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Evidence in the form of opinion of lay people lowest It should be clear from these examples that there is no one ‘hierarchy of evi- dence’ that works for all research questions malegra fxt plus 160mg with mastercard. Therefore you should treat any claim that there is just ‘one hierarchy of evidence’ with some discernment cheap malegra fxt plus 160 mg overnight delivery. As suggested above purchase malegra fxt plus in united states online, it is far better if you identify your ‘own hierarchy of evi- dence’ (Aveyard 2010) buy malegra fxt plus 160mg lowest price, according to what evidence you need to address your own situation or problem. Secondary sources are those that report the fndings of other people’s work without giving full details of the work they discuss. A secondary source is a source that does not report the data from a primary research study directly but it might refer to the study without giving full details. A secondary source is therefore a step removed from the ideas you are referring to. You may see it written as: Author A (2009) cited in Author B (2010) 82 What are the different types of research? Let’s say that the author (Author B) of a paper you are reading cites the work of a well-known author (Author A) who has done a lot of work in the area. If you refer to the work of Author A without accessing the original work, you are using a secondary source. You are relying on the interpretation of Author B to inform you about the work of Author A. You can see that this could lead to a case of ‘Chinese whispers’ and this is why it should be avoided. Unless you read the original work by Author A directly, you are relying on Author B’s interpretation of this work. This means that you cannot comment on the way it is represented, the full context or upon the strengths and limitations of the original work. Access this example of the pitfalls of using secondary sources without access- ing the primary source (Bradshaw and Price 2006). Ideally, these guidelines and policies are developed from the best available evidence. They should be written in a user-friendly way so that you can apply the evidence easily in your professional setting. There are some useful websites for national guidance and policy available at http://www. They do not replace current guidance and do not provide formal practice recommendations. It claims to be a high-level over- view to be used by professionals that can be shared with patients (http:// healthguides. There are also clinical and professional guidelines specifc to individual profes- sions and sometimes specifc disorders. It is also worth accessing societies, colleges and organizations specifc to your pro- fession or specialty. You might also fnd that research evidence is integrated into other user- friendly publications. This means that you do not always have to fnd the ‘raw’ data from the research but instead you fnd publications which have 84 What are the different types of research? Examples of such publications are: • Government or professional organizations’ policy, reports, guidance or standards • National Institute for Health and Clinical Excellence Guidelines which are compiled with close reference to Cochrane and Campbell Collaboration reviews • Care pathways or protocols • Results from audits • Reports from international, national or local organizations • Information from trusted websites • Patient/client information leafets. As with other forms of evidence it is important that these forms of evidence are evaluated – this is explored further in Chapter 6. This may be in situations where you are unable to identify a focussed question you can ‘ask of the literature’. This may be where there is complexity, circumstances or context that are individual to the particular patient/client or situation or where you really need to decide or act in a ‘one off’ situation. In this case, you may use alternate forms of evidence (such as intuition, expert opinion, refective judgement or discussion papers and so on) to address the question you seek to answer at that moment. In this case, it is especially important that you assess the quality of the evidence that you have as we will discuss in Chapter 6. When you use non-research evidence in your assignments (if it is all that is available) or practice (because of time or complexity issues) be clear that you are aware that it is not strong evidence even if it is the best available and that you know about the limitations in the quality of evidence you are using. If you can you should at a later point fnd out if there is better quality direct or indirect research evidence that would better inform your practice next time. It is Key points 85 important that you can recognize different types of research and understand when and why different approaches are used. There is no easy formula for determining what evidence is best in any given context – you need to consider carefully the types of evidence that will meet your needs. There is no one hier- archy of evidence; we suggest you develop your own for any given situation. We will discuss how you search for and make sense of what you come across in the next two chapters. It is important that you are aware that different types of research evidence will assist you in addressing different types of ques- tions that arise in practice. Key points 1 You are likely to encounter a wide range of research and other information that is relevant to your specifc question. You may have a more specifc interest in mind which has arisen from your academic studies, or an assignment you need to write, or an issue that has arisen in practice. We have already emphasized that the evidence you search for will depend on the question you need to answer. However it is also important to refne what you need to fnd out so that you are not inundated with information. In Chapter 2 we discussed the information revolution and how as practitio- ners we are inundated with information about our practice. If you undertake searches on ‘large’ topics such as diabetes, child protection or depression you will get a very large number of results (hits) from your search and the results will seem unmanageable. You have probably found this already when under- taking search engine searches (such as Google). If you ask for information on a particular country or event, you may get thousands of hits. When you refne this to something more specifc you probably come nearer to fnding what you are looking for. Your enquiry may relate to: assessment, screening, diagnosis, prognosis, prevention, interventions, management, outcomes, cost-benefts, patient/client/service user or staff or student experience, and so on. If you are searching for information, it helps to break down the topic into an aspect of the topic. For example, ‘blood sugar level control in diabetes’ or ‘children’s reaction to child protection services’ or ‘depression in the older person’. It is important to be really clear about what you want to fnd out before you start looking in order to be more effcient with your time. This means that you seek an answer to a specifc question rather than seeking information about the entire topic. There are many approaches you can take when you are starting to defne the question. Sometimes what you need to search for is not immediately clear and it might help to think around the topic. In addition to focussing down on a specifc question, it is also useful to con- sider exactly what type of evidence will help you address your question. In Chapter 3 we discussed how different problems need different types of evi- dence and you need to be clear about what you are looking for. For example, older people in residential care, those who are homeless, mothers under 45, patients/clients who have had knee replacements, patient/clients who have accessed paramedic services for chest pain, staff who work out of hours, students who access study advice. Intervention/issue (quantitative/qualitative): These can be diagnostic, ther- apeutic, preventative, exposure, managerial, experiences, perceptions, costs and so on. Comparisons/context (quantitative/qualitative): This can be against another intervention or no intervention; comparisons can be made against national or professional standards or guidelines. The context of the study can be where the study takes place or factors that impact on an experience. Outcome: Faster, cheaper, reasons why, reduction or increase in, for example: symptoms, benefts, events, episodes, prognosis, mortality, accuracy. Time: This may or may not be relevant, for example: three days postoperative or fve hours post-intervention, within 24 hours of accessing the service. Once you have identifed what you are trying to fnd out, you need to con- sider what evidence will enable you to answer the question.

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Sterile technique during the procedure and meticulous catheter care afterward if a drain is left in place minimize this risk cheap malegra fxt plus 160mg without prescription. As the Mayo series suggests buy malegra fxt plus 160mg without a prescription, the risk of catheter-related infection is very low discount malegra fxt plus 160 mg with visa, even among cancer patients purchase malegra fxt plus with american express. This is exceptionally rare when procedures are performed by experienced operators with echocardiographic guidance. A postprocedure chest film should be obtained in all patients to exclude pneumothorax. Patients without significant comorbidities who have uncomplicated diagnostic taps do not require inpatient care following the procedure. Care of an indwelling pericardial catheter is similar to that for any central line. After the catheter is sutured in place, the site is treated with an antibacterial ointment and then dressed sterilely. Continuous drainage can also be used, but the risk of catheter obstruction is higher. If the fluid becomes purulent or the patient becomes septic, the catheter must be removed. The catheter is typically left in place for 1 to 2 days, but extended drainage has been associated with lower rates of effusion recurrence. Before pulling the drain, an echocardiogram should be obtained to ensure resolution of the effusion. Sometimes, when the drainage volume is minimal, it may be useful to clamp the catheter for few hours and observe the patient for clinical signs of tamponade. Alternatively, an echocardiogram can also be performed in order to assess for reaccumulation once the drain is clamped. Consecutive 1127 therapeutic echocardiographically guided pericardiocenteses: clinical profile, practice patterns, and outcomes spanning 21 years. Safety, efficacy, and complications of pericardiocentesis by real-time echo-monitored procedure. Pericardial effusion after cardiac surgery: risk factors, patient profiles, and contemporary management. Systematic review of percutaneous interventions for malignant pericardial effusion. Choosing Among Antibiotics Within a Class: Beta-lactams and Beta-lactamase Inhibitors, Macrolides, Aminoglycosides, and Fluoroquinolones 1 Gram-negative organisms as one goes from the frst-generation cephalosporins (cepha- lexin and cefadroxil), to the second generation (cefaclor, cefprozil, and cefuroxime) that demonstrates activity against Haemophilus infuenzae (including beta-lactamase– producing strains), to the third-generation agents (cefdinir, cefxime, cefpodoxime, and cefibuten) that have enhanced coverage of many enteric Gram-negative bacilli (Escherichia coli, Klebsiella spp). The palatability of generic versions of these products may not have the same better-tasting characteristics as the original products. A second-generation cephalosporin (cefuroxime) and the cephamycins (cefoxitin and cefotetan) provide increased activity against many Gram-negative organisms, particularly Haemophilus and E coli. Cefoxitin has, in addition, activity against approximately 80% of strains of Bacteroides fragilis and can be considered for use in place of the more active agents, like metronidazole or carbapenems, when that organism is implicated in nonseri- ous disease. Tird-generation cephalosporins (cefotaxime, cefriaxone, and cefazidime) all have enhanced potency against many enteric Gram-negative bacilli. As with all cephalosporins, at readily achievable serum concentrations, they are less active against enterococci and Listeria; only cefazidime has signifcant activity against Pseudomonas. Cefotaxime and cefriaxone have been used very successfully to treat meningitis caused by pneumococ- cus (mostly penicillin-susceptible strains), H infuenzae type b, meningococcus, and susceptible strains of E coli meningitis. Tese drugs have the greatest usefulness for treat- ing Gram-negative bacillary infections due to their safety, compared with other classes of antibiotics (including aminoglycosides). Because cefriaxone is excreted, to a large extent, via the liver, it can be used with little dosage adjustment in patients with renal failure. With a serum half-life of 4 to 7 hours, it can be given once a day for all infections, includ- ing meningitis, that are caused by susceptible organisms. Cefepime, a fourth-generation cephalosporin approved for use in children in 1999, exhibits (1) enhanced antipseudomonal activity over cefazidime; (2) the Gram-positive activity of second-generation cephalosporins; (3) better activity against Gram-negative enteric bacilli; and (4) stability against the inducible ampC beta-lactamases of Entero- bacter and Serratia (and some strains of Proteus and Citrobacter) that can hydrolyze third-generation cephalosporins. It can be used as single-drug antibiotic therapy against 2019 Nelson’s Pediatric Antimicrobial Therapy — 3 these pathogens, rather than paired with an aminoglycoside, as is commonly done with 1 third-generation cephalosporins to decrease the emergence of ampC-resistant clones. The pharmacokinetics of cef- taroline have been evaluated in all pediatric age groups, including neonates and children with cystic fbrosis; clinical studies for pediatric community-acquired pneumonia and complicated skin infection have now been published. Neither renal function nor drug levels need to be followed with cefaroline therapy. Penicillinase-Resistant Penicillins (dicloxacillin [capsules only]; nafcillin and oxacillin [parenteral only]). Nafcillin difers pharmacologically from the others in being excreted primarily by the liver rather than by the kidneys, which may explain the relative lack of nephrotoxicity compared with methicillin, which is no longer available in the United States. The combinations extend the spectrum of activity of the primary antibiotic to include many beta-lactamase–positive bacteria, including some strains of enteric Gram-negative bacilli (E coli, Klebsiella, and Entero- bacter), S aureus, and B fragilis. Cefepime, meropenem, and imipenem are relatively stable to the beta-lactamases induced while on therapy and can be used as single-agent therapy for most Pseudomonas infections, but resistance may still develop to these agents based on other mechanisms of resistance. For Pseudomonas infections in compromised hosts or in life-threatening infections, these drugs, too, should be used in combination with an aminoglycoside or a second active agent. The benefts of the additional antibiotic should be weighed against the potential for additional toxicity and alteration of host fora. Aminopenicillins (amoxicillin and amoxicillin/clavulanate [oral formulations only, in the United States], ampicillin [oral and parenteral], and ampicillin/sulbactam [parenteral only]). Amoxicillin is very well absorbed, good tasting, and associated with very few side efects. Amoxicillin/clavulanate has undergone many changes in formulation since its introduction. The ratio of amoxicillin to clavulanate was originally 4:1, based on susceptibility data of pneumococcus and Haemophilus during the 1970s. With the emergence of penicillin-resistant pneumococcus, recommendations for increasing the dosage of amoxicillin, particularly for upper respiratory tract infections, were made. However, if one increases the dosage of clavulanate even slightly, the incidence of diarrhea increases dramatically. If one keeps the dosage of clavulanate constant while increasing the dosage of amoxicillin, one can treat the relatively resistant pneumococci while not increasing gastrointestinal side efects of the combination. The original 4:1 ratio is present in suspensions containing 125-mg and 250-mg amoxicillin/5 mL and the 125-mg and 250-mg chewable tablets. A higher 7:1 ratio is present in the suspensions containing 200-mg and 400-mg amoxicillin/5 mL and in the 200-mg and 400-mg chewable tablets. The high serum and middle ear fuid concentrations achieved with 45 mg/kg/dose, combined with the long middle ear fuid half-life (4–6 hours) of amoxicillin, allow for a therapeutic antibiotic exposure to pathogens in the middle ear with a twice-daily regimen. However, the prolonged half-life in the middle ear fuid is not necessarily found in other infection sites (eg, skin, lung tissue, joint tissue), for which dosing of amoxicillin and Augmentin should continue to be 3 times daily for most susceptible pathogens. For older children who can swallow tablets, the amoxicillin to clavulanate ratios are as follows: 500-mg tablet (4:1); 875-mg tablet (7:1); 1,000-mg tablet (16:1). At present, we recommend them for treatment of infections caused by bacteria resistant to standard therapy or for mixed infections involving aerobes and anaerobes. Meropenem was not associated with an increased rate of seizures, compared with cefotaxime in children with meningitis. Imipenem and meropenem are active against virtually all coliform bacilli, including cefotaxime-resistant (extended spectrum beta-lactamase–producing or ampC-producing) strains, against Pseudomonas aeruginosa (including most cefazidime- resistant strains), and against anaerobes, including B fragilis. While ertapenem lacks the excellent activity against P aeruginosa of the other carbapenems, it has the advantage of a prolonged serum half-life, which allows for once-daily dosing in adults and children aged 13 years and older and twice-daily dosing in younger children. Newly emergent strains of Klebsiella pneumoniae contain K pneumoniae carbapenemases that degrade and inactivate all the carbapenems. Tese strains, as well as strains carrying the less common New Delhi metallo-beta-lactamase, which is also active against carbapenems, have begun to spread to many parts of the world, reinforcing the need to keep track of your local antibiotic susceptibility patterns. As a class, these drugs achieve greater concentrations intracellularly than in serum, particularly with azithromycin and clarithromycin. Gastrointestinal intolerance to erythromycin is caused by the breakdown products of the macrolide ring structure. Azithromycin, clarithromycin, and telithromycin extend the clinically relevant activity of erythromycin to include Haemophilus; azithro- mycin and clarithromycin also have substantial activity against certain mycobacteria. Azithromycin is also active in vitro and efective against many enteric Gram-negative pathogens, including Salmonella and Shigella. Aminoglycosides Although 5 aminoglycoside antibiotics are available in the United States, only 3 are widely used for systemic therapy of aerobic Gram-negative infections and for synergy 6 — Chapter 1.

After his first failure order generic malegra fxt plus canada, the fear of a repeated performance may make him impotent not only in extramarital relations but also in marital relations discount malegra fxt plus express. Young men order discount malegra fxt plus on-line, whether married or unmarried cheap generic malegra fxt plus canada, may “fall into impotence” quite by accident because of alcoholic intoxication. As Shakespeare correctly surmised, “alcohol provokes the desire, but it takes away the performance. When sober once more, he may begin a pattern of failure to get an erection simply because of the fear that it will happen again and he will be embarrassed beyond belief. Some other supratentorial causes of impotence are endogenous: depression, schizophrenia, latent homosexuality, repressed hostility toward the partner, and fear of pregnancy. It is important to note that all of the above psychologic causes may occur in the female patient as well as the male. A careful examination of the external genitalia, the prostate, and secondary sex characteristics is essential. The laboratory workup may include a glucose tolerance test, blood testosterone, free testosterone, serum prolactin and cortisol levels, thyroid function studies, a spinal tap, a skull x-ray, and a chromosomal analysis. If the physical examination is normal, it may be wise to administer psychometric tests or to refer the patient to a psychiatrist before doing an extensive endocrine and neurologic workup. A sympathetic physician may be able to find the supratentorial cause and cure it with a few long discussions with the patient. Case Presentation #54 A 56-year-old diabetic man complained of increasing erectile dysfunction. Physical examination revealed diminished dorsalis pedis and tibialis pulses in both lower extremities. Given your knowledge of anatomy and physiology, what is your differential diagnosis? His examination discloses diminished femoral pulses and bruits over the femoral arteries and abdominal aorta. The pathway of voluntary control of this function begins in the cerebrum and travels through the brain stem, spinal cord, and nerve roots, to the “end organ,” which is the rectal sphincter. Cerebrum: This should help recall the incontinence of Alzheimer disease, normal pressure hydrocephalus, and other causes of organic brain syndrome. It will also prompt the recall of the incontinence in functional psychosis and epilepsy. Brainstem and spinal cord: This would bring to mind trauma, multiple sclerosis, transverse myelitis, syringomyelia, and brainstem and spinal cord tumors in which there is loss of voluntary control due to pyramidal tract damage. Nerve roots: This should prompt the recall of cauda equina tumors, tabes dorsales, and spinal stenosis. Rectal sphincter: Primary rectal sphincter incompetence leads to the release of small amounts of stool associated with anal fissures, hemorrhoids, and postoperative incontinence following a fistulectomy or episiotomy. Approach to the Diagnosis 519 Before beginning an expensive diagnostic workup, pay attention to the history and physical examination. If the incontinence is sporadic, look for organic brain syndrome, epilepsy, or functional psychosis. If the neurologic examination reveals pathologic or hyperactive reflexes in the lower extremities, consider a spinal cord or brain stem lesion. If there are hypoactive reflexes in the lower extremities, consider the possibility of cauda equina tumor or tabes dorsalis. Anorectal manometry and defecography will assist in the diagnosis of anal and rectal sphincter dysfunction. Stress incontinence occurs on coughing or straining and is due to damage to the urethra or pelvic floor from pregnancy and delivery. Loss of voluntary control: The neurologic causes include multiple sclerosis, normal pressure hydrocephalus, neurosyphilis, syringomyelia, encephalitis, cerebral arteriosclerosis, frontal lobe tumors and abscesses, senile dementia, and transverse myelitis from trauma or infection. The local causes are a cystocele (often following a hysterectomy) and a damaged urethral sphincter from prostatectomy. Bladder neck obstruction: Benign prostatic hypertrophy, chronic prostatitis, prostate carcinoma, median bar hypertrophy, vesical calculus, and urethral stricture are important mechanical causes of obstruction. Flaccid neurogenic bladder: Drugs such as atropine, 520 tranquilizers, and anesthetics and diseases of the cauda equina and nervi erigentes such as diabetic neuropathy, poliomyelitis, tabes dorsalis, and cauda equina tumors will cause a flaccid neurogenic bladder with overflow incontinence. Catheterization and examination, smear, and culture of the urine are essential at the outset. Surgical repair of a cystocele or a parasympathomimetic drug in cases of a flaccid neurogenic bladder and oxybutynin (Ditropan) for spastic neurogenic bladders may be all that is necessary. A neurologist and urologist often need to cooperate in the diagnosis and treatment of these unfortunate individuals. Transrectal ultrasound (benign prostatic hyperplasia) Case Presentation #55 A 48-year-old white woman is brought to your office by her daughter who complains that she is getting forgetful and frequently wets herself. She denies that her mother abuses drugs but admits she consumes a moderate amount of alcohol and falls occasionally. The causes are easy to arrive at by merely asking the question, “Why would food cause these symptoms? Air swallowing from nerves is a frequent cause of belching, especially in talkative individuals. Chronic appendicitis and regional ileitis may cause partial obstruction or paralytic ileus. Yes, the application of the “target” method to the anatomy of the internal organs. Approach to the Diagnosis The association of other symptoms and signs is important. If there is relief by antacids, esophagitis, gastritis, or an ulcer may be present. Awareness that a systemic disease such as an electrolyte disturbance or uremia may be the cause will suggest the need for other studies, especially if there are systemic symptoms, fever, or shortness of breath. Lactose tolerance test Case Presentation #56 A 55-year-old obese black mother of five complained of indigestion that she described as a fullness in the stomach and belching following meals. She denies abuse of alcohol or drugs but takes occasional aspirin for arthralgias. Utilizing the target method described above, what would be your differential diagnosis? Her examination revealed mild tenderness in the right upper quadrant but was otherwise unremarkable. Stools were negative for occult blood, and ultrasonography was positive for gall stones. By visualizing the path the sperm must follow to reach the egg, one can identify many important causes of infertility. Male fertility, however, depends on a healthy pituitary gland and testicles, and female fertility depends on a healthy ovary and pituitary. Thus, in the man, hypopituitarism, testicular atrophy (as in mumps), vas deferens obstruction (due to gonorrhea or tuberculosis), prostatitis and other prostatic disease, hypospadias, and other abnormalities of the urethra may cause infertility. Lack of copulation may cause infertility; the causes of this disorder are discussed in the sections on frigidity and impotence (see pages 185 and 260). In the female genital tract, the sperm may encounter antibodies, 525 vaginitis, vaginal deformities, cervicitis, cervical carcinoma, endometritis, carcinoma of the endometrium, a retroverted uterus and other deformities, and obstruction of the tubes by a tubo-ovarian abscess or endometriosis. The ovary may not be able to develop an egg because of hypopituitarism or ovarian diseases, such as Stein–Leventhal polycystic ovaries, ovarian cysts, and tumors (especially hormone-secreting tumors of the ovary that prevent the variation in estrogen–progesterone concentration necessary during the cycle that allows maturation of the egg). There may be no ovaries present from birth (Turner syndrome), or there may be acquired ovarian failure (surgical removal or early menopause). Table 41 Indigestion Approach to the Diagnosis The workup of infertility first involves doing a sperm count on the man. If that is normal and the examination of the woman discloses no gross abnormality, a temperature chart is kept by the patient or the Spinnbarkeit test is used to determine if ovulation occurs. Other tests such as tubal insufflation, hysterosalpingogram, and a trial of clomiphene will be useful in selected cases. Establishing the time of ovulation and ensuring copulation at that time often solve the problem. Sperm fructose (epididymal obstruction) Case Presentation #57 A 23-year-old white woman and her husband have been trying to get pregnant for 2 years. Utilizing anatomy and physiology, what would be your list of possible causes of this woman’s problem? General physical and vaginal examinations are normal except for erythema and induration of the cervix.

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Antibiotic-dependent platelet antibody testing to distinguish vancomycin versus ceftriaxone as the cause of the platelet refractoriness (Answer D) is not the frst step in the management—it may be performed after ruling out immune mediated platelet destruction by doing the 1-h post platelet count best order malegra fxt plus. Treating the fevers with acetaminophen is not the frst treatment for platelet refractoriness before ruling out immune mediated platelet destruction (Answer E) buy 160 mg malegra fxt plus fast delivery. Prior to the transfusion of apheresis-derived 9 9 platelets buy malegra fxt plus with amex, the platelet count is 15 × 10 /L generic malegra fxt plus 160mg without a prescription, and posttransfusion, it is 23 × 10 /L. A similar increase in her platelet count was noted after a second unit was transfused. What is the interpretation of this result based on the response to platelets and the information provided to you in the original case scenario? Appropriate response at 1-h posttransfusion suggesting the cause is immune mediated B. Appropriate response at 1-h posttransfusion suggesting the cause is nonimmune mediated C. Inappropriate response at 1-h posttransfusion suggesting the cause is nonimmune mediated E. Other choices (Answers A, B, C, and D) are wrong based on the above calculation and explanation. The other choices (Answers A, B, D, and E) are incorrect based on the table above. A 32-year-old pregnant woman is being followed because she has an anti-c and the biological father of the child is known to be positive for the c antigen. An antibody titration study is performed today in the blood bank and the results are as follows: Dilution 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 Score Titer Agglutination 4+ 3+ 2+ 2+ 1+ 1+ w+ 0? Given this information, what are the score and titer for this antibody titration study? Therefore, when maternal alloantibodies are detected during pregnancy, antibody titration studies are performed to determine the strength of the antibody. This information is used for determining the level of monitoring that is needed for adverse effects on the fetus. Serial dilutions of the patient serum that contains the antibody are tested against red cells that are positive for the antigen in question. The titer is the reciprocal of the highest dilution in which agglutination (not including weak reaction or reaction <1+) was observed. A score can also be calculated in which each level of agglutination is assigned a given value and the score is the sum of the values. The agglutination and score values are as follows: 4+ = 12, 3+ = 10, 2+ = 8, 1+ = 5). In the case of alloimmunization against an Rh antigen, generally pregnancies in which antibody titers are 8 or lower can be managed by serial monitoring of the maternal antibody titers. In addition, the results of the current specimen should be compared with prior specimens and a change in titer of 2 or more tubes or a change in score of 10 or more are considered signifcant. Answer: A—Using the above information: Correlating the agglutination to the scoring values: 4+ = 12, 3+ = 10, 2+ = 8, 2+ = 8, 1+ =5, 1+ = 5) Score = 12 + 10 + 8 + 8 +5 +5 = 48 Titer = reciprocal of the highest dilution that showed agglutination: dilution of 1:64—Titer 64. The other choices (Answers B, C, D, and E) are incorrect based on the above information and calculations. He states that over the past 24 h he has noticed bruising on his arms, bleeding from his gums when brushing his teeth this morning, and bleeding from his nose. Most patients with thrombocytopenia with no bleeding or only mild bleeding can be managed with observation alone. A platelet count > 50 9 × 10 /L is generally accepted as a threshold for satisfactory response. The dosage and frequency of maintenance therapy depends on the patient’s clinical status and laboratory parameters (platelet count, hemoglobin, and reticulocyte counts). If the patient does not respond, redosing is based on the hemoglobin level If hemoglobin < 8 g/dL, then alternative therapies should be considered (i. Thus, the patient needs to be monitored closely for signs, symptoms, and laboratory evidence of intravascular hemolysis in the healthcare setting for at least 8 h. Dipstick urinalysis to monitor hemoglobinuria and hematuria should be performed at baseline, at 2 h, at 4 h, and before the end of the monitoring period. Answer: E—Using the above information: Initial dose(g)6 5kg g/kg=3,250 µg Initialdose(µg)=65 kg × 50 µg/kg = 3250 µg 14. A 68-year-old man with multiple myeloma is preparing to undergo an autologous stem cell transplant. Per her obstetrics record, the patient is O Rh negative with anti-E (titer of 16) identifed at 28 weeks of gestation. Her current type and screen shows that she is O Rh negative and has anti-D and anti-E (titer of 16). The other choices (Answers B, C, D, and E) are incorrect based on the information above. Her current type and screen shows again that she is O Rh negative and has anti-D and anti-E (titer of 32). Therefore, the reconstituted whole blood for the exchange should be 2 × 240 = 480 mL. A 27 year-old female (blood type O Rh negative with negative antibody screen) is hospitalized with meningococcemia. Please answer Questions 22 and 23 based on the following scenario: An 80-lb woman who is known to have a rare red blood cell antigen phenotype presents for blood donation at her local blood center. Based upon her weight, what is the maximum amount of whole blood she can donate today? If the donor weighs less than 110 lbs, then the maximum allowable whole blood volume (including the amount of blood used for testing and discarded via the diversion pouch) is 10. Answer: A—This donor only weighs 80 lbs (∼36 kg); thus, the maximum amount of whole blood (including samples for testing) she can donate today is 36 × (10. If a donor weighs more than 110 lbs, she can donate a maximum of 500 + 50 mL whole blood, and most donors are able donate this volume at each donation. A unit is labeled as a “low-volume collection” when the amount collected into a 450 mL collection bag is between 300 and 404 mL, or when the amount collected into a 500 mL collection bag is between 333 and 449 mL, and the amount of anticoagulant in the collection bag is not adjusted. The blood center staff is able to remove the appropriate amount of anticoagulant from the phlebotomy bag for this donor. Based on the maximum amount of blood that this donor is able to donate, how much anticoagulant does the staff need to remove from the primary bag, if the blood center uses the standard 450mL phlebotomy bag? The following describes the steps involved in calculating the amount of anticoagulant required for low-volume whole blood units using the standard 450 mL phlebotomy bags. Step 1: Calculate the amount of blood that can be removed:  Donor weight inlbs  Volumetoberemoved (inmL) = (450 mL)   110 lbs  Volumetoberemoved(in mL)=(450 mL)(Donorweightinlbs110 lbs) 20. Volume of anticoagulant toberemoved 63 mL Volume of anticoagulant required Volumeofanticoagulanttoberemoved=63 mL−Volumeofanti- coagulantrequired Answer: D—Since the facility only has standard 450 mL phlebotomy bags, the maximum amount  80 lbs  of whole blood should be removed is (450 mL) = 327. He has multiple transfusions in the past (but none within the past 3 months), and his antibody panel currently shows that he is O Rh positive, and has anti-C, E, K, a a b Js , Fy , Jk , and s. If he receives simple transfusion (2 units), then what will his Hct and hemoglobin S (HgbS) likely be post transfusion? Simple transfusion may be able to achieve HgbS goal without a dramatic increase in iron storage B. Simple transfusion may be able to achieve HgbS goal without a dramatic increase in blood viscosity C. Simple transfusion may not be able to achieve HgbS goal without a dramatic increase in iron storage D. Simple transfusion may not be able to achieve HgbS goal without a dramatic increase in blood viscosity E. The other choices (Answers A, C, D, and E) are incorrect based on the formulas and information above. Based on your institutional protocol, the patient’s HgbS post-procedure should be less than 20% and Hct should be ∼27%–30%. She has history of bleeding with surgical procedures; thus, her coagulopathy should be corrected. Therefore, plasma is used to treat coagulopathy and/or bleeding in these patients. This is a large volume transfusion, and thus, the patient should be monitored closely for signs and symptoms of volume overload. Obstetrician should be consulted regarding the risks versus benefts of using diuresis, such as furosemide, during the transfusion in this scenario.

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