specific assignment? Clearly think about: What degree of confidence do I need to develop about my own abilities? When you think about group coordination, decision-making is primarily about setting protocols-mutually agreed upon ways of interacting. As a group be very clear about how you will procedurally make decisions within this speaking group; and how the group will make decisions that require assimilating large amounts of information, exploring different ideas, Delivery techniques to be appropriate for the different stages of group presentations. Further, you will need to maintain ethical relationship boundaries with group members as appropriate to your interaction roles. Kelley (1992) suggests individuals be "skilled followers" who engage in two critical activities: (1) they are independent and critical thinkers, and (2) they actively engage in the work, rather than waiting to be told what to do. You can contribute best by being aware of and monitoring your strengths and weakness and the effect they have on group members. You will always have to apply and modify your individual knowledge, skills, and Yes/No & Either/Or: Most Common Types of Decisions Focus on whether a group should do something or not: Should we have handouts? Deciding between options: Should we use this inductive argument or that deductive argument? Should we use an operational definition or a logical definition to define this concept? Decisions put on hold until after certain decisions are met: Should we wait to determine visual aids until after we decide on how much technical language we use?

Physicians are typically paid through fee-for-service methods and hospitals through billed (discounted) charges chronic gastritis gallbladder discount 500 mg clarithromycin overnight delivery, per diem or per case gastritis symptoms diarrhoea clarithromycin 500 mg for sale. Some surveys suggest that capitation may be increasing for physicians (Kane et al gastritis gurgling stomach discount 500 mg clarithromycin free shipping. The use of capitation for hospitals may also be declining in favor of per diem gastritis pepto bismol order 500 mg clarithromycin with mastercard, perhaps influenced by reductions in length of stay so that health plans prefer to "rent beds" on as as-needed basis (Rauber, 1999). It is important to note, however, that most providers receive payment from a variety of payers that may rely on different methods. Therefore, any given provider faces a mix of incentives and rewards, rather than a consistent set of expectations. This mix has a significant influence on how payment methods can inhibit quality improvement, as discussed in the following section. Information on the privately insured obtained from the Household Survey was used to contact insurers/health plans and obtain information on characteristics of the health insurance products they offer. Insurers and health plans were asked to report the typical method of payment used for each type of service for each product. These responses were then matched to Household Survey respondents to describe their insurance coverage. Estimates are enrollee-weighted, representing all people under age 65 with private insurance. For beneficiaries enrolled in Medicare+Choice, health plans are paid on a capitated basis. First, quality-related problems can result in waste, such as when a step in the care process fails so that treatment must be repeated. Second, quality-related problems can lead to inefficiencies, as when two processes can produce the same outcome, but the more costly alternative is selected. An additional issue is that some processes may produce superior outcomes but utilize more resources, therefore resulting in cost increases. In an environment that evaluates costs but not results, Anderson and Daigh (1991) suggest that quality waste accounts for 25­40 percent of all hospital costs. In fact, there are cases in which significant financial losses have resulted in the elimination of quality projects rather than the intensification of such efforts (Shulkin, 2000). Indeed, a variety of barriers embodied in current payment methods prevent health care organizations from pursuing quality improvement. The following subsections describe examples of four such payment barriers: perverse payment methods, adverse risk selection, annual contracting arrangements, and up-front investments required by provider groups. Brent James of the Intermountain Health System, Salt Lake City, Utah: 2Much of the discussion in this section draws on a paper prepared by Brent James, M. Data from two randomized controlled trials demonstrated that better sugar controls should translate into lower rates of retinopathy, nephropathy, peripheral neurological damage, and heart disease (The Diabetes Control and Complications Trial Research Group, 1993). Across the more than 13, 000 diabetic patients managed by the physician group, the project had the potential to generate over $10 million in net savings each year. Second, over time, as diabetic complication rates fell, the project would reduce patient visits and, thus revenues as well. The savings from avoided complications would fall to the insurer or a self-funded purchaser. In a prospective nonrandomized controlled trial using other Utah hospitals as controls, compliance with the guideline in the intervention hospitals increased from 22 to 40 percent (p < 0. The cost savings in those ten small rural hospitals totaled more than $500, 000 per year, but an analysis of net operating income showed a loss to the facilities of over $200, 000 per year. Overuse is the provision of a health care service under circumstances in which its potential for harm exceeds the possible benefit. Underuse is the failure to provide a health care service when it would have produced a favorable outcome for a patient. With misuse an appropriate service is provided, but a preventable Copyright National Academy of Sciences. Efforts to correct each of these kinds of problems are affected differently by alternative payment methods, given the theoretical incentives described in the previous section. An example is provided below of what happens at the delivery level in trying to correct each type of quality problem, along with the effects of different payment methods. An example of correcting problems of overuse is a reduction in unnecessary surgical procedures.

Highly saturated colors may also be too controversial gastritis diet forum clarithromycin 250 mg on line, triggering unpleasant associations in the mind of the guest (Carey chronic gastritis mucosa cheap clarithromycin 250 mg amex, 1986) gastritis diet meal plan clarithromycin 500 mg with visa. The wall the patient faces may serve as a different colored end wall to add interest and color change to the room gastritis diet ������� clarithromycin 500 mg buy line. For reasons of refinement, and because strong colors may be unduly unsettling or grow monotonous to a patient confined for a long term, caution must be exercised in purity of color. The need to consider psychological and physiological effects in design for the well-being of the user must be explained to the client. The balance between unity and complexity, color variety within reason, must be respected. This balance depends on the visual information rate within a space produced in majority by dominant walls, subdominant (incidental surface areas, such as end walls, also flooring and ceiling), and accent color (furnishings-including decorative items), and color contrasts. Visual ergonomics (agreeable seeing conditions) depend on the colors used and on contrast. Rules must be respected especially in the workplace, health facilities, industry, schools. Satisfying the mood or atmosphere desired depends on the specification of colors based on their psychological content (effects, impression, association, synesthetic aspects (p. An efficient tool that eliminate guesswork by bringing order to the many factors to be considered is the semantic differential chart, or polarity profile. It supports the function of a building, and the tasks that are being carried out in it. Spivack (1984) Patients in their most vulnerable phases of illness, especially the manic and the schizophrenic, may find that rooms with strong and ubiquitous colors swamp their sensory systems. In this case, bright color, because of its presence everywhere in the room, even though it is relatively weak, presents a conflict between the signal and the noise. In the case where the background stimulus is so strong as to compete with signals. I question the wisdom of a philosophy which specifies that a different color paint, any color paint, should be applied to panels and trim in a standardized way, for engineering or any other purpose. By articulating surfaces, junctures of surfaces, their positions and distances, paint and/ or wall covering color choices can clarify and simplify a chaotic environment. Color and Healthcare With yellowed lenses, blue, blue-green or violet color schemes may appear gray, especially in daylight or fluorescent light (in a blue color spectrum). Texture makes tones appear darker (Hiatt, 1981), absorbing important ambient light. A monochromatic color scheme throughout the building may be perceived as institutional. Color relationships 57 Review of the content analysis of color recommendations provides an understanding of agreement, contradiction, and conjecture among the various authors. We found general agreement in the following areas: Authors accept the hypothesis that color can influence healthcare either positively or negatively and accept the premise that color can help to make the healthcare setting appear less institutional. In some situations, high-contrast is called 58 for, and in other situations, it is not. As a result of the heavy cost of healthcare design and the pressure to support decisions with solid evidences, some aesthetic consideration in color selection processes may be compromised. Color in Healthcare Environments Conjectures and contradictions among the authors occur in the following areas: Various authors tend to develop their own series of hypotheses regarding color relationships. For example, avoid red with epilepsy and neurological diseases; red raises blood pressure; avoid strong colors for the manic and the schizophrenic; use red in therapy; use warm colors in patient rooms to build up from a "cold" illness like arthritis; use cool colors for breaking down inflammation and warm illnesses; use blue to relieve headaches, bleeding, and open wounds. Further contradictions exist in what yellow can or cannot do: yellow is noted for mood enhancing; yellow is optimistic; yellow is sometimes unsettling; yellow can intensify to the point of annoying; yellow is to be avoided because of how it makes the skin look; yellow is to be avoided because of the association with urine. Some claim that these colors give a sickly look or jaundiced skin tones, while others see value in the use of the same colors. They argue that purple/violet tones are used to dissolve or break down inflammation and yellow evokes a sense of energy and excitement and its brilliance is most often associated with the sun and that it is a stress reducer and will create feelings of inner calm. Although these outcomes are unsubstantiated in the literature, some authors claim that red has qualities of energy and passion; yellow supports optimism; green provides unconditional love; blue promotes loyalty; and violet has spirituality. Some say green is a healer of blood and prescribe green because of its associations with nature, pleasant odors Color and Healthcare 59 26 Inpatient Center Hospice of the Central Coast Monterey, California Architect: Anshen+Allen Architects & Chong Partners Architecture, 1994 and tastes; green is helpful when extended concentration and high visual acuity is needed; and green should be used with chronically ill patients because it makes them feel more at ease.

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References

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