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Implementation of a Tool to Identify Early Sepsis by Nurses

Share this: Facebook Twitter Reddit LinkedIn WhatsApp ABSTRACT Sepsis is defined as the immune system’s overwhelming response to infection that results in life-threating organ dysfunction (Singer et al., 2016). In the United States sepsis affects 1.7 million hospitalized patients and causes approximately 270,000 deaths each year (Rhee et al., 2014). Because of their unique position of having frequent patient interaction, nurses can have significant impact in identifying patients with sepsis (Kleinpell, 2017). The purpose of this evidenced based project was to develop a policy that would assist nursing staff in the early identification of patients with signs and symptoms of sepsis. Within the timeframe of this project, a policy was developed using guidelines developed by the Surviving Sepsis Campaign (www.survivingsepsis.org, 2018) for a rural critical access hospital, train the nursing staff on one of the medical-surgical floors in the facility, and evaluate the compliance in use of the Evaluation of Severe Sepsis Screening Tool (www.survivingsepsis.org, 2018). For this project, 15 nurses were trained to use a paper-based, 3-tired sepsis assessment tool to identify patients that presented with a history suggestive of infection, presented with at least two signs or symptoms of a systemic inflammatory response syndrome (SIRS), and identify the possibility of organ dysfunction not associated with a chronic condition. The staff was asked to perform the screening at the beginning of each shift as part of their daily assessment and notify the patient’s provider of any patient whose screen indicated either a new onset of sepsis or severe sepsis to request additional diagnostic and treatment orders. The initial medical-surgical floor consisted of a staff of both registered nurses (RNs) and licensed practical nurses (LPNs) working 12-hour shifts. Training consisted of 1 on 1 meetings with the staff that was conducted as time allowed around their normal shift activities. After the first 2 training days a total of 83% of the full-time nursing staff received the training and agreed to participate in the study. Additional follow up found that of those staff members that initially agreed to participate 86.7% initiated the use of the paper screening tool and only 40% used the screening tool consistently. The project was limited by the chosen 1:1 training method since the information provided to the nursing staff with a narrow scope of information and training with paper screening tool. While moving forward with the policy to the reminder of the facility it is recommended that a formal training program is developed and presented to the nursing staff during a designated time period that will allow the staff to concentrate and ask questions to clarify understanding of the implementation and use of the policy and screener. LIST OF ABBREVIATIONS CDC Centers for Disease Control and Prevention EHR electronic health record ICU Intensive Care Unit IRB Institutional Review Board LOS length of stay LPN Licensed Practical Nurse RN Registered Nurse SEP-1 CMS Sepsis Core Measurement SIRS Systemic Inflammatory Response Syndrome SECTION 1 INTRODUCTION Problem Description Sepsis is defined as the life-threatening organ dysfunction caused by a dysregulated host response to infection (Marik
The Biological Effects Of Ionizing Radiation Biology Essay. The biological effects of ionizing radiation are determined by both the radiation dose and the radiation quality ionization density. To understand the radiation protection concerns associated with different types of ionizing radiation, knowledge of both the extent of exposure and consequent macroscopic dose absorbed – gray value, as well as the microscopic dose distribution of the radiation modality is required. The definitions of these variables are discussed below but in general to advance the knowledge of the biological effects of different radiation types one needs to know the dose absorbed, the radiation quality and effectiveness of a particular radiation type to induce biological damage. In this study the biological effect of high energy neutrons is compared to that of a reference radiation type 60Co γ-rays for a cohort of donors, mostly radiation workers. Comparisons are made at different dose levels in blood cells from each donor to ascertain the relative biological effectiveness of the test radiation modality against that of a recognized reference radiation (Hall, 2005). Such studies are essential to determine the radiation quality for high energy neutron sources applicable to practises in radiation protection. In some nuclear medicine applications radionuclides are used to treat malignant disease. For this the use of short lived alpha particle emitters or other radiation modalities that deliver high ionization densities in cells, are particularly attractive. This as the cellular response in relation to inherent radiosensitivity of the effected cells is thought to be more consistent compared to the use of radionuclides that emit radiation with a lower ionization density e.g. β-particles. The relative biological effectiveness of the high energy neutrons used in this study is followed as a function of the inherent radiosensitivity of different individuals. This allows the identification of cell populations that are relatively sensitive or relatively resistant to radiation. As such research material is available to investigate cellular response too Auger electrons. The latter is known to induce biological damage akin to that of alpha particles. A short description of the physical and biological variables applicable to this study is summarised below. Ionizing Radiation The term ionizing radiation refers to both charged particles (e.g., electrons or protons) and uncharged particles (e.g., photons or neutrons) that can impart enough energy to atoms and molecules to cause ionizations in that medium, or to initiate nuclear or elementary-particle transformations that in turn result in ionization or the production of ionizing radiation. Ionization produced by particles is the process by which one or more electrons are liberated in collisions of the particles with atoms or molecules (The International Commission on Radiation Units and Measurements [ICRU] Report 85, 2011). Interaction of Ionizing Radiation with Matter Ionizing radiation is not restricted to ionization events alone. Several physical and chemical effects in matter such as: heat generation, atomic displacements, excitation of atoms and molecules, destruction of chemical bonds and nuclear reactions may occur. The effects of ionizing radiation on matter depend on the type and energy of radiation, the target, and the irradiation conditions. Radiation can be categorized in terms of how it induces ionizations: Directly ionizing radiation, consist of charged particles such as electrons, protons and alpha particles. Indirectly ionizing radiation consists of neutral particles and/or electromagnetic radiation such as neutrons and photons (γ-rays and X-rays). Ionising radiation interacts with matter by: Interaction with the electron cloud of the atom, or by Interaction with the nucleus of the atom. Types of ionizing radiation linked to this study γ-rays Ionizing photons (γ- and X-rays) are indirectly ionising radiation. These wave like particles have zero rest mass and carry no electrical charge. Low energy (E>2m0c2) may be absorbed by atomic nuclei and initiate nuclear reactions (Cember, 1969). The charged electrons emitted from the atoms, produce the excitation and ionisation events in the absorbing medium. Neutrons Neutrons, similar to ionizing photons are indirectly ionizing radiations; however, these particles do have a rest mass. There is negligible interaction between neutrons and the electron cloud of atoms since neutrons do not have a net electrical charge (Henry, 1969). The principle interactions occur through direct collisions with atomic nuclei during elastic scattering events. In this process, ionisation is produced by charged particles such as recoil nuclei and nuclear reaction products. The production of secondary ionising photons will result in the release of energetic electrons. In turn these charged particles can deposit energy at a considerable distance from the interaction sites (Pizzarello, 1982). Auger electrons Auger electron emission is an atomic-, not a nuclear process. In this process an electron is ejected from an orbital shell of the atom. A preceding event, e.g. electron capture (EC) or internal conversion (IC) leaves the atom with a vacant state in its electron configuration. An electron from a higher energy shell will drop into the vacant state and the energy difference will be emitted as a characteristic x-ray (Cember, 1969). The energy of the x-ray (Ex-ray) being the difference in energy (E) between the two electron shells L and K. Ex-ray = EL -EK Alternatively, the energy may be transferred to an electron of an outer shell, causing it to be ejected from the atom (Fig. 1). The emitted electron is known as an Auger electron and similarly to the x-ray has an energy: EAuger = EΔ -EB where: EΔ = the energy of inner-shell vacancy – energy of outer-shell vacancy EB = binding energy of emitted (Auger) electron Auger emission is favoured for, low-Z materials where electron binding energies are small. Auger electrons have low kinetic energies; hence travel only a very short range in the absorbing medium (Cember, 1969). File:Auger Process.svg Fig. 1: Schematic representation of the Auger electron emission process, where an orbital electron is ejected following an ionization event. Dosimetric Quantities Several dosimetric quantities have been defined to quantify energy deposition in a medium when ionizing radiation passes through it. Radiation fields are well described by physical quantities such as particle fluence or air kerma free in air are used. However these quantities do not relate to the effects of exposure on biological systems (International Commission on Radiological Protection [ICRP] Publication 103, 2007). The absorbed dose, D, is the basic physical quantity used in radiobiology, radiology and radiation protection that quantifies energy deposition by any type of radiation in any absorbing material. The International System of Units (SI) of absorbed dose is joule per kilogram (J.kg-1) and is termed the gray (Gy). Absorbed dose, D, is defined as the quotient of mean energy, dε, imparted by ionising radiation in a volume element and the mass, dm, of the matter in that volume (Cember, 1969). The absorbed dose quantifies the energy imparted per unit mass absorbing medium, but does not relate this value to radiation damage induced in cells or tissue. The radiation weighted dose (HT) is used as a measure of the biological effect for a specific radiation quality on cells or tissue. It is calculated from equation where DT,R is the mean absorbed dose in a tissue T due to radiation of type R and wR is the corresponding dimensionless radiation weighting factor. The unit of radiation weighted dose is J.kg-1 and is termed the sievert (Sv). Radiation weighting factors are recommended by the International Commission on Radiological Protection (International Commission on Radiological Protection [ICRP] Publication 103, 2007) and are derived from studies on the effect of the micro-deposition of radiation energy in tissue and on its carcinogenic potential. Linear Energy Transfer (LET) Ionizing radiation deposits energy in the form of ionizations along the track of the ionizing particle. The spatial distribution of these ionization events is related to the radiation type. The term linear energy transfer (LET) relates to the rate at which secondary charged particles deposit energy in the absorbing medium per unit distance (keV/µm). LET is a realistic measure of radiation quality (Duncan, 1977). The LET (L) of charged particles in a medium is defined as the quotient of dE/dl where dE is the average energy locally imparted to the medium by a charged particle of specified energy in traversing a distance dl (Pizzarello, 1982). For high energy photons (x- and γ-rays), fast electrons are ejected when energetic photons interact with the absorbing medium. The primary ionization events along the track of the ionizing particle are well separated. This type of sparsely ionizing radiation is termed low-LET radiation. The LET of a 60Cobalt teletherapy source (1.3325 and 1.1732 MeV) is in the range of 0.24 keV/µm (Vral et al., 1994). Neutrons cause the emission of recoil protons, alpha particles and heavy nuclear fragments during scattering events. These emitted charged particles interact more readily with the absorbing medium and cause densely spaced ionizing events along its track. The p66(Be) neutron beam used in this study has an ionization density of 20 keV/µm and hence regarded as high-LET radiation. Auger electrons travel very short distances in the absorbing medium due to their low kinetic energies. All the energy of these particles is liberated in small volumes over short track lengths. Ionization densities are therefore very high, up to 40 keV/µm this is comparable to high-LET alpha particles (Godu et al., 1994). Relative Biological Effectiveness (RBE) The degree of damage caused by ionizing radiation depends firstly on the absorbed dose and secondly on the ionization density or quality of radiation. Variances in the biological effects of different radiation qualities can be described in terms of the relative biological effectiveness (RBE). RBE defines the magnitude of biological response for a certain radiation quality compared to a distinct reference radiation. It is expressed in terms of the ratio (Quoc, 2009): Megavoltage X-rays or 60Co γ-rays are commonly employed as the reference radiation since these are standard therapeutic sources of radiation. Thus for an identical dose neutrons the biological effect observed would be greater, compared to 60Co γ-rays. The fundamental difference between these radiation modalities is in the spatial orientation or micro deposition of energy. Furthermore, RBE varies as a function of the dose applied – increase in RBE is noted for a decrease in dose. By evaluating dose response curves (Fig 2), it is evident that the shoulder of the neutron curve is much shallower (smaller β-value) compared to the reference radiation curve. Therefore changes in RBE are prominent over low dose ranges (Hall, 2005). Fig 2: Dose response curves based on the linear quadratic model demonstrate differences in RBE as a function of dose. Through evaluation of the biological effect curves it is apparent that the RBE for a specific radiation quality may vary. This is characterized by the type of tissue or cells being investigated, dose and dose rates applied oxygenation status of the tissue, energy of radiation and the phase of the cell cycle and inherent radiosensitivity of cells. The RBE increases with a decrease in dose, to reach a maximum RBE denoted RBEM this is calculated from the ratio of the initial slope of the dose response curves for both radiation modalities. RBE LET relationship For a given absorbed dose, differences in the biological response for several cell lines, exposed to different radiation qualities have been demonstrated (Slabbert et al., 1996). Cells exposed to a specified dose low LET radiation do not exhibit the same biological endpoint than those exposed to same dose high LET radiation. This since with low LET radiation a substantial amount of damage may be repaired because the energy density imparted to each ionization site is relatively low. The predominant mode of interaction for this radiation type is indirect through chemical attack from radiolysis of water. As the LET increases, for a specific dose, fewer sites are damaged but the sites that are located along the track of the ionizing particle are severely damaged because more energy is imparted. Thus the probability of direct interaction between the particle track and the target molecule increases with an increase in LET. The RBE of radiation can be correlated with the estimates of LET values. However, as the LET increases, exceeding 10keV/µm it is no longer possible to assign a single value for the RBE. Beyond this LET, the shape of the cell survival curve changes markedly in the shoulder region compared to low-LET. Since RBE is a measure of the biological effect produced, comparison of the low-LET and high-LET curves will reveal that RBE increases with decreasing dose (Hall, 2005). The average separation in ionizing events at LET of about 100 keV/μm is equal to the width of deoxyribonucleic acid (DNA) double strand molecule (Fig. 3). Further increase in LET results in decreased RBE since ionization events occur at smaller intervals than DNA molecule strand separation (Fig. 3) and this energy imparted does not contribute to DNA damage. Fig 3: Average spatial distribution of ionizing events for different LET values in relation to the DNA double helix structure (Hall 2005). Cellular Radiosensitivity Tissue radiosensitivity models In 1906 the radiobiologists Bergonie and Tribondeau established a rule for tissue radiosensitivity. They studied the relative radiosensitivities of cells and from this could predict which type of cells would be more radiosensitive (Hall, 2005). Bergonie and Tribondeau realized that cells were most sensitive to radiation when they are: Rapidly dividing (high mitotic activity). Cells with a long dividing future. Cells of an unspecialised type. The “law” of Bergonie and Tribondeau was later adapted by Ancel and Vitemberger; they concluded that radiation damage is dependent on two factors: the biological stress on the cell. the conditions to which the cell is exposed pre and post irradiation. Cell division causes biological stress thus cells with a short doubling time express radiation damage at an earlier stage than slowly dividing cells. Undifferentiated rapidly dividing cells therefore are most radiosensitive (Hall, 2005). A comprehensive system of classification was proposed by Rubin and Casarett, cell populations were grouped into 4 categories based on the reproduction kinetics: Vegetative intermitotic cells were defined as rapidly dividing undifferentiated cells. These cells usually have a short life cycle. For example: erythroblasts and intestinal crypt cells and are very radiosensitive. Differentiating intermitotic cells are characterized as actively dividing cells with some level of differentiation. Examples include: meylocytes and midlevel cells in maturing cell lines these cells are radiosensitive. Reverting postmitotic cells are regarded as to not divide regularly and generally long lived. Liver cells is an example of this cell type, these cell types exhibit a degree radioresistance. Fixed postmitotic cells do not divide. Cells beloning to this classification are regarded to be highly differentiated and highly specialized in both morphology and function. These cells are replaced by differentiating cells in the cell maturation lines and are regarded as the most radioresistant cell types. Nerve and muscle cells are prime examples (Hall, 2005). Michalowski proposed a type of classification which divides tissues into hierarchical (H-type) and flexible (F-type) populations. Within this classification cells are grouped in 3 distinct categories: Stem cells, that continuously divide and reproduce to give rise to both new stem cells and cells that eventually give rise to mature functional cells. Maturing cells arising from stem cells and through progressive division eventually differentiate into an end-stage mature functional cell. Mature adult functional cells that do not divide Examples of H-type populations include the bone marrow, intestinal epithelium and epidermis; these cells are capable of unlimited proliferation. In F-type populations the adult cells can under certain circumstance be induced to undergo division and reproduce another adult cell. Examples include; liver parenchymal cells and thyroid cells. The two types represent the extremes in cell populations. It should be noted that most tissue populations exist between the extremes, these exhibit characteristics of both types where mature cells are able to divide a limited number of times. The sensitivity to radiation can be attributed to the length of the life cycle and the reproductive potential of the critical cell line within that tissue (Hall, 2005). Cell cycle dependent radiosensitivity As cells progress through the cell cycle various physical and biochemical changes occur (Fig. 4). These changes influence the response of cells to ionizing radiation. Variations in radiosensitivity for several cell types at different stages of the cell cycle has been documented (Hall, 2005). Following the law of Bergonie and Tribondeau that cells with high mitotic activity are most radiosensitive, it was found that cells in the mitotic phase (M-phase) of the cell cycle are most sensitive. Late stage gap 2 (G2) phase cells are also very sensitive with gap 1 (G1) phase being more radioresistant and synthesis (S phase) cells the most resistant (Domon, 1980). Fig. 4: Cell cycle of proliferating cells representing the different phases leading up to cell division. The G0 resting phase for cells that do not actively proliferate has been included since T-lymphocytes naturally occur in this phase (Hall, 2005). Nonproliferating cells, generally cells that are fully differentiated, may enter the rest phase G0 from G1 and remain inactive for long periods of time. Peripheral T-lymphocytes seldom replicate naturally and remain in G0 indefinately. Lymphocyte Radiosensitivity The hematopoietic system is very sensitive to radiation. Differential blood analyses are routinely employed as a measure of radiation exposure. This measurement is based on the sensitivity of stem cells and the changes observed in the constituents of peripheral blood due to variations in transit time from stem cell to functioning cell (Hall, 2005). It has been shown that lymphocytes, although they are resting cells (G0 phase) which do not actively proliferate nor do have a long dividing future hence do not meet the criteria of a radiosensitive cell type as described above are of the most radio sensitive cells. The reasons for their acute sensitivity cannot be explained (Hall, 2005). Furthermore two distinct subpopulations T-lymphocytes with respect to radiosensitivity were found in peripheral blood. The small T-lymphocyte which is extremely radiosensitive and disappears almost completely from the peripheral blood at doses of 500 mGy (Kataoka, 1974, Knox, 1982 and Hall, 2005). Cytogenetic expression of ionizing radiation induced damage The primary target in radiotherapy is the double helix deoxyribonucleic acid (DNA) molecule (Rothkam et al. 2009). This macro molecule contains the genetic code critical to the development and functioning of most living organisms. The DNA molecule consists of two strands held together by hydrogen bonds between the bases. Each strand is made up of four types of nucleotides. A nucleotide consists of a five-carbon sugar (deoxyribose), a phosphate group and a nitrogen containing base. The nitrogen containing bases are adenine, guanine, thymine or cytosine. Base pairing between two nucleotide strands is universally constant with adenine pairing with thymine and guanine with cytosine (Fig. 5). This attribute permits effective single strand break repair since the opposite strand is used as a template during the repair process. The base sequence within a nucleotide strand differs; the arrangement of bases defines the genetic code. The double helix DNA molecule is wound up on histones and bound together by proteins to form nucleosomes. This structure is folded and coiled repeatedly to become a chromosome. Fig. 5: The double helix structure of a DNA molecule consists of two neucleotide strands held together by hydrogen bonds between the bases. Figure modified from http://evolution.berkeley.edu/evolibrary/article/history_22 by P Beukes. Ionizing radiation can either interact directly or indirectly with the DNA strand. When an ionization event occurs in close proximity to the DNA molecule direct ionization can denature the strand. Ionization events that occur within the medium surrounding the DNA produce free radicals such as hydrogen peroxide through radiolysis of water. Damage induced by ionizing radiation to the DNA include base damage (BD), single strand breaks (SSB), abasic sites (AS), DNA-protein cross-links (DPC), and double strand breaks (DSB) (Fig. 6). Fig. 6: Examples of several radiation induced DNA lesions. Figure modified from Best B (9) by P Beukes. Low-LET radiation primarily causes numerous single strand breaks, through direct and indirect interaction (Hall, 2005). Single strand breaks are of lesser biological importance since these are readily repaired by using the opposite strand as a template. High-LET radiation damage is dominated by direct interactions with the DNA molecule. Densely ionizing radiation has a greater probability to induce irreparable or lethal double strand breaks since energy deposition occurs in discrete tracks (Hall, 2005). The number of tracks will be fewer but more densely packed compared to low-LET radiation of equivalent doses. Several techniques to quantify chromosomal damage and chromatid breaks have been established. These range from isolating DNA and passing it through a porous substrate or gel (Hall, 2005) by applying an external potential difference too advanced techniques of visually observing and numerating chromosomal aberrations of interphase cells. Cytogenetic chromosome aberration assays of peripheral blood T-lymphocytes to assess radiation damage include but are not limited to: premature chromosome condensation (PCC) assay, metaphase spread dicentric and ring chromosome aberration assay (DCA), metaphase spread fluorescence in situ hybridisation (FISH) translocation assay and cytokinesis blocked micronuclei (CBMN) assay (Fig. 7). Fig. 7: Different cytogenetic assays on peripheral T-lymphocytes for use in biological dosimetry. Figure modified from Cytogenetic Dosimetry IAEA, 2011. PCC occurs when an interphase cell is fused with a mitotic cell. The fusion causes the interphase cell to produce condensed chromosomes prematurely. Chromosomal aberrations can thus be analysed immediately following irradiation without the need for mitogen stimulation or cell culturing. Numeration of dicentrics in metaphase spreads has been used with great success to assess radiation damage in cells since the 1960’s (Vral et al, 2010). The incidence of these aberrations follows a linear quadratic function with respect to the dose. Unstable aberrations like dicentrics or centric rings are lethal to the cell hence not passed on to daughter cells (Hall, 2005). In contrast translocations are stable aberrations; these are not lethal to the cell and passed on to daughter cells. Examination of translocations thus provides a long term history of exposure. Although the abovementioned techniques are very accurate and well described, the complexity and time consuming nature of the assays has stimulated the development of automated methods of measuring chromosomal damage. Micronuclei (MN) formation in peripheral blood T-lymphocytes lends itself to automation, since the outcome of radiation insult is visually not too complex with limited variables. DNA damage incurred from ionizing radiation or chemical clastogens induce the formation of acentric chromosome fragments and to a small extent malsegregation of whole chromosomes. Acentric chromosome fragments and whole chromosomes that are unable to engage with the mitotic spindle lag behind at anaphase (Cytogenetic Dosimetry IAEA, 2011). Micronuclei originate from these acentric chromosome fragments or whole chromosomes which are excluded from the main nuclei during the metaphase/anaphase transition of mitosis. The lagging chromosome fragment or whole chromosome forms a small separate nucleus visible in the cytoplasm of the cell. Image recognition software can thus be employed to quantify radiation damage by applying classifiers that describe cell size, staining intensity, cell separation, aspect ratio and cell characteristics when numerating MN frequency in BN cells. The classifiers are fully customizable depending on cell size, staining technique or cell type that will be used. Rationale for this study The principal objective of this study is to define RBE variations for high-LET radiation with respect to radiosensitivity. Specifically this is done for very high energy neutrons and Auger electrons. In general the response of different cell types vary much more to treatment with low-LET radiation compared to high-LET radiation (Broerse et al. 1978). Radiosensitivity differences have been demonstrated for different cancer cell lines (Slabbert et al. 1996) as well as various clonogenic mammalian cells (Hall, 2005) exposed to both high and low-LET radiation. In general there is an expectation and in certain cases some experimental evidence to support less variations in radiosensitivities of cells to high-LET radiation. Furthermore the ranking in the relative radiosensitivity of cell types changed for neutron treatments compared to exposure to X-rays (Broerse et al. 1978). To quantify the radiation risk of individuals exposed to cosmic rays or mixed radiation fields of neutrons and γ-rays, several experiments were conducted to ascertain biological damage induced by neutron beams of various energies (Nolte et al., 2007). Clonogenic survival data (Hall, 2005), dicentric chromosome aberrations (Heimers 1994) and micronuclei formation (Slabbert et. al 2010) have been followed. Chromosome aberration frequencies have been quantified and this represent radiation risk to neutron energies ranging from 36 keV up to 14.6 MeV (Schmid et al. 2003). To complement these studies additional measurements have been made for blood cells exposed to 60 MeV and 192 MeV quasi monoenergetic neutron beams (Nolte et al. 2007). Comparisons of RBE values obtained in these studies are shown in figure 1. Significant changes in the maximum relative biological effectiveness (RBEM) of these neutron sources are demonstrated as a function of neutron energy, with a maximum value of 90 at 0.4 MeV. RBEM drop to ±15 for neutron energies higher than 10 MeV and it appears that the RBEM remain constant up to 200 MeV. The RBEM value of 47 -113 reported by Heimers et al. (1999) is not consistent with these observations. Fig. 1: RBEM values for neutrons of different energies after Nolte et al. (2007) The data shown in Fig. 1 was obtained by using the blood of a single donor. This to ensure consistency in the biological response for different neutron energies used in different radiation facilities in different parts of the world. Keeping the donor constant has the advantage that only a single data set for the reference radiation was needed. These measurements were done over several years. In all these studies, dicentric chromosome aberrations were followed. As informative as these investigations may be, it is doubtful if RBE values obtained from blood samples from a single donor are indeed representative for the wider population to state radiation weighting factors. It is unclear if RBE values for high energy neutrons will vary when measured with cells with different inherent radiosensitivities. Warenius et al. (1994) demonstrated that the RBE of a 62.5 MeV neutron beam increases with increase in radioresistance to 6 MV X-rays. Similarly Slabbert et al (1996) using a 29 MeV p(66)/Be neutron with an average energy of 29 MeV, noted a statistically significant increase in the RBE values for cell types with increased radioresistance to 60Co γ-rays. Although these investigators used 11 different cell types, few of these were indeed radioresistant to 60Co γ-rays. Close inspection of the data shows that the relationship between neutron RBE and radioresistance to photons disappear when the cell type with the highest resistance to γ-rays (Gurney melanoma) is removed from the data set Slabbert et al. 1996). In a follow up study the authors failed to demonstrate the relationship for a p(66)/Be neutron beam but such a relationship was demonstrated for a d14/Be neutron beam (Slabbert et al. 2000). It therefore appears that the relationship for RBE and radioresistance is dependent on the selection of cells used in the study as well as the neutron energy. Using lymphocytes Vral et al. (1994) demonstrated a clear reduction RBEM values for 5,5 MeV neutrons with an increase in the α-values of dose effect curves obtained for 60Co γ-rays. This for lymphocytes obtained from six healthy donors. Using only four donors Slabbert et al. (2010) also demonstrated a relationship between RBEM neutrons and radiosensitivity to 60Co y rays. In the latter case the RBEM values are lower – as can be expected since these investigators used a higher energy neutron source. Although a significant relationship between these parameters has been demonstrated by the investigators, the cohort of 4 donors in the study is very small. In fact 2 out of the 4 donors have different RBEM values but appear to have the same radiosensitivity. A study using larger number of donors with blood cells exposed to high energy neutrons is clearly needed. This in particular too verify the findings above indicating a different wR for donors of different sensitivity. The studies of RBE variations with neutron energy by Schmid et al., (2003), Nolte et al. (2005) and were conducted dicentric formations observed in metaphase spreads. It is known that more than six months were used to analyse the data for different doses for blood cells obtained from a single donor exposed to a single neutron energy. It follows that some method of automation to assist the radiobiological evaluation of cellular radiation damage is needed to quantify wR values as a function of radiosensitivity. Recently a semi-automated image analysis system, Metafer 4, this holds promise to test numerous donors for micronuclei formations Study to include more participants hence Metafer…. The Biological Effects Of Ionizing Radiation Biology Essay
Share this: Facebook Twitter Reddit LinkedIn WhatsApp Nursing staff have seen their roles and responsibilities change considerably within the ‘modernisation’ of the NHS, but is this a good thing? There are some big changes in the nursing field in the last 50 years such as, uniform, salaries, job demand, the roles of nurses, the different roles for men and women nurses, the technology used, Litigation and Documentation, Holistic Care and patient load. Nurses are becoming more popular and demanding in all sorts of different working environments such as, working in nursing homes, hospitals, home help, travel nurse, school nurse and more. Years ago, nurses were seen just as little more than helpers or assistants for doctors. Today in 2010, nurses are health care professionals in their own right. They are bright, capable, and often have a clearer picture of the overall situation than the doctors they work alongside with. Nursing has not only changed on the face of it but the background work of a nurse has changed to, for example the education given to nurses, the scope of policies and practice, the structures of nurses and the principles of the care of the patient. People are lead to believe that the ‘modernisation’ of the NHS will be beneficial to the care of the patient, but is this really the case? Due to the increasingly shortage of nurses, they have learned to be more independent which is an outstanding way to increase skills and keep up to date with the new trends in health care. As well as nursing changing, health care in general has changed too. Within the modernisation of the NHS and nursing the care of the patients is still the everlasting goal. This means that there is more work for the nurses, which then has a knock on affect leading to less satisfaction of patient care. Although the NHS and government are doing their best to modernize nursing with the patients interests are heart, it seems like there is less time for care due to time, but more time for paperwork. The Department of Health has laid down certain policy initiatives, targets and structural and organizational changes that can improve the quality of care received by patients through the NHS. These changes are emphasized along with the need for multi-agency and multi-organizational collaborative working across disciplinary boundaries. The four key interfaces for which collaboration and coordination measures are being suggested are health and social care; general medical and community health services; primary and secondary care; and interface with carers (DoH, 1996). The education of nurses now days are a lot more intense and harder than it was 10 years ago. Over the last 10 years, there has been a gradual shift for the education and training of nurses. Currently all nurses have to be trained to a degree university level before they can practice as a fully qualified nurse. Opportunities for nurses have increased by large, with one training opportunity being through the internet although this method of training has to be approved by the NHS. On the other hand, years ago nurses only had to have a diploma or LPN’S. Now days all nurses have to attend and complete continuing education courses to keep up to date with the new trends and information used in the current day. In addition to the higher and more advanced education, which nurses now have to have, there comes an increases scope of practice. In the current worlds, nurses are doing more and going places that in the past they would not be allowed to have done. The scope of practice is an expression used for various professions that define the procedures, actions, and processes that are allowed to be used and practiced. In the health care profession, there are many different jobs with very different defined scope of practice laws and regulations. These include nursing, social workers, speech and language pathology, audiologists, training, radiography, nuclear medicine, dentists, surgeons, paramedics, physicians and many more. In the interest of the patients, it is a good thing that nurses are allowed to do more and more as there are more doctors than nurses, so the patients may be seen quicker, but on the other hand, it is not a good thing as nurses are doing more and maybe caring for the patient need and wished less. Nowadays in hospitals, the wards are not gender mixed although the nurses are gender mixed between wards. The stereotypical roles of a nurse have change a lot since the 1990’s. There are more male nurses but still not enough. However although there are still not enough male nurses, the female domination of nurses is slowly decreasing and now more men are entering the caring profession. For patients the more male nurses is a good thing because some patients i.e. men prefer to be treated by a man. For example, a man may like to be washed by a man and not a woman for dignity reasons. In addition, for years, the majority of nursing was thought of as a female profession but every year more and more males are joining the nursing profession. Nowadays being a male nurse does not have a stigma attached to it and is now seen as a very good career. The demand of nurses now in 2010 is by large massive. The NHS is always asking for more nurses. When the baby boom started there was a very large need for nurses but as the baby boom is decreasing now there is time and money for improvement of standards of living and disease control, our citizens are living longer. As the general population increases, so too does the demand for nurses. Now more than ever nurses are overworked but with the increasingly shortage of nurses they have to work harder and longer hours, which again is not benefiting the patients. Because of the nursing demand and staff shortage, staffs are taking more sick days due to excessive stress and lack of sleep and self-time. This is because nursing is very demanding on a person not just mentally but physically too. This is seriously compromising the NHS. In 2010 compared to 1980, there is a lot more technology for nurses to use and to be trained to use. Nurses today have to keep up to date with a lot more technology than a nurse 50 years would have had to. Technology can be seen as a good gadget and as a bad gadget, because not only do nurses have to provide basic and skilled care, they also have to learn how to work with many types of equipment that are specific to their area of expertise. The more popular piece of technology used every day by a nurse is a computer. Nurses use them every day as a way to document the care given to a patient. Although new technology is a good advantage for health care, it has its negatives, for example training the staff to use it costs a lot of money, but on the other hand, it can save life’s. Other important technology that is used every day that benefits a patient is, air mattresses as they help to prevent DVT’s and assistance with IV insertion which has made things a lot simpler. All of the new high tech equipment being simplified is for user- friendliness, which means that the new methods are speeding things up. Lastly, infection control plays a big part in the NHS every day, so new technology is being developed all the time, although the basic hand washing procedures remain very much the same. There are many different approaches to nursing care, one being the holistic care. This type of care has become more and more popular. The commutations between the Health and Allied Health services improving, a total Patient Care Model has come about. Resulting in decreased in-patient times and better health outcomes. The holistic care has been seen more popular within the complementary therapies and concepts. The patient load that a nursed has is massive. In America, there was a debate about the amount of patients under care of nurses. In 1999, the debate was won and there was a cap of the amount of patients allowed under care of one nurse. The results have been very effective from happier staff and better care for patients. There should be a cap in the UK. The changes of nursing over the last 10 years have been welcomed with open arms, but there are still teething problems and views that need to be heard. Optimal patient care is in a constant battle with budget and we can expect to see new policy reforms, new technology, and new demands created in the decade to come. It remains the responsibility of not only the nurses, but also the patients of the future, to voice their opinions in order to guide the Industry in the right direction. Nurses are now expected to come with a bigger patents load but more paper work as well. The importance of the paper work has increases over the last 10 years. This is due to the society that we now live in as it has been raised to need someone to blame for everything. As a nurse or doctor there are many emotional people around you every day as people are dying all the time. Therefore, sometimes people sue the nurses and doctors as they are upset and think the person died due to the NHS’s fault. Following this, nurses and doctors keep finding themselves in court. Even if they have not done anything, all allegations have to be investigated. This is the reason for paperwork there is to write up. Paperwork is the only solid setting stone and proof/ backup of a nurse’s care. A nurse is required to document every blood pressure reading, every medication, every incident, and every day. They have to account for every action, and put it all in writing. The problem with documentation is that it takes time. More time for documentation means less time for patients. Plain and simple. The polices that nurses have to follow are very similar across the whole world. In Australia, the ‘no-lift’ policy was introduced in the late 1990’s. To date the policy is still used and the nurses are trained using this policy. No-Lift means using Lifting Machines to mobilise patients, using slide sheets to manoeuvre them around the bed and promoting back care in general. Although this concept is yet to be adopted in the UK, the benefits are becoming obvious and discussions have begun on the implementation of a similar policy in the UK. There are many different types of nurses that work in the community and in the hospitals. These can range from, Adult nurses, mental health nurses, Children’s nurses, Learning disability nurses, District nurses, Neonatal nursing, Health visitors, Practice nurses, Prison nurses, School nurses and Healthcare assistants. There are also many different levels to being a nurse. A health care assistant is under a nurse, and then you have staff nurses, then sisters and ward sisters and then nurse manager/ matron. All in all these all make up our NHS and work as a team to provide the best possible care for the patient. There is a large scale of pay, which starts at around £13,000 to £67,000. The above table shows how the NHS works. The last 40 years nurses’ uniform has changed but not that much. In the 1960’s nurses still wore dresses and stocking .In the 1970′s more changes came to the way nurses dressed. Dresses were a little shorter and the white caps were beginning to lose importance in some hospitals across the country. In the 1980′s there was an end of the nursing caps altogether. Nurses also began wearing disposable aprons at this point rather than cloth aprons and medical facilities became much less militant in regards to restrictions on jewellery and cosmetics. During the 1990′s and today, nursing dresses have been replaced with much more user-friendly scrub suits. Scrub suits can be found in a wide variety of colours and styles. Some hospitals have specific scrub suit colours for different types of hospital staff and others allow nurses and other staff to choose colours and styles that appeal to them. Today’s nursing uniforms are designed more for function than form but are also considered much more comfortable than those worn throughout history are. There are many different theories towards nursing. The three main ones are needs based theories. The main point being that the focus of nursing is the assessment and care of the patients / clients’ needs, which they are unable to meet for themselves. The second theory is interactions theories. The main point of this being the focus of nursing is the relationship between the nurse and the patient / client. Lastly, the other theory is the goal-based theories. The main point again being that the focus of nursing is the outcome and emphasis is placed on facilitating the ability of the patient / client to adapt to changes in their health and regain stability and harmony. Today in the NHS nursing takes on a role of the biomedical model. The biomedical model has been around since the mid- nineteenth century as the most common model used to diagnose diseases. The biomedical model states that All illness and symptoms arise from underlying abnormality in the body, all diseases give rise to symptoms and that health is absence of disease. The model overlooks the fact that the diagnosis is a result of commutation between doctor and patient. Biomedical model has no doubt led to huge medical advances although the patient has little responsibility for presence /cause of illness. In conclusion, the changes in roles and responsibilities of nurses in the modernisation of the NHS can beneficial towards the patients but can also be damaging towards the patients. This is due to lack of staff and increased working hours, more paperwork, and more tasks that a nurse has to do and there are generally more patients now than 10 years ago. Therefore, a nurse has less time caring for the patients needs. On the other hand, the modernisation is seen as a good thing because there is more technology nowadays to make the nurses life easier, which also get a more persist result. Within the context of policies and procedures there are no many more rules than year ago, which does make a nurse’s life maybe easier but maybe harder. With all of these changes to nurses and the NHS in general, is the modernization is good thing, does it have the patients interests are heart or is it about saving money? Share this: Facebook Twitter Reddit LinkedIn WhatsApp
CUNY York College How to Survive a Plague Summary.

Watch the documentary: How to Survive a Plague and write up a 2-3 page summary about the overall key points of the film.Write up a 2-3-page summary addressing all the below listed questions:What were your knowledge, attitudes, and beliefs regarding the experience before engaging in it?What were your expectations of the experience?What exactly occurred during the experience?What were your thoughts and feelings during the experience?What were your thoughts and feelings immediately after the experience?How did the experience change your knowledge, values, attitudes, and beliefs regardingthe experience?How might this experience influence you in your personal or professional life in thefuture?
CUNY York College How to Survive a Plague Summary

SLU Unit 6 State & Federal Judges In Texas Government Code Discussion

SLU Unit 6 State & Federal Judges In Texas Government Code Discussion.

Answer States question and respond to 2 classmatesStated question: Each jurisdiction has its own position on who and how judges are selected. Please discuss the various methods of judicial selection and explain why you believe your jurisdiction’s process is good or bad (elected or appointed).Classmate 1 Ronald: Under the Federal selection process for judges, the U.S. Constitution process is followed. In the Federal process, the judge is appointed for life by the President. The President selects his/her nominee and then must be confirmed by a majority vote in the U.S. Senate. Confirmation hearings could take days or weeks.A district court judicial selection normally defers to senatorial courtesy. A state senator will recommend his/her nominee for the vacant position. The President will normally confer the decision based on the state senator’s pick.State judicial selection process has four different methods of how judges are chosen:1. Appointment2. Partisan elections3. Nonpartisan elections4. Merit selection plansWhen the appointment method is used, the governor appoints his/her selection. A majority of judges are elected through partisan or nonpartisan elections held throughout the state. The merit selection process calls for a bi-partisan selection committee to recommend three candidates. The governor from that state is then required to appoint one of the three candidates. In Ohio, our judicial selection process is carried out through the partisan election. While I believe this is the fairest process for citizens, we see elections in smaller counties where a judge runs unopposed. This could be two-tiered issue.1. The judge is primarily doing an excellent job with his/her judicial duties and no one from the opposing party believes that they could run against the incumbent and win.2. Sometimes this creates a political issue sometimes referred to as the “good ole boy” syndrome. Nothing changes within the court jurisdiction and causes stagnation.
SLU Unit 6 State & Federal Judges In Texas Government Code Discussion

INTL 646 American Public University Policy Recommendation for The US Case Study

essay helper free INTL 646 American Public University Policy Recommendation for The US Case Study.

POLICY PAPER: YAKUZA Instructions Propose a policy recommendation for the US, UN, IGO, or NGO to ameliorate and potentially eliminate your transnational crime group (JAPANESE YAKUZA). Make sure your policy recommendation addresses each of the causes and effects of your case study group and who you propose should do them. Be sure to cite sources/facts/statistics/information. Attached is the Case Study Paper. History Location Geopolitics Economy Organization Logistics Effect on the host state and cooperation with terror groups (if applicable) Technical Requirements This assignment will be submitted to Turnitin® so please avoid PLAGIARISM. Scholarly and credible references should be used. A good rule of thumb is at least 2 scholarly sources per page of content. Students will follow the current APA Style as the sole citation and reference style used in written work submitted as part of coursework. Points will be deducted for the use of Wikipedia or encyclopedic type sources. It is highly advised to utilize books, peer-reviewed journals, articles, archived documents, etc. Your paper must be at a minimum of 4 pages SINGLE SPACED (the Title and Reference pages do not count towards the minimum limit).
INTL 646 American Public University Policy Recommendation for The US Case Study

Animal Abuse And Cruelty Is Wrong Sociology Essay

Animal abuse and cruelty is wrong. Animals arent given their rights that they are supposed to have in the first place. Using animals as “lab rats” is cruel and unfair. Most animal abuse or cruelty goes on with nothing be reported or said about. The punishment for abusing an animal isn’t as harsh as it should be. There are not enough laws preventing animal abuse. There are not enough laws preventing animal abuse. Animals being caged up is unfair to the animals themselves. The cruelness of caging an animal up for days, weeks, months, or even years at a time with no food, water or care is the cruelest thing any human being could possibly ever do. Cruelty and neglect are also two subjects that have to deal with animal abuse. Most animal abuse goes unreported and nothing has been done to fix the problem of owners locking their pet up and leaving them for long periods of time without food, water, or care. The most common form of animal abuse has to do with an owner locking their dog or pet up for times on end, just completely neglecting them and not giving them any care or attention. More than half the cases involving animal cruelty had to do with pets. There are little laws about animal abuse or animal cruelty. In some states its actually taken seriously like in Colorado abusing or putting an animal through any kind of cruelty is a $500,000 fine, up to 6 years in jail, and a ban on owning or being around any form of living animal. Colorado is the only state to have a fine over $150,000. (“U.S. Cruelty Laws Felony vs. Misdemeanor”, 2011) The state with the smallest fine is Tennessee which has no fine for abusing or putting any kind of animal through cruelty.(“U.S. Cruelty Laws Felony vs. Misdemeanor”, 2011) The two states that have the most time that you can get up to in jail are Alabama and Louisiana at, up to ten years in jail.(“U.S. Cruelty Laws Felony vs. Misdemeanor”, 2011) The laws that we have now aren’t enforced enough as they should be. There isn’t enough attention being given to this subject as there should be. There are laws about animal cruelty and abuse but aren’t used as much as they should be. We don’t recognize animal abuse as much as we should either. There are animals being abused, tortured, or neglected every day that no one reports, notices, or does anything about. The rights that animals have now aren’t given to the animals like they should be or where created to be. Animal abuse isn’t a case that most people look as a highly serious problem. The rights that we have given to animals or pets or have created for them aren’t highly used as much or given to an animal as much as they should be. Using animals as “lab rats” is looked down upon and felt that it shouldn’t be done but yet people still test on animals all the time and nothing is done about it. Scientists do research and study on rats because they are said to be unneeded, but yet they are living therefore they are needed. If that was how everyone thought of animals we would have none left on our planet. Animals are a big role in our lives today we use them for almost everything we do and thinking that some one would neglect, torture, or abuse an animal is just wrong. Most animals that are in animal abuse or cruelty cases are pets because of a domestic dispute.(“Facts About Animal Abuse and Domestic Violence”, 2011) Some parents even abuse their pet in front of their child to coerce them to do what they say and what the child is told to do.(“Facts About Animal Abuse and Domestic Violence”, 2011) More households have pets than they do children so why spend money on an animal that is going to be a pet if your just going to abuse it?(“Facts About Animal Abuse and Domestic Violence”, 2011) Most families have a pet of which they consider a companion or a part of the family. Out of the 50 states there are only three that do not have animal abuse or cruelty laws.(“U.S. Cruelty Laws Felony vs. Misdemeanor”, 2011) If they do not fix animal abuse or animal cruelty soon we will have no more animals in the future. Hopefully in the future they will create better and more laws against abuse or cruelty, or they will pay more attention to animals being abused or not being given their rights. The rights that we have now for animals are perfectly fine its just that the animals aren’t given the rights they deserve to be given or have. If the government would follow through on paying attention to the case of animals being abused or treated unfair itself, there would be harsher punishment for an act as of doing so. Giving animals the rights they deserve is how it should be instead of using animals as lab rats, test subjects, or a teenagers thought of just a prank, when really in realization pushing a cow over on its back as “just a prank” can be very deadly for the cow actually. Animals aren’t given that much of their rights as they have to begin with. If they were to investigate and go deeper into the topic and subject of animals being abused there would be a lot of things that they would find out that they didn’t know. Harsher punishment is another thing to talk about. If they had harsher punishment just for neglecting an animal and not taking care of it there would be a lot more animals safe. If there was harsher punishment for abusing an animal there wouldn’t be as many animals getting abused, beaten, or neglected. Animal abuse, cruelty, and neglect are bad and animals aren’t given the rights they deserve. There are not enough laws preventing animal abuse.

SCI 115SC University of Florida Why Evolution Is True By Jerry Coyne Essay

SCI 115SC University of Florida Why Evolution Is True By Jerry Coyne Essay.

This is a 10-page essay in which you will reflect upon each of the chapter themes in Why Evolution Is True by Jerry Coyne ISBN 978-0143116646 . It should include reflections on your development and understanding of what evolution is and is not. It should include your personal journey of discovery related to the concept of evolution. It should also include philosophical, theological, and sociological reflections as well as a demonstration of a scientific understanding of evolution. Additionally, you should critique and evaluate the ideas presented in the book using your scientific understanding of the process of evolution. The term paper is a major assignment for this course and so ought to evidence the following:Understanding of the relevant scienceThe ability to use relevant literature in support of your conclusionsYour individual response to the material and readings. This may involve an assessment of what you found to be particularly compelling and/or problematic; your personal thoughts and/or reactions to what is being considered; consideration of implications implicit in the materials being addressed; an assessment of the strengths and/or shortcomings of particular points; etc.
SCI 115SC University of Florida Why Evolution Is True By Jerry Coyne Essay

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