Security Updates and Reevaluations the biosecurity risk assessment and program should be reviewed and updated routinely and following any biosecurity-related incident ucsf mt zion women's health center radiology generic estrace 2 mg online. Biosecurity program managers should develop and conduct biosecurity program audits and implement corrective actions as needed womens health tampa safe estrace 2mg. Principles of Laboratory Biosecurity Select Agents If an entity possesses menstrual taboos discount estrace on line, uses or transfer select agents women's health center towson md estrace 2mg generic, it must comply with all requirements of the National Select Agent Program breast cancer cookies purchase estrace without a prescription. Laboratory security and emergency response guidance for laboratories working with select agents menstrual migraine prevention buy estrace from india. This is accomplished by limiting opportunities for exposure menopause kansas city theater buy estrace 2 mg without prescription, promptly detecting and treating exposures women's health clinic of johnson county cheap estrace online visa, and using information gained from work injuries to further enhance safety precautions. Occupational health and safety in biomedical research settings is a responsibility shared by healthcare providers, safety specialists, principal investigators, employers, and workplace personnel. Optimal worker protection depends on effective, ongoing collaboration among these groups. First line supervisors and safety professionals should identify the potential worksite health hazards. The health provider should design medical support services in consultation with representatives from the institutional environmental health and safety program and the principal investigators. Workers should be fully informed of the available medical support services and encouraged to utilize them. Requisite occupational medical services are described below and expanded discussions of the principles of effective medical 1,2 support services are available in authoritative texts. Risk assessments should define potential hazards and exposures by job responsibility. Contracted workers, students, and visitors should be provided occupational medical care by their employer or sponsor equivalent to that provided by the host institution for exposures, injuries, or other emergencies experienced at the worksite. Occupational medical services may be provided through a variety of arrangements. The interaction between worker, healthcare provider and employer may be complex, such as a contract worker who uses his own medical provider or uses contract medical services. Thus, plans for providing medical support for workers should be completed before work actually begins. The medical provider must be knowledgeable about the nature of potential health risks in the work environment and have access to expert consultation. Prospective workers should be educated about the biohazards to which they may be occupationally exposed, the types of exposures that place their health at risk, the nature and significance of such risks, as well as the appropriate first aid and follow up for potential exposures. Occupational Health and Immunoprophylaxis That information should be reinforced annually, at the time of any significant change in 9-11 job responsibility, and following recognized and suspected exposures. Medical support services for biomedical research facilities should be evaluated annually. Joint annual review of occupational injury and illness reports by healthcare providers and environmental health and safety representatives can assist revision of exposure prevention strategies to minimize occupational health hazards that cannot be eliminated. Healthcare providers should be cognizant of potential hazards encountered by the worker. With that information, the healthcare provider determines what medical services are indicated to permit the individual to safely assume the duties of the position. If pre-existing medical records are unavailable or are inadequate, the healthcare provider may need to perform a targeted medical exam. During the visit, the healthcare provider should inform the worker of potential health hazards in the work area and review steps that should be taken in the event of an accidental exposure. When occupational exposure to human pathogens is a risk, employers should consider collecting and storing a serum specimen prior to the initiation of work with the agent. It can be used to establish baseline sero-reactivity, should additional blood samples be collected for serological testing subsequent to a recognized or suspected exposure. Some occupational exposures present substantially more hazard to identifiable sub-populations of workers. Immunodeficient workers or non-immune pregnant female workers may experience devastating consequences from exposures that pose a chance of risk to pregnant women with prior immunity and other immunocompetent workers. Serologic testing should be used to document baseline vulnerability to specific infections to which the worker might be exposed, and non-immune workers should be adequately informed about risks. In specific settings, serologic documentation Occupational Health and Immunoprophylaxis that individual workers have pre-existing immunity to specific infections also may be 10 required for the protection of research animals. Vaccines Commercial vaccines should be made available to workers to provide protection 12-16 against infectious agents to which they may be occupationally exposed. If the potential consequences of infection are substantial and the protective benefit from immunization is proven, acceptance of such immunization may be a condition for employment. Current, applicable vaccine information statements must be provided whenever a vaccine is administered. When occupational exposure to highly pathogenic agents is possible and no commercial vaccine is available, it may be appropriate to immunize workers using vaccines or immune serum preparations that are investigational, or for which the specific indication constitutes an off-label use. Use of investigational products, or of licensed products for off-label indications must be accompanied by adequate informed consent outlining the limited availability of information on safety and efficacy. Recommendation of investigational products as well as of commercial vaccines that are less efficacious, associated with high rates of local or systemic reactions, or that produce increasingly severe reactions with repeated use should be considered carefully. Periodic Medical Evaluations Occupational Health and Immunoprophylaxis Routine, periodic medical evaluations generally are not recommended; however, limited periodic medical evaluations or medical clearances targeted to job requirements 3 may occasionally be warranted. In special circumstances, it may be appropriate to offer periodic laboratory testing to workers with substantial risk of exposure to infectious agents to detect pre-clinical or sub-clinical evidence for an occupationally acquired infection. Before asymptomatic workers without specific exposures are tested for seroreactivity, the benefit of such testing should be justified, plans for further investigation of indeterminate test results should be delineated, and clearly defined criteria for interpretation of results should be developed. Medical Support For Occupational Illnesses And Injuries Workers should be encouraged to seek medical evaluation for symptoms that they suspect may be related to infectious agents in their work area, without fear of reprisal. A high index of suspicion for potential occupational exposures should be maintained during any unexplained illness among workers or visitors to worksites containing biohazards. Modes of transmission, as well as the clinical presentation of infections acquired through occupational exposures, may differ markedly from naturally acquired infections. The healthcare provider should have a working understanding of the biohazards present in the workplace and remain alert for subtle evidence of infection and atypical presentations. A close working relationship with the research or clinical program in which the affected employee works is absolutely essential. All occupational injuries, including exposures to human pathogens, should be reported to the medical support services provider. Proper post-exposure response is facilitated by exposure-specific protocols that define appropriate first aid, potential post-exposure prophylaxis options, recommended diagnostic tests, and sources of expert medical evaluation. These protocols should address how exposures that occur outside of regular work hours are handled and these protocols should be distributed to potential healthcare providers. In exceptional cases, the protocols should be reviewed with state and community public health departments. Emergency medical support training should be provided on a regular basis for both employees and healthcare providers. The adequacy and timeliness of wound cleansing or other response after an exposure occurs may be the most critical determinant in preventing infection. First aid should be defined, widely promulgated, and immediately available to an injured worker. Barriers to subsequent medical evaluation and treatment should be identified and minimized to facilitate prompt, appropriate care. Healthcare providers must use appropriate barrier precautions to avoid exposure to infectious agents and toxins. In some instances, it may be possible to prevent or ameliorate illness through post-exposure prophylaxis. Protocols should be developed in advance that clearly identify the situations in which post-exposure prophylaxis are to be considered, the appropriate treatment, and the source of products and expert consultation. Accurate quantification of risk associated with all exposures is not possible, and the decision to administer post exposure prophylaxis may have to be made quickly and in the absence of confirmatory laboratory testing. Thus, protocols should exist that delineate the circumstances under which it would be appropriate to consider use of each product following exposure, as well as the limits of our understanding of the value of some post exposure interventions. Estimating the significance of an exposure may be difficult, despite having established protocols. Appropriate post-exposure prophylactic response is always pathogen and exposure-dependent, may be host-factor dependent, and may also be influenced by immediate post-exposure management. Before prophylactic treatment is undertaken, confirm the likelihood that an exposure occurred, that prophylaxis is indicated and is not contraindicated by past medical history. Conveying this information to the injured worker requires clear, honest communication. The supervisor must receive a description of the accident or incident, confirm the circumstances of the injury or exposure and provide relevant advice. The report also should be distributed to all other relevant parties, such as the safety professional. Each incident should receive prompt reconsideration of the initial risk assessment and reevaluation of current strategies to reduce the possibility of future exposures. Post-exposure serologic testing may be useful, but it is important to determine how information obtained from serologic testing will be interpreted. It is also essential to collect serum specimens at the appropriate interval for a given situation. Assessment of sero-reactivity in exposed workers is most helpful when the results of specimens collected over time can be compared. Ideally specimens collected prior to , at the time of and several weeks following exposure should be tested simultaneously and results compared to assess changes in the pattern of sero-reactivity. Serum collected too early after exposure may fail to react even when infection has occurred, because antibodies have not yet been produced in detectable quantities. When immediate institution of post exposure prophylaxis may delay seroconversion, or when the agent to which the worker was exposed results in seroconversion completed over months. Testing of a single serum specimen is generally discouraged and can result in misinterpretation of nonspecific sero-reactivity. Evidence of sero-conversion or a significant (> 4 fold) increase in titer associated with a compatible clinical syndrome is highly suggestive of acute infection. However, the significance of and appropriate response to sero-conversion in the absence of illness is not always clear. If sero-reactivity is evident in the earliest specimen, it is important to re-test that specimen in tandem with serum specimens archived prior to occupational exposure and/or collected serially over time to investigate whether a change in titer suggestive of new infection can be identified. In some exposure situations, it may be appropriate to store serially collected serum samples, and to send them for testing as evidence of seroconversion only if symptoms develop that suggest an infection may have occurred. Serum collected at the time of employment, and any other specimens not o immediately tested should be stored frozen at a temperature of -20 C or lower in a freezer that does not experience freeze-thaw cycles. An inventory system should be established to ensure the accurate and timely retrieval of samples, while protecting patient privacy. When investigational or other non-commercial assays are utilized, the importance of appropriate controls and the ability to compare serially collected specimens for quantification/characterization of reactivity is increased. The availability of aliquoted samples that allow additional testing may be essential to assist interpretation of Occupational Health and Immunoprophylaxis ambiguous results. Caution should be taken to avoid placing more confidence in testing outcomes than can be justified by the nature of the assays. Infections of laboratory staff by such agents may be expected to result in serious or lethal disease for which limited treatment options exist. Potential (if unlikely) transmission from infected staff into the human or animal populations in the areas surrounding the laboratories may raise such concerns to higher levels. Occupational health: recognizing and preventing th work-related disease and injury, 4 ed. Non-mandatory Compliance Guidelines for Hazard Assessment and Personal Protective Equipment Selection, 29 C. Recommendations for prevention of and therapy for exposure to B virus (cercopithecine herpesvirus 1). Update: vaccine side effects, adverse reactions, contraindications, and precautions. Information on Submitting an Investigational New Drug Application for a Biological Product [about3 screens]. Most mammals are susceptible to anthrax; it mostly affects herbivores that ingest spores from contaminated soil and, to a lesser extent, carnivores that scavenge on the carcasses of diseased animals. In the United States, it occurs sporadically in animals in parts of the West, Midwest and Southwest. The infectious dose varies greatly from species to species and also is route dependent. It is believed that very few spores (10 or less) are required 2 for cutaneous anthrax. Occupational Infections Occupational infections are possible when in contact with contaminated animals, animal products or pure cultures of B. Numerous cases of laboratory-associated anthrax (primarily 3,4 cutaneous) have been reported. Recent cases include suspected cutaneous anthrax in a laboratory worker in Texas and a cutaneous case in a North Dakota male who disposed of 5,6 five cows that died of anthrax. While naturally occurring disease is no longer a significant public health problem in the United States, anthrax has become a bioterrorism concern. In 2001, 22 people were diagnosed with anthrax acquired from spores sent through the mail, including 11 cases of 7 inhalation anthrax with five deaths and 11 cutaneous cases. The primary hazards to laboratory personnel are; direct and indirect contact of broken skin with cultures and contaminated laboratory surfaces, accidental parenteral inoculation and rarely, exposure to infectious aerosols. In addition, regular routine swabbing specimens for culture should be routinely obtained inside the rotor and rotor lid and, if contaminated, rotors should be autoclaved before re-use. Worker vaccination is recommended for activities that present an increased risk for repeated exposures to B. Vaccination is not recommended for workers involved in routine processing of clinical specimens or environmental swabs in general diagnostic laboratories. A Department of Commerce (DoC) permit may be required for the export of this agent to another country. Agent: Bordetella pertussis Bordetella pertussis, an exclusively human respiratory pathogen of worldwide distribution, is the etiologic agent of whooping cough or pertussis. The organism is a fastidious, small gram-negative coccobacillus that requires highly specialized culture and transport media for cultivation in the laboratory. Occupational Infections Occupational transmission of pertussis has been reported, primarily among 10-16 healthcare workers. Outbreaks, including secondary transmission, among workers have been documented in hospitals, long-term care institutions, and laboratories. Natural Modes of Infection Pertussis is highly communicable, with person-to-person transmission occurring via aerosolized respiratory secretions containing the organism. The attack rate among susceptible hosts is affected by the frequency, proximity, and time of exposure to infected individuals. Although the number of reported pertussis cases declined by over 99% following the introduction of vaccination programs in the 1940s, the 3 to 4-year cycles 19-21 of cases have continued into the post-vaccination era. Because the natural mode of transmission is via the respiratory route, aerosol generation during the manipulation of cultures and contaminated clinical specimens generates the greatest potential hazard. Primary containment devices and equipment, including biological safety cabinets, safety centrifuge cups or safety centrifuges should be used for activities likely to generate potentially infectious aerosols. Agent: Brucella species the genus Brucella consists of slow-growing, very small gram-negative coccobacilli whose natural hosts are mammals. Seven Brucella species have been described using epidemiologic and biological characteristics, although at the genetic level all brucellae are closely related. Hypersensitivity to Brucella antigens is a potential but rare hazard to laboratory personnel.
Individualized features could be used to modify generic algorithms based on key parental dislikes or predilections regarding medical and non-medical traits women's health issues research paper cheap 2mg estrace. Parents might indicate that a specifc category of disease risk pregnancy underwear order estrace 2 mg with amex, such as a propensity for conditions that require specialized diets women's health clinic rockingham wa buy estrace once a day, like Celiac disease women's health clinic rock island cheap estrace 2 mg without prescription, would be a deal breaker menstrual gas pain order estrace without prescription. All embryos 121 As noted above regional womens health group 08043 discount estrace 1mg mastercard, cost may infuence whether clinics are able to ofer more than one algorithm package women's health and birth control order estrace 1 mg amex. To the extent that individuals have the wherewithal to choose among diferent clinics menstrual man generic estrace 1mg with mastercard, the type of algorithm the clinic ofered might infuence their choice of clinics. Algorithms might also factor in whether the variant is associated with great variability in expressivity. The former are normally measured on a scale in which 1 represents full health and 0 represents death, therefore higher values correspond to more desirable statesandstatesdeemedworsethandeathcantakenegativevalues. Telateraremeasuredonascaleinwhich 0 represents no disability, therefore lower scores correspond to more desirable states. Conversely, only embryos with a signifcantly increased propensity for a particular trait, such as vari ants associated with intelligence (assuming a meaningful correlation between variant and trait)126 would be selected for ranking according to the generic algorithm. Individualized algorithms could ofer parents the opportunity to decide what kinds of non-medical traits they wanted to include and the weight they would assign those traits. As with variants associ ated with disease, values assigned to traits would have to be discounted based on the probabilities of expression. For example, it is unlikely that providers would let future parents decide whether or not to select embryos based on lethal or debilitating childhood illnesses like Tay Sachs or Lesch Nyhan. Most clinics would likely use algorithms with a baseline selection against such devastating conditions. A more complicated issue is whether providers would be willing to honor other kinds of requests, particularly those that involve the selection for less serious disabilities. Some clinics, however, will implant such embryos,129 125 Of course, one would have to decide what constituted a signifcantly increased propensity. The mosthighlyrankedembryoswouldthenbefurthernarroweddownbasedonparentalinputaboutafewtraits that they particularly valued or considered deal breakers. Even with respect to a particular trait, like height, diferent genetic variants can have signifcantly difer ent impacts. Some might ofer highly individualized algorithms for those who wanted full choice; others might ofer more limited individualized algo rithms. She notes that discussions of physician autonomy tend to address conscien tious objection to decisions such as abortion and/or refusal to ofer futile care. Fairfax Cryobank, for example, ofers an advanced search that allows for greater specifcity than its basic search with respect to ethnicity (fned tuned by country of origin), shades of skin tone (medium light, medium dark, light, dark, or medium), hair type (straight, curly, wavy), etc. It also ofers a lifestyle search that selects donors based on astrology sign, favorite subject, religion, favorite pet, personal goals, and talents. Outofapoolof410donors,therewerenoHighmatchesand only 12 and 8, Med and Low matches, respectively. Instead of eHarmony, imagine EmbryoHarmony,153 and instead of Donor MatchMe, imagine BabyMatch. As long as parents use reproductive technologies to choose among embryos (or make decisions about pregnancies), certain preferences (whether expressed in mathematical formulas or not) inevitably shape those decisions. This argument presumes, however, that people have a clear understanding of and can articulate their values and preferences (generally and in this context). The more complex and elaborate the individualized algorithms, the more likely people would opt for generic algorithms, which would be problematic for several reasons. First, we might worry that using generic algorithms would be an abdication of deci sion making with respect to a technology intended to enhance reproductive choice. Lee Raine & Janna Anderson, Pew Research Center, Code-Dependent: Pros and Cons of the Algorithm Age 4 (Feb. Typically, we relinquish decision-making authority for important decisions to those who have special knowledge of us and our individual circumstances. Generic algorithms, however, falsely suggest a uniformity of views161 regarding genetic information and its relevance to reproductive decision making. By defnition, they do not depend on, and therefore could easily lead to decisions inconsistent with, individual values or preferences. Obviously, there are individual diferences in the extent to which people rely on others and on whom they rely. For example, 40% of highly religious evangelical Protestants say they turn to religious leaders a lot for advice when making major life decisions. The less individual preferences would be incorporated, the more problematic the algorithm would be, with a fully generic algorithm being the most problematic. The possibility of hidden biases in algorithms was 296 r The tyranny of choice a mathematical expression of values and preferences. Indeed, the appeal of these algo rithms might be precisely their apparent objectivity. By standardizing reproductive choices based on the variants that were especially determinative in the program, algorithms would tend to favor certain kinds of traits (medical or non-medical) and disfavor others. This would be less likely with individualized algorithms, as long as individual preferences were sufciently variable. We might worry about the long-term evo lutionary implications, if they reduced genetic diversity. The efects of the algorithms would dwarf cultural pressures that infuence routinization. Such choices could stigmatize the groups routinely a common concern among respondents in the Pew study on algorithms. The tyranny of choice r 297 screened against,171 ultimately leading to and/or reinforcing discrimination against those groups. To be sure, there have always been worries that prenatal selection encourages future parents to fxate on the future child in terms of the presence or absence of a particular trait(whichtodatehasmostlybeendiseases). Either way, they would not have the opportunity to make the more fnely tuned selec tions that algorithms would allow. To the extent that algorithms allow for the ability to select on the basis of a combination of traits that ofer societal advantages, we would once again see individuals of higher socioeconomic status multiplying the opportuni ties for their future children in stark contrast to those with fewer economic resources. Quite apart from general concerns about algorithms, particularly generic algorithms, specifc concerns might arise based on who develops the algorithms. In many ways, medical professionals or professional societies seem best suited for the task. They have special insight and expertise as to what information is clinically relevant and the kinds of considerations that infuence reproductive decisions. Tisstudynotedthatthisphenomenonmaynotbecomeapparentimmediatelybecauseof the complexity of the choices, the desire to publicly justify the choices, and the need for processing time. Nevertheless,thedevelopmentofgenericalgorithmsbymedicalprofessionalsmight challenge their professional norms and identities in several ways. Such algorithms would deviate from the long-held perspective that the right reproductive choice for one person might not be the right choice for another. A generic algorithm by defni tion would imply that one size actually does ft all. Developing generic algorithms would also depart from the neutral stance that such professionals, particularly genetic counselors, have long advocated. Even though pa tients would presumably have the option to reject the algorithms, assigning relative val ues to diferent genetic variants would overtly signal that the profession is not actually neutral about the reproductive choices. Further, professionals might have unique biases that do not refect those of the patient or broader population, which could dis tort decision making, particularly if their generic algorithms were widely adopted. Although the feld of clinical genetics grew out of this movement,176 clinical geneticists and genetic counselors have worked hard to distance themselves from eugenics. Beyond concerns about professional identities and norms, we might further worry that the creation of generic algorithms by professionals would make these algorithms inordinately enticing. When faced with the overwhelming task of selecting from a mul titude of embryos or providing input for individualized algorithms, people might fnd generic algorithms created by the very professionals to whom they turn for reproduc tive guidance a calming alternative in the chaos of choice. Nei ther is it like considering professional views when facing difcult decisions. In many ways, this would amount to professionals giving advice about non-medical maters, which exceeds the scope of their expertise. Even today, reproductive decisions (such as choosing to undergo prenatal screening or testing) are ofen seen as medically re sponsible decisions, rather than personal decisions. Tat perspective might further tempt patients to forego individualized decision making in fa vor of generic algorithms, enhancing concerns about the societal efects of algorithms dramatically routinizing reproductive choices. The market power to routinize this kind of decision making would potentially be much greater in this context for a few reasons. Tird, if such eforts were successful, market pres sures would push toward expansive genetic analysis and potentially also toward specifc outcomes based on whatever genetic variants the algorithms favored and disfavored. If widely used, these algorithms could narrow reproductive decisions in ways we have never seen. Moreover, because proft motives, rather than fduciary obligations, would 178 See supra text accompanying notes 166. One could argue, however, that the patient is simply trying on diferent kinds of choices, not entirely puting her choice in the hands of the genetic counselor. We cannot know with certainty what technological advances will be possible and what the institutional and cultural reactions will be to those that unfold. In this article, I hope to demonstrate that the tyranny of choice couldleadtotheabdicationofchoicebysome,whichmayleadtoefortsbyprofessional groups, fertility clinics, and commercial labs to intervene. Instead, we should think carefully about what kind of reproductive choice we want and whether it ofers all that it promises. The industry is centred around the provision of genetic tests directly to the public. A consumer purchases a genetic test online, the company will then send the consumer a collection kit, which allows her to take a saliva sample, which she then sends back to the company for analysis. The company may also store both the physical sample and the sequenced genetic data and often performs secondary research, which the consumer may not know about. Some companies allow consumers to engage in social networking on their websites and this differs from other forms of social media in that consumers are encouraged to share health information not just about themselves, but also about their families online. Each of these steps involves digital data or physical material, each of which raises privacy and security issues. Overall, these potential consumers are reasonably confident that, as a consumer of these services, they themselves control the privacy and release of their genetic information. Overall, it was found that many contracts contain clauses that might raise concern from a consumer protection perspective. When it comes to privacy and privacy breaches stored genetic data differs from other forms of personal data in that, unlike say a hacked bank password, it cannot be changed and the privacy breach extends beyond the affected individual to their genetic relatives. With the increasing use of biometrics in security systems, insecure storage of genetic data may pose as yet unforeseen risks for consumers. In the future, there may be an incentive for hackers to target genetic databases in order to acquire data than can be used in financial or identity fraud. There are a number of other risks associated with the use of genetic data, including: targeted marketing of drugs to individuals and family groups; potential genetic discrimination resulting from sharing genetic information with third parties; and sharing with law enforcement or government agencies without appropriate consent. Our research is timely because the industry is developing rapidly and the law is not keeping pace with its development. While there is a lack of specific legal regulation, contracts are being used as the dominant governance mechanism, which raises a number of issues. The lack of traditional gatekeepers, such as clinicians and genetic counsellors who have generally assisted people with understanding genetic test results is also problematic. Phillips, Jan Charbonneau from GeneWatch 28-3 | Oct-Dec 2015 Race and Genetics For centuries, human societies have divided population groups into separate races. While there is no scientific basis for this, people unquestioningly accept these classifications as fact. Questions have been raised about the quality of health-related direct-to-consumer genetic tests and whether results are understandable by the average consumer. For tests to provide personal utility information someone can do something with consumers must be able to first understand their test results. While many companies actively suggest consumers consult their doctors or genetic counselors, that also is left to the consumer. Analysis revealed that for some consumers, interpretation of these two numbers is anything but objective.
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Decontamination of the entire laboratory must be performed using a validated gaseous or vapor method when there have been significant changes in laboratory usage 3 menstrual cycles in 1 month discount 2mg estrace visa, before major renovations or maintenance shut downs contemporary women's health issues for today and the future 5th edition pdf buy discount estrace on line, and in other situations menopause gag gifts discount estrace 2 mg overnight delivery, as determined by risk assessment womens health 4 week fat blaster best order estrace. An eyewash station must be readily available in the laboratory area for use during maintenance and repair activities womens health doctor estrace 1 mg otc. The exhaust air discharge must be located away from occupied spaces and air intakes women's health center rockford il purchase 2 mg estrace visa. Biological safety cabinets can also be connected to the laboratory exhaust system by either a thimble (canopy) connection or a direct (hard) connection womens health 8 healthy eating instagram purchase estrace with a mastercard. Liquid effluents from chemical showers womens health practice champaign il buy cheap estrace 1 mg line, sinks, floor drains, autoclave chambers, and other sources within the laboratory must be decontaminated by a proven method, preferably heat treatment, before being discharged to the sanitary sewer. The decontamination process for liquid wastes must be validated physically and biologically. Effluents from personal body showers and toilets may be discharged to the sanitary sewer without treatment. A double-door, pass through autoclave(s) must be provided for decontaminating materials passing out of the cabinet laboratory. Appropriate communication systems must be provided between the laboratory and the outside. In both instances, the institutional management must provide facilities, staff, and established practices that reasonably ensure appropriate levels of environmental quality, safety, security and care for laboratory animal. As a general principle, the biosafety level (facilities, practices, and operational requirements) recommended for working with infectious agents in vivo and in vitro are comparable. In the animal room, the activities of the animals themselves can present unique hazards not found in standard microbiological laboratories. Animals may generate aerosols, they may bite and scratch, and they may be infected with a zoonotic agent. The co-application of Biosafety Levels and the Animal Biosafety Levels are determined by a protocol driven risk assessment. These recommendations presuppose that laboratory animal facilities, operational practices, and quality of animal care meet applicable standards and regulations. In addition, the organization must have an occupational health and safety program that addresses potential hazards associated with the conduct of laboratory animal research. Facilities for laboratory animals used in studies of infectious or non-infectious disease should be physically separate from other activities such as animal production and quarantine, clinical laboratories, and especially from facilities providing patient care. Traffic flow that will minimize the risk of cross contamination should be incorporated into the facility design. The recommendations detailed below describe four combinations of practices, safety equipment, and facilities for experiments with animals involved in infectious disease research and other studies that may require containment. Investigators that are inexperienced in conducting these types of experiments should seek help in designing their experiments from individuals who are experienced in this special work. Facility standards and practices for invertebrate vectors and hosts are not specifically addressed in this chapter. The reader is referred to Appendix E for more information on the Arthropod Containment Guidelines. Animal Biosafety Level 1 Animal Biosafety Level 1 is suitable for work involving well characterized agents that are not known to cause disease in immunocompetent adult humans, and present minimal potential hazard to personnel and the environment. Special containment equipment or facility design may be required as determined by appropriate risk assessment (See Chapter 2). Personnel must have specific training in animal facility procedures and must be supervised by an individual with adequate knowledge of potential hazards and experimental animal procedures. Each institute must assure that worker safety and health concerns are addressed as part of the animal protocol review. Personnel are advised of potential hazards and are required to read and follow instructions on practices and procedures. Personnel must receive annual updates or additional training when procedures or policies change. Appropriate medical surveillance program is in place, as determined by risk assessment. Therefore, all personnel and particularly women of child-bearing age should be provided information regarding immune competence and conditions that may predispose them to infection. A sign incorporating safety information must be posted at the entrance to the areas where infectious materials and/or animals are housed or are manipulated. Security-sensitive agent information should be posted in accordance with the institutional policy. Only those persons required for program or support purposes are authorized to enter the facility. All persons including facility personnel, service workers, and visitors are advised of the potential hazards (natural or research pathogens, allergens, etc) and are instructed on the appropriate safeguards. Gloves are worn to prevent skin contact with contaminated, infectious and hazardous materials, and when handling animals. Persons must wash their hands after removing gloves, and before leaving the areas where infectious materials and/or animals are housed or are manipulated. Eye and face and respiratory protection should be used in rooms containing infected animals, as dictated by the risk assessment. Non-disposable sharps must be placed in a hard-walled container for transport to a processing area for decontamination, preferably by autoclaving. Equipment and work surfaces are routinely decontaminated with an appropriate disinfectant after work with an infectious agent, and after any spills, splashes, or other overt contamination. All wastes from the animal room (including animal tissues, carcasses, and bedding) are transported from the animal room in leak-proof, covered containers for appropriate disposal in compliance with applicable institutional, local and state requirements. Decontaminate all potentially infectious materials before disposal using an effective method. Special containment devices or equipment may not be required as determined by appropriate risk assessment. A risk assessment should determine the appropriate type of personal protective equipment to be utilized. Protective outer clothing is not worn outside areas where infectious materials and/or animals are housed or manipulated. Protective eyewear is worn when conducting procedures that have the potential to create splashes of microorganisms or other hazardous materials. Persons who wear contact lenses should also wear eye protection when entering areas with potentially high concentrations or airborne particulates. A risk assessment should be performed to identify the appropriate glove for the task and alternatives to latex gloves should be available. Persons must wash their hands after handling animals and before leaving the areas where infectious materials and/or animals are housed or are manipulated. The animal facility is separated from areas that are open to unrestricted personnel traffic within the building. Doors to areas where infectious materials and/or animals are housed or open inward, are self-closing, are kept closed when experimental animals are present, and should never be propped open. Sink traps are filled with water, and/or appropriate liquid to prevent the migration of vermin and gases. The animal facility is designed, constructed, and maintained to facilitate cleaning and housekeeping. It is recommended that penetrations in floors, walls and ceiling surfaces are sealed, to include openings around ducts, doors and door frames, to facilitate pest control and proper cleaning. Chairs used in animal area must be covered with a non-porous material that can be easily cleaned and decontaminated. External windows are not recommended; if present windows must be resistant to breakage. Ventilation should be provided in accordance with the Guide for Care and 1 Use of Laboratory Animals. Ventilation system design should consider the heat and high moisture load produced during the cleaning of animal rooms and the cage wash process. Internal facility appurtenances, such as light fixtures, air ducts, and utility pipes, are arranged to minimize horizontal surface areas to facilitate cleaning and minimize the accumulation of debris or fomites. If floor drains are provided, the traps are filled with water, and/or appropriate disinfectant to prevent the migration of vermin and gases. Illumination is adequate for all activities, avoiding reflections and glare that could impede vision. Emergency eyewash and shower are readily available; location is determined by risk assessment. It also addresses hazards from ingestion as well as from percutaneous and mucous membrane exposure. Appropriate personal protective equipment must be utilized to reduce exposure to infectious agents, animals, and contaminated equipment. The animal facility director establishes and enforces policies, procedures, and protocols for institutional policies and emergency situations. A safety manual specific to the animal facility is prepared or adopted in consultation with the animal facility director and appropriate safety professionals. Personnel are advised of potential hazards, and are required to read and follow instructions on practices and procedures. Consideration should be given to specific biohazards unique to the animal species and protocol in use. Supervisor must ensure that animal care, laboratory and support personnel receive appropriate training regarding their duties, animal husbandry procedure, potential hazards, manipulations of infectious agents, necessary precautions to prevent hazard or exposures, and hazard/exposure evaluation procedures (physical hazards, splashes, aerosolization, etc. Facility supervisors should ensure that medical staff is informed of potential occupational hazards within the animal facility, to include those associated with research, animal husbandry duties, animal care and manipulations. Personnel using respirators must be enrolled in an appropriately constituted respiratory protection program. A sign incorporating the universal biohazard symbol must be posted at the entrance to areas where infectious materials and/or animals are housed or are manipulated when infectious agents are present. Security-sensitive agent information and occupational health requirements should be posted in accordance with the institutional policy. Only those persons required for program or support purposes are authorized to enter the animal facility and the areas where infectious materials and/or animals are housed or are manipulated. All persons including facility personnel, service workers, and visitors are advised of the potential hazards (natural or research pathogens, allergens, etc. Protective laboratory coats, gowns, or uniforms are required to prevent contamination of personal clothing. Gloves are worn to prevent skin contact with contaminated, infectious and hazardous materials and when handling animals. Gloves and personal protective equipment should be removed in a manner that minimizes transfer of infectious materials outside of the areas where infectious materials and/or animals are housed or are manipulated. All procedures are carefully performed to minimize the creation of aerosols or splatters of infectious materials and waste. Animal care staff, laboratory and routine support personnel must be provided a medical surveillance program as dictated by the risk assessment, and administered appropriate immunizations for agents handled or potentially present, before entry into animal rooms. Procedures involving a high potential for generating aerosols should be conducted within a biosafety cabinet or other physical containment device. When a procedure cannot be performed within a biosafety cabinet, a combination of personal protective equipment and other containment devices must be used. Decontamination is recommended for all potentially infectious materials and animal waste before movement outside the areas where infectious materials and/or animals are housed or are manipulated by an appropriate method. This includes potentially infectious animal tissues, carcasses, contaminated bedding, unused feed, sharps, and other refuse. Consideration should be given to means for decontaminating routine husbandry equipment, sensitive electronic and medical equipment. Materials to be decontaminated outside of the immediate areas where infectious materials and/or animals are housed or are manipulated must be placed in a durable, leak proof, covered container and secured for transport. Medical evaluation, surveillance, and treatment should be provided as appropriate and records maintained. These include necropsy of infected animals, harvesting of tissues or fluids from infected animals or eggs, and intranasal inoculation of animals. When indicated by risk assessment, animals are housed in primary biosafety containment equipment appropriate for the animal species, such as solid wall and bottom cages covered with filter bonnets for rodents, or larger cages placed in inward flow ventilated enclosures or other equivalent primary containment systems for larger animal cages. Reusable clothing is appropriately contained and decontaminated before being laundered. Gloves and personal protective equipment should be removed in a manner that prohibits transfer of infectious materials. If the animal facility has segregated areas where infectious materials and/or animals are housed or manipulated, a sink must also be available for hand washing at the exit from each segregated area. Penetrations in floors, walls and ceiling surfaces are sealed, to include openings around ducts, doors and door frames, to facilitate pest control and proper cleaning. External windows are not recommended; if present, windows should be sealed and must be resistant to breakage. The direction of airflow into the animal facility is inward; animal rooms should maintain inward directional airflow compared to adjoining hallways. Provisions to assure proper safety cabinet performance and air system operation must be verified. An autoclave should be considered in the animal facility to facilitate decontamination of infectious materials and waste. Animal Biosafety Level 3 Animal Biosafety Level 3 involves practices suitable for work with laboratory animals infected with indigenous or exotic agents, agents that present a potential for aerosol transmission and agents causing serious or potentially lethal disease. Personnel are advised of potential and special hazards, and are required to read and follow instructions on practices and procedures. Records are maintained for all hazard evaluations, employee training sessions and staff attendance. A sign incorporating the universal biohazard symbol must be posted at the entrance to areas where infectious materials and/or animals are housed or are manipulated. Access to the animal room is limited to the fewest number of individuals possible. Gloves are worn to prevent skin contact with contaminated, infectious/ and hazardous materials and when handling animals. Eating, drinking, smoking, handling contact lenses, applying cosmetics, and storing food for human use should only be done in designated areas and are not permitted in animal or procedure rooms. Needles and syringes or other sharp instruments are limited to use in the animal facility when there is no alternative for such procedures as parenteral injection, blood collection, or aspiration of fluids from laboratory animals and diaphragm bottles. Used disposable needles must be carefully placed in puncture-resistant containers used for sharps disposal. Broken glassware must not be handled directly; it should be removed using a brush and dustpan, tongs, or forceps. All wastes from the animal room (including animal tissues, carcasses, and bedding) are transported from the animal room in leak-proof containers for appropriate disposal in compliance with applicable institutional, local and state requirements. Decontaminate of all potentially infectious materials before disposal using an effective method. Consideration should be given to the use of restraint devices and practices that reduce the risk of exposure during animal manipulations. Actively ventilated caging systems must be designed to prevent the escape of microorganisms from the cage.
The effect of an educational program to improve health-related quality of life in patients with osteoarthritis on waiting list for total knee replacement: A randomized study menstrual flow chart generic estrace 2mg free shipping. National service improvement framework for osteoarthritis menstruation hut estrace 1mg generic, rheumatoid arthritis and osteoporosis 1800s menstrual cycle order estrace 2 mg fast delivery. Complications from therapeutic modalities: Results of a national survey of athletic trainers women's health clinic markham purchase generic estrace line. Contraindications for superfcial heat and therapeutic ultrasound: Do sources agree Clinical practice guidelines for physical therapy in patients with osteoarthritis of the hip or knee: Royal Dutch Society for Physical Therapy; 2003 womens health 30s book order cheapest estrace and estrace. Transcutaneous electrical nerve stimulation and interferential current combined with exercise for the treatment of knee osteoarthritis: A randomised controlled trial women's health new zealand cheap estrace on line. Acupuncture for peripheral joint osteoarthritis: A systematic review and meta-analysis menstrual flow cups order 1mg estrace visa. Acupuncture in patients with osteoarthritis of the knee or hip: A randomized menstruation extraction 1 mg estrace amex, controlled trial with an additional nonrandomized arm. Laser acupuncture in knee osteoarthritis: A double-blind, randomized controlled study. Effcacy of knee tape in the management of knee osteoarthritis: A blinded randomised controlled trial. Immediate effects of adhesive tape on pain and disability in individuals with knee osteoarthritis. Taping the patella medially: A new treatment for osteoarthritis of the knee joint Health outcomes of two telephone interventions for patients with rheumatoid arthritis or osteoarthritis. Effcacy of static magnetic feld therapy in chronic pelvic pain: A double-blind pilot study. Randomised controlled trial of magnetic bracelets for relieving pain in osteoarthritis of the hip and knee. Effectiveness of leech therapy in osteoarthritis of the knee: A randomized, controlled trial. Multi-disciplinary integrative approach to treating knee pain in patients with osteoarthritis. Do selective cyclo-oxygenase-2 inhibitors and traditional non-steroidal anti-infammatory drugs increase the risk of atherothrombosis Celecoxib versus diclofenac and omeprazole in reducing the risk of recurrent ulcer bleeding in patients with arthritis. Adverse effects of cyclooxygenase 2 inhibitors on renal and arrhythmia events: Meta-analysis of randomized trials. Prevalence of opioid adverse events in chronic non-malignant pain: Systematic review of randomised trials of oral opioids. Effcacy and safety of opioids for osteoarthritis: A meta-analysis of randomized controlled trials. Transdermal fentanyl for improvement of pain and functioning in osteoarthritis: A randomized, placebo-controlled trial. Longterm effcacy of topical nonsteroidal antiinfammatory drugs in knee osteoarthritis: Meta-analysis of randomized placebo controlled clinical trials. The analgesic effcacy of topical capsaicin is enhanced by glyceryl trinitrate in painful osteoarthritis: A randomized, double blind, placebo controlled study. Effcacy and safety of intraarticular hyaluronic acid in the treatment of hip osteoarthritis: A systematic review. Comparison between high and low molecular weight hyaluronates in knee osteoarthritis patients: Open-label, randomized, multicentre clinical trial. A prospective, randomized, double-blind, placebo controlled study to evaluate the effcacy of intraarticular hyaluronic acid for osteoarthritis of the knee. Glucosamine sulfate in the treatment of knee osteoarthritis symptoms: A randomized, double-blind, placebo-controlled study using acetaminophen as a side comparator. A systematic review of lateral wedge orthotics: How useful are they in the management of medial compartment osteoarthritis Pulsed electromagnetic energy treatment offers no clinical beneft in reducing the pain of knee osteoarthritis: A systematic review. Clinical questions relevant to the area of guideline focus were developed to focus the search for relevant literature. Identifcation, appraisal and selection of existing clinical guidelines Due to extensive research that has been published on arthritis and its management, it was not feasible for the Working Group to conduct appraisals and a review of all the relevant research within the time and budget constraints of this project. As clinical guidelines have previously been published on the management of osteoarthritis, it was determined that the most feasible methodology would be to use an appropriate existing guideline as a primary reference and conduct a literature search to identify newly available evidence. Existing guidelines were identifed through database searches and those known to the Working Group. Report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials. Clinical guidelines for managing lower-limb osteoarthritis in Hong Kong primary care setting. Guidelines for the diagnosis, investigation and management of osteoarthritis of the hip and knee. Report of a Joint Working Group of the British Society for Rheumatology and the Research Unit of the Royal College of Physicians. Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises and manual therapy in the management of osteoarthritis. This guideline presented a comprehensive review of pharmacological and non-pharmacological management of knee and hip osteoarthritis within the Australian health care context, based on evidence identifed in literature searches to June 2005. The process used for the literature search is reported in more in detail in Non-surgical management of hip and knee osteoarthritis: a literature review of recent evidence ( An additional search was conducted in March 2007 to identify evidence for interventions not represented in the initial search. Articles identifed via personal contact with authors were also considered for inclusion. Types of participants Studies that included adults (aged 18 years or more) with a diagnosis of osteoarthritis of the hip and/or knee were considered for inclusion. Types of interventions Both pharmacological and non-pharmacological interventions were eligible for inclusion in this review. Surgical interventions and interventions for patients following joint replacement surgery were not eligible for inclusion. Critical appraisal One reviewer critically appraised all studies that met the inclusion criteria, with a second reviewer appraising 40% of the papers. A second reviewer checked data extraction for 40% of the papers and no discrepancies were found. Data from included studies was presented in a descriptive literature review as well as a tabulated format. The literature 57 Guideline for the non-surgical management of hip and knee osteoarthritis July 2009 searches identifed minimal-no evidence directly related to these populations, thus a broader search was conducted to identify any research that addressed management of arthritis in the special population groups. All 10 papers were excluded as they did not directly relate to osteoarthritis, or were historical health information. Each recommendation was given a fnal grading (Table 4) representing its overall strength. The gradings refect implementability in terms of confdence practitioners can use in a clinical situation. The overall grade of each recommendation was reached through consensus and is based on a summation of the grading of individual components of the body of evidence assessment. In reaching an overall grade, recommendations did not receive a grading of A or B unless the volume and consistency of evidence components were both graded either A or B. An interactive survey was designed to collect comments from all potential stakeholders. The public consultation period was advertised in major national newspapers and over 200 known stakeholders (eg. Feedback collected from the survey and independent submissions were collated and addressed by the Working Group. The Working Group would like to thank respondents who provided feedback during the consultation phase of the project. Making decisions about tests and treatments: Principles for better communication between healthcare consumers and healthcare professionals. Land based exercise Pisters M, Veenhof C, van Meeteren N, Ostelo R, de Bakker D, Schellevis F, Dekker J. Long-term effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee: a systematic review. Physical therapy including Jamtvedt G, Dahm K, Christie A, Rikke H, Haavardsholm E, Holm I, Hagen K. A systematic review magnetic therapy and and meta-analysis of randomised placebo-controlled trials. Short-term effcacy of interventions pharmacotherapeutic interventions in osteoarthritic knee pain: A meta-analysis of randomised placebo-controlled trials. Cyclooxygenase-2 selective non-steroidal anti-infammatory drugs (etodolac, meloxicam, celecoxib, rofecoxib, etoricoxib, valdecoxib and lumiracoxib) for osteoarthritis and rheumatoid arthritis: a systematic review and economic evaluation. Chondroitin sulphate for symptomatic osteoarthritis: critical appraisal of meta-analyses. Systematic review of the dietary therapies nutritional supplement Perna Canaliculus (green-lipped mussel) in the treatment of osteoarthritis. Differences between systematic reviews/meta analyses of hyaluronic acid/hyaluronan/hylan in osteoarthritis of the knee. Hylan versus hyaluronic acid for osteoarthritis of the knee: a systematic review and meta-analysis. Hyaluronic acid and hylan Samson D, Grant M, Ratko T, Bonnell C, Ziegler K, Aronson N. I have been referred to a physiotherapist to help me work out a physical activity program that will suit me. My doctor has advised me on what tests and physical checks are needed to detect and prevent side effects. Palpation over the may include sensitivity to grooming, resistance to lumbosacral area produces a painful response. There may be considerable these symptoms may arise as issues secondary to resistance on the part of the horse to have one of the 1 other lameness problems, particularly of the hind hind legs picked up. Rocking the pelvis may cause limb, and frequently the dif culty is determining the horse to grunt. A thorough physical ex lameness may be apparent in the opposite hind amination, coupled with a complete therapeutic ap limb after an upper limb exion test. The horse may proach, can most frequently relieve symptoms of be observed to have one more prominent tuber lumbosacral and sacroiliac pain. Many horses are mildly affected on a joint region, but this can be tricky, with a misplaced chronic basis and continue to perform, although injection causing dif culty for the horse to stand. In Nuclear scintigraphy can be useful in assessing if more severe cases, performance is usually signi signi cant in ammation is present in the area. Using rectal ultrasound, the ventral aspect of the sacroiliac and lumbosacral joints may be vi sualized as well as the foramina for the last lumbar and sacral nerve roots. Rest and time are the two most signi cant factors in treating serious injuries of the sacroiliac joint region. In the case of severe strain, which is likely to be accompanied by sudden-onset lameness, heal ing of the injured tissue probably will require 6 months or longer. The horse should be stall-rested C for 30 days, followed by 2 to 3 months of controlled O L paddock rest (tranquilized at rst, if necessary). O After this, light exercise on at surfaces with a grad R ual increase in the amount of work over the next 3 months will allow time for healing and regaining Fig. Deep injection of the sacroiliac joint region may be of additional bene t and will be described herein. Peri-articular in Injection Technique jection of corticosteroids over the sacroiliac region the rst of the two more commonly used techniques may signi cantly reduce pain and allow for contin 3 was described by Engeli et al (2002). Various injection techniques have been a blind dorsomedial technique using a 6 to 10-inch described utilizing blind and ultrasound-guided meth (12. There are two more commonly used tech along the cranial edge of one contralateral tuber niques for injection of the lumbosacral and sacroiliac sacrale and directed obliquely and slightly caudally joints that will be outlined in this article. The rst across the midline to the medial aspect of the oppo technique will describe a blind injection technique site tuber sacrale. Not directing the needle suf and the second will outline the steps for an ultra ciently caudally may result in hitting the spinous sound-guided technique. Longer nee Proper site preparation is essential for success in dles will obviously be required in larger horses. Clipping the needle is then directed along the medial surface of the injection site(s) may provide for a more com of the ilium toward the sacrum as deeply as possible. Horses with a ne coat needle slightly to accommodate placement for larger can be adequately cleansed for injection, and ultra gauge needles. F1,F2 should be clipped for both blind and ultrasound the area is then in ltrated with 10 to 15 mL of a guided techniques. This technique may within the cover for ultrasound coupling, and alcohol produce successful results, but the margin for error will suf ce for cleaning the skin surface. The use of the larger needle may require local anesthetic Restraint in ltration and a small stab incision to facilitate Appropriate sedation and restraint is indicated for the injection. The author than 18 gauge) may result in excessive bending of prefers a combination of detomidine hydrochloride the needle and an inaccurately placed injection. This technique requires more is inserted and passed in the plane of the ultrasound preparation and equipment, but it provides more beam deep to the wing of the ilium in a direction complete coverage of the sacroiliac region. An 8-inch needle will be F6 the spinal column approximately 5 to 7 cm off of the necessary in most large horses, but a 6-inch needle midline adjacent to and slightly cranial of the tuber is normally suf cient for a medium pony. From this dle typically ends up rmly seated on bone in the interosseous sacroiliac ligament. Ten milliliters of corticosteroid mixture is injected locally, and the needle is withdrawn. For horses that have demon strated considerable lumbosacral pain, there may be an advantage to partially withdrawing the needle and to redirect it in the plane of the ultrasound beam C O L O R Fig. Since the fth lumbar transverse process injection of interleukin-1 receptor antagonist pro is a landmark for this technique, the needle passes h tein may be used to reduce local in ammation and from view only brie y before hitting the dorsal sur possibly stimulate local healing for more serious face of the sixth lumbar transverse process. The caudal aspect of the sacroiliac joint region is then visualized from a spot caudal to the tuber 3. Results sacrale with the probe placed transversely (obliqued slightly caudally) to visualize the caudal margin of At Fair eld Equine Associates, between 2007 and the ilium and the lateral sacral crest. A 6-inch needle 2011, the two discussed techniques have been used is directed ventrally in the plane of the ultrasound to inject the sacroiliac joint region of horses and ponies beam to the lateral sacral crest at the caudal margin of 1,096 times. Patient imately 5 mL of corticosteroid mixture is deposited at response in those horses judged to have back pain each site. Care must be taken to adequately visualize related to the lumbosacral and sacral region have uni the needle as it approaches the lateral sacral crest. Good response has on occa Inaccurate placement may affect the sciatic nerve or sion been followed by a return of symptoms in several C O L O R Fig. These techniques have proven effective in relieving References and Footnotes pain from minor to moderate strains and chronic 1. Clinical features of pain associated arthritis of the lumbosacral and sacroiliac joint re with the sacroiliac joint region: a European perspective, in gion. In: Diagnosis and Man however, the blind technique may be more appro agement of Lameness in the Horse 2nded. How to inject the sacroiliac because of acoustic impedance, and the caudal ap joint region in horses, in Proceedings.
