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Human analysis Violations via america Eye medical professional showcase a country wide issue | killexams.com Real Questions and Pass4sure dumps

Share this text: Facebooktwittergoogle_plusredditpinterestlinkedinmail A black light illuminates a man’s eye after he received fluorescein drops during an exam. (U.S. Department of Defense)A black mild illuminates a person’s eye after he received fluorescein drops throughout an examination. (U.S. branch of protection) Brad Racino & Jill Castellano | inewsource inewsourceinewsource is an independent and nonprofit journalism company in San Diego, and depends on offers and philanthropists to guide its investigative content material. click on right here to study more.

Tens of tens of millions of americans have volunteered their time and their bodies to support create breakthroughs in medication. You see the results with the ache relievers on your medication cabinet, the vaccines that give protection to you from disease, the pacemakers that hold your heart beating and the improvements happening now with stem cells.

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Yet the techniques supposed to give protection to these volunteers from damage are removed from ultimate, and research violations with the aid of Dr. Kang Zhang, a watch doctor on the school of California San Diego, display just how without problems that neatly-intentioned framework can cave in.

Zhang is the chief of eye genetics at u.s. and has a lab named after him on the tuition. He receives millions of dollars in federal delivers and gifts at symposiums all over.

a couple of years in the past, he helped develop a method to get rid of cataracts from toddlers and regenerate their lenses using their own stem cells. He additionally developed a tool that scanned over a million patient information and diagnosed diseases with more than 90% accuracy.

but a couple of of Zhang’s reports were riddled with violations of primary human analysis requisites. A U.S. food and Drug Administration warning in 2017 and a usa audit that adopted display a sample that put patients in damage’s means for years.

The 56-yr-historic doctor enrolled individuals he shouldn’t have for his clinical trials, did not document what came about to 25 units of a look at drug, carried out HIV tests on participants without their permission, stored poor records on his patients and didn’t comprehensive indispensable ethics working towards for a stem telephone study.

When asked via the FDA to create a plan to steer clear of extra violations from happening in the future, Zhang didn’t deliver one.

“There must be some severe penalties for this variety of thing,” talked about Spencer good day, a Harvard scientific school expert in biomedical analysis ethics.

inewsource reached out to Zhang, the director of the attention institute where he works and the director of u.s.a.’s human research coverage application for interviews. In response, america sent an announcement that referred to the college had “carried out a finished management plan to tackle these considerations” and suspended Zhang indefinitely from serving as a first-rate researcher overseeing human research experiences at u.s.. He might also proceed to apply for federal gives you, submit in scientific journals and teach the subsequent technology of scientists.

Dr. Kang Zhang is the executive of eye genetics at the institution of California San Diego. (usa)

america later informed inewsource, “Zhang’s research had gone through multiple audits due to the fact 2012,” which caused his suspension. When asked if that supposed the college had prevalent about Zhang’s violations for five years earlier than taking action, a u.s. spokeswoman would not remark extra.

After speakme with five ethics specialists for this story, it seems Zhang’s violations — and what took place after they had been found — are symptomatic of larger problems impacting the field of human area analysis within the U.S. these include patchwork oversight and terrible verbal exchange between watchdog businesses, a lack of transparency and talk with the general public, and a combination of cash and status that sometimes shield an institution’s popularity greater than affected person welfare.

“Science is accelerating all the time,” stated Stacey Springs, Harvard school’s analysis integrity officer. “nonetheless it feels that it’s accelerating in methods which are pushing on regulatory compliance like on no account earlier than. So they actually need to focal point now, and be taught from every different, and follow these most advantageous practices – because it’s coming quickly.”

An early warning

Zhang acquired his medical diploma and doctorate in genetics from Harvard, then taught at Johns Hopkins school and the school of Utah earlier than founding usa’s Institute for Genomic drugs in 2009.

His accomplishments have landed him on CBS’ “60 Minutes” and within the new york times, The Wall road Journal and the los angeles instances. He’s got dozens of honors from country wide and overseas associations and universities, published or co-authored greater than one hundred peer-reviewed manuscripts in accurate journals and recruited human research subjects from all over – including from the San Diego VA and united states of america’s Shiley Eye Institute on the La Jolla campus.

It become all the way through Zhang’s time at the institute, in the summer of 2016, when the FDA inspected one of his ongoing human trials to ensure the “rights, safety, and welfare” of his sufferers have been covered.

For five years, Zhang had been testing a drug to reverse the consequences of a standard age-linked eye ailment. He acquired approval to join patients whose imaginative and prescient had already all started to say no – to see if the drug may fix their sight.

Zhang’s analysis group injected ranibizumab as soon as a month into every test discipline’s eyes, 12 times complete for each and every affected person. The drug can produce aspect outcomes that encompass eye haemorrhages, pain, inflammation and spots in a container of vision. In rare circumstances, it will probably prompt severe cataracts or blindness.

photographs of the back of the eye showing early (left) and superior age-related macular degeneration. (national Eye Institute, countrywide Institutes of fitness)

Twelve individuals had participated within the look at by the point the FDA stepped in and found 5 of them were ineligible because they didn’t have the imaginative and prescient complications Zhang outlined for individuals. a further affected person’s eyesight wasn’t appropriately evaluated before the person changed into injected with the drug.

“If it had been one out of 100, they might likely chalk that up to an error that doesn’t replicate a sample of misconduct,” stated Michael Carome, a former affiliate director on the U.S. workplace for Human analysis Protections, one of many federal organizations that protects human research subjects.

“but to join half the subjects not assembly enrollment criteria – this is greater than simply an occasional error. that implies whatever systematically incorrect with how they’re doing the research,” referred to Carome, who spent years investigating these sort of violations whereas on the agency.

He left the office for Human research Protections in 2010 all the way through a decade of decline, when the workplace all but stopped the use of its enforcement equipment in desire of “a greater pleasant strategy toward institutions,” he talked about.

Carome is now a director of the health analysis community at Public Citizen, a purchaser advocacy nonprofit based mostly in Washington, D.C.

He told inewsource that analysis on in any other case healthy sufferers must be performed carefully, as a result of they aren’t unwell sufficient to justify taking options.

“each from a scientific standpoint and moral human topics standpoint, now not complying with the enrollment standards is a large deal,” Carome said, calling the guidelines “vital in terms of ensuring that human subjects are blanketed.”

The FDA agreed. It issued Zhang a warning letter in January 2017 that known as out his use of ineligible patients and his failure to perform required screenings and approaches, poor recordkeeping and shortage of documentation about what took place to 25 devices of the unused examine drug (which Zhang noted have been destroyed).

notwithstanding not mentioned within the letter, the USA audit that followed spoke of Zhang additionally enrolled sufferers while the analyze become suspended.

The FDA uses warning letters to document critical analysis problems and mandate corrective movements. 3 times in the letter, it told Zhang his actions raised “considerations concerning the validity and integrity of the facts accumulated,” and thrice it advised Zhang he didn’t have an adequate plan to preserve his patients secure moving forward.

The U.S. meals and Drug Administration issued Dr. Kang Zhang a warning letter in January 2017. study the whole FDA report.

“we're unable to undertake an counseled comparison of your written response since you did not deliver a corrective action plan that, if safely carried out, would evade this class of violation in the future,” the FDA wrote.

The study was at last shut down, and inewsource might find no articles published in line with the analysis.

The FDA letter induced america to droop enrollment in all of Zhang’s active research initiatives at the time, pending the consequences of an interior audit.

Amy Caruso Brown is an assistant professor of bioethics, humanities and pediatrics at manhattan’s Upstate clinical institution. She is also a member of an institutional evaluation board – a security committee that approves and oversees projects like Zhang’s.

Brown spoke to inewsource after reading the USA audit and mentioned, “I have not considered this variety of considerations in the five years that I’ve been on an IRB.”

‘primary league science’

Zhang’s work at united states should be seen in context.

he is certainly one of more than 1,600 faculty contributors within the schools of drugs and pharmacy, one a part of a healthcare gadget at a institution ranked amongst the desirable research institutions within the nation.

america secured $1.2 billion in backed research guide in 2018 – with $686 million going towards UC fitness Sciences – and had more than 7,000 patients participating in scientific trials. Its scientists have made breakthroughs in diabetes research, figuring out cancer genes, picking early signals of autism and treating Alzheimer’s sickness. It counts 16 Nobel laureates among existing and former faculty.

All of that makes united states’s investigation of Zhang interesting. The school has published 249 inner audits because July 2010, and the Zhang document is the only one inewsourcecould find selected to an individual researcher.

Auditors reviewed Zhang’s training facts, enrollment logs, regulatory binders and data for ongoing projects that had enrolled human research sufferers. They discovered complications everywhere they looked: Zhang did not get the appropriate consent from all sufferers; didn’t file problems to united states of america’s institutional evaluate board; misplaced documents; stored inaccurate data; wrongly billed patients; and didn’t finished the practicing required to work with human embryonic stem cells.

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in a single study, Zhang’s personnel established patients’ blood for HIV and AIDS without telling them, towards federal policy.

“He’s lucky there weren’t any most important patient harms,” Brown stated. ”but if you act like this all of the time, finally you'll damage somebody.”

The auditors found Zhang’s actions may have “negatively impacted the rights, welfare, and safeguard of human subjects in clinical analysis.” certainly one of his reports, sponsored by using the California Institute for Regenerative drugs, accrued tissue from donors with blinding eye disorder for a stem mobilephone financial institution. California voters created the institute in 2004 to fund this class of analysis.

The study’s guidelines mentioned no one beneath 50 years historical become allowed to sign up. u.s.a. audited information for 50 of the greater than 400 patients and found seven were too young, including a minor.

Carome, the former federal director, laughed when he examine that part.

“That’s now not a refined mistake,” he stated.

a different discovering mentioned the value of “credible and legitimate information” when describing a examine that turned into missing 25 of 50 affected person development reviews.

“This isn’t minor league stuff. here is major league science,” noted hey, the Harvard bioethicist, who added, “this form of pattern should still lift questions in regards to the validity of (Zhang’s) posted work.”

Zhang did post a correction in January, however now not for a analyze protected within the audit. It worried gene modifying in animals, and Zhang’s paper observed u.s.a. supervised and approved the analysis. That wasn’t proper – it became overseen via a college and medical center in China.

inewsource couldn’t discover any published articles according to the six stories reviewed by using the FDA and u.s.a.. Yet right through the audits and analyze suspensions, Zhang is listed as having endured a genetics analysis venture on the San Diego VA, which did outcomes in 10 published articles.

united states of america doctors regularly work as attending physi cians at the San Diego VA and share funding, analysis samples, information and lab space. The VA health facility is less than a mile from the Shiley Eye Institute and on the identical campus. Yet the VA referred to it became under no circumstances notified of the U.S. or FDA stories unless inewsource asked about them in March.

A VA spokeswoman would no longer reply questions about even if Zhang turned into nonetheless working towards at the VA, enrolling patients in trials or proposing new research on the institution. The San Diego VA has one of the crucial biggest research courses in the countrywide VA community.

Nor had been different linked federal or state regulators notified. That includes the federal workplace for Human research Protections, which protects analysis topics from harm; the national Institutes of fitness, which dollars lots of Zhang’s experiences; the office of research Integrity, which oversees analysis misconduct cases; or the California State medical Board, which gave Zhang a license to apply medication.

“communique is fraught with complexity in compliance matters,” mentioned Springs, Harvard’s analysis integrity officer. issues occasionally take place on a necessity-to-understand foundation, she noted, and confidentiality plays a huge half.

but, she spoke of, “If there are lively experiences and individuals are in hazard, the confidentiality is out the window.”

symptoms of a bigger issue

image the framework for protecting research subjects as a apartment.

The groundwork contains a examine, planned with sound scientific and moral principles, and a accountable, moral researcher. If and when things go wrong or trade, they're communicated and addressed automatically. That didn’t occur during this case.

Institutional assessment boards, the first flooring, are sometimes composed of skilled volunteers who spend countless hours poring over hundreds of pages of research protocols, guidelines and laws whereas additionally working their general jobs. They depend on researchers to retain them updated, alert them to issues and talk the truth, however they may also have the vigor and responsibility to audit ongoing reports. It’s often a proactive equipment, however wasn’t in Zhang’s case.

And the institutional review board equipment is “liable to unethical manipulation, exceptionally by way of corporations or people who intend to abuse the device or to commit fraud,” based on an undercover federal investigation from 2009.

An undated photograph of the Shiley Eye Institute at the institution of California San Diego campus in La Jolla. (u.s.)

bigger-america an institution – the 2nd floor – may have explanations and methods to keep violations quiet and away from public scrutiny. The Zhang audit is an ideal instance: It become posted greater than two years ago but didn’t reach the VA throughout campus, not ever made the news, and sure wouldn’t have greatly surprised any individual who stumbled upon it since it under no circumstances named Zhang as the researcher under scrutiny. The only region his name seems is on the report’s cover page – as one of sixteen individuals copied on its transmittal within the UC gadget, together with america’s chief ethics and compliance officer, vice chancellors, a number of directors and others.

“It doesn’t appear decent for the school to be calling out these high-profile school for these types of violations and making a large deal out of it and making use of sanctions, as a result of that’s now not the kind of consideration you need to draw to your researchers,” Harvard’s howdy noted.

Calling out profitable researchers can additionally outcome in misplaced funding. closing fiscal yr, federal companies together with the national Institutes of health, national Science basis and U.S. department of defense gave usa $681 million in research funding. u.s. prides itself on how an awful lot grant money flows its way every 12 months and has defended that movement aggressively: It sued the institution of Southern California in 2015 for poaching one of its most profitable researchers.

And as straight away as these funding corporations supply, they could put off – and even require repayment if severe violations came about the usage of taxpayer dollars.

on the very desirable of the residence, the roof is made of businesses that alter human area insurance policy throughout the nation. The massive one – the office for Human analysis Protections – protects these involved in research funded or carried out by way of the U.S. fitness and Human services branch. it could examine allegations of wrongdoing however regularly does not, identifying as a substitute to refer investigations again to the associations themselves. it may well additionally revoke an entire establishment’s skill to function human research, even though that hasn’t came about seeing that 2007.

At Harvard, Springs observed she commonly uses these corporations as a lever in talks with researchers to get them to remember and comply with rules. She mentioned the patchwork of institutional, tutorial and statewide regulations will also be messy, so there’s a hope that the feds will act invariably, “because they definitely are the heavy in these conversations.”

but, she brought, “Then they aren’t predictable, and you’re like, ‘Wow, good enough. so that they have these enforcement mechanisms and that they’re not the usage of them. Or they’re using them selectively.’”

The workplace for Human research Protections by no means took action in the Zhang case, which isn’t striking for 2 motives. One, they weren’t counseled via the FDA or united states of america of his violations. Two, the agency has tremendously reduce down on enforcement during the last decade.

as an example, it charged institutions with investigating misconduct allegations ninety four instances in 2002. In 2015, it did that thrice. for a similar length, the company went from issuing 146 “choice letters” – an important device for speaking findings of misconduct – to issuing 5.

It’s now not as a result of an absence of funding or a drop in complaints. in fact, institutional misconduct reports despatched to the workplace jumped 400 percent from 2002 to 2014.

Carome observed his former company’s current management is “less attracted to issuing harsh findings and embarrassing associations.”

The issue with that, he observed, is enforcement actions are “one of the most greater essential tools the office has to exchange conduct.”

The workplace of research Integrity, yet another federal company that oversees analysis misconduct investigations, has additionally been criticized for slowing its enforcement. It recently went a whole 12 months with out issuing a single discovering of analysis misconduct – “nothing wanting appalling,” in keeping with one scientific ethicist quoted in an industry publication in 2017 – even though the agency has due to the fact that stepped up its moves.

however oversight corporations were operating at full pace, an absence of transparency and information sharing would nonetheless be main flaws in safeguarding patients that may rip the roof apart.

Compliance statistics on the workplace for Human research Protections is stored in-apartment and offline, and getting at it requires a public facts request, weeks to months of wait time after which expert information analysis. The California medical Board publishes medical professional counsel online, however it’s greater concerned with issues like scientific malpractice judgments, health professional substance abuse and negligence at some point of movements fitness care than monitoring human research and medical trials. Its database isn’t designed to include audit findings, FDA warning letters or federal databases.

educational investigations – as a minimum in California – are stored removed from Google’s attain, and typically require a public facts request and the advantage they exist. The same goes for institutional assessment board investigations, stories and audits.

And none of those methods talk with each and every other in any significant means.

Carome delivered an extra difficulty plaguing the field: “tons noncompliance goes undetected or omitted.”

Zhang’s audit likely would have long past unnoticed if inewsource weren’t digging into the risks associated with human analysis, yet Springs noted this may prove a chance for united states.

“When these instances emerge within the press, or americans come to hear about them come what may, it highlights their screw ups – and that should still occur,” she pointed out.

but even then, Springs said, it doesn’t always “turn into valuable dialogue and communicate round how they will fix it.”

Audits like Zhang’s are sometimes unintelligible to the group, to patients enrolled and even to lecturers, although they are the americans who may still be offering comments and criticism, she stated.

“These are alternatives the place they can in reality promote transparency,” she spoke of, “and say, ‘hello, this is what came about. this is how they approached it,’ and model constructive speak with communities on how they are able to work better on this.”

Human analysis Violations by way of u.s. Eye doctor showcase a countrywide difficulty turned into closing modified: April 19th, 2019 by means of inewsource follow Us: Facebooktwittergoogle_plusrss

Kadapa: research centre remains a white elephant | killexams.com Real Questions and Pass4sure dumps

Kadapa: it is 10 years considering that the Andhra Pradesh Centre for advanced research on livestock (APCARL) became install in Pulivendala at a cost of Rs 280 crore to aid dairy farmers in Kadapa district. however not a single analysis institute has deploy shop, and in fact, the constructions are in disuse.

Two or three institutions claimed that they had been doing analysis right here. but, there isn't any lab or any of the different facilities obligatory to do analysis. The government ought to organize two to a few laboratories with all amenities for researchers, sources cited. Bio security degree -three (BSL-three) and Animal Bio defense degree-three (ABSL-3) are essentially the most critical labs that should be supplied, however haven't been.

 

in addition, the animal leisure apartment is also an important amenity however, it has been left incomplete. devoid of these amenities, no supplier is attracted to starting research work, the supply said.  despite people from the district worrying that APCARL be accomplished for the welfare of dairy farmers, nothing has been accomplished.

Sources say that APCARL has been a victim of politics. basically when it became inaugurated on January 25, 2009 by the then CM Y.S. Rajasekhar Reddy, it changed into referred to as the Indira Gandhi Centre for advanced research on cattle (IGCARL) and eighty per cent of the work which started in 2007 turned into finished.  because it changed into a distinct economic Zone venture, it’s firstly charge of Rs 380 crore got here all the way down to Rs 280 crore.

till 2012, pretty much ninety per cent works have been completed. In 2014, when the TD government took workplace, a couple of ministers visited and promised to start full-fledged research.

Opposition leader Y.S. Jagan Mohan Reddy visited APCARL on April 2, 2015 and alleged that the govt changed into neglecting the celebrated institution. instantly the Animal Husbandry Minister Mr Prattipati Pulla Rao and Council Deputy chairman S.V. Satish Kumar Reddy, MP C.M. Ramesh visited the institute together with government officers.

once more, in April, 2018, the current animal husbandry minister Adinarayana Reddy visited the institute with senior officers and promised to birth research work inside a few months. He ordered officials to comprehensive the basic works and begin the institute inside three or four months. but his promise has not been implemented.

the man in can charge of APCARL, Enjeti Laxmi Prasad, speaking with this correspondent mentioned that two to a few institutes had been able to beginning research labs presently.

He added that Tropical Bovine Genetics from Haryana was ready to start research on embryo switch technology in partnership with GV ideas (GVC).  He referred to that the suggestion was in the MoU stage.

...

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Marijuana Users Might Need More Anesthesia in Medical Procedures | killexams.com real questions and Pass4sure dumps

This article originally appeared on VICE US

In 2015, at a 60-bed hospital in Grand Junction, Colorado, the nurses began to notice something odd.

When patients came in for routine medical procedures, like endoscopies or colonoscopies, some of them needed a lot more of the drugs that kept them sedated, like propofol, fentanyl, and midazolam. Those same people also seemed to be the ones who reported that they used cannabis frequently.

Doctors always ask before invasive procedures and surgeries about illicit drug use. But when marijuana became legal in Colorado in 2012, the nurses realized that since cannabis was no longer “illicit” and they started to inquire if, and how often, patients used marijuana.

That’s when they started to see that people who used cannabis chronically were being given much higher doses of sedatives than non-users. “It seemed like even if people were alcohol users or on other chronic medicines, that marijuana seemed to have more of an effect than any of those other drugs,” Mark Twardowski, a doctor of osteopathic medicine at Community Hospital-Grand Junction, says.

After about a year of swapping word-of-mouth stories, Twardowski and his colleagues decided to research the phenomenon more closely. The resulting study was published today in the Journal of the American Osteopathic Association. “We didn't expect to see the numbers that they saw,” Twardowski tells me.

They looked back at the medical records of a small group—25 people—who had procedures with Twardowski like colonoscopies and endoscopies, who also said that they used cannabis on a daily or weekly basis—both by smoking and eating edibles. They compared them to 225 people who had the same kinds of procedures, but who did not report using marijuana.

They found that the people who said they used cannabis needed 14 percent more fentanyl, 19.6 percent more midazolam, and 220.5 percent more propofol during their procedures—higher doses of all three of the commonly used sedative drugs.

1555333241945-weed-anesthesia-graph-edited

Effects of Cannabis Use on Sedation Requirements for Endoscopic Procedures. Twardowski et al. 2019. The Journal of the American Osteopathic Association

Cannabis’s active ingredient, THC, attaches to cannabinoid receptors in the brain, but those receptors are different than the ones sedative drugs interact with. This led to a befuddling question: why would cannabis use lead to such an increased need for those other drugs?

Twardowski says that it’s possible the cannabinoid receptors downregulate, or suppress the activity of other receptors in the brain that anesthetic drugs interact with. But honestly, he tells me, that’s just a guess. “I don't have any good scientific basis for that,” he says. “The basic science really needs to be done.”

What worries him, outside of their findings, is that no one seems to have done that basic science research—a problem he attributes to cannabis still being a Schedule I drug. When he and his co-authors surveyed existing research, they expected their study to be added to a pile of already completed work. Instead, it’s one of the first in the country.

“We did these huge literature searches and found nothing,” he says. “Really? We're going to do the first study on this and it's just us? That was cool to be the first, but it's pretty scary too.”

Kevin Hill, an addiction psychiatrist at Beth Israel Deaconess Medical Center and a clinical expert on marijuana hadn’t heard of this effect but agrees that more research is crucially needed—especially as more states move towards legalization. Marijuana is currently legal for recreational use in 10 states, and 33 states have legalized medical marijuana. And marijuana use has increased 43 percent between 2007 and 2015.

“This preliminary report highlights the kind of research that they desperately need as states race forward with medical and recreational cannabis policies,” Hill says. “Physicians of all types must try to understand the impact of regular cannabis use upon their specialties.”

But just because no one has studied it officially doesn’t mean other clinicians aren’t aware of the impact marijuana has on anesthesia. Ethan Bryson, a professor of anesthesia and psychiatry at the Icahn School of Medicine at Mount Sinai, who was not involved in the study, says that he is well aware of this, and has been for awhile. “Anybody who has practiced anesthesia for any amount of time recognizes that this is definitely something that affects their job,” he tells me.

When he plans an anesthetic, he says that he has to consider a person’s drug use, and its effect on their tolerance levels. This goes not just for marijuana, but for alcohol and other drugs as well.

Bryson started observing the effects of marijuana and anesthesia around 12 years ago, and noticing that his patients chronically using marijuana and other drugs had a much higher tolerance. He tells me about a recent healthy patient, who was in his late 40s, who came in for a minor procedure. Normally, Bryson would have given him one dose of anesthesia. But after interviewing him, he found out that he smoked weed on a regular basis, had smoked the day before, drank alcohol daily, and had used cocaine two weeks prior.

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“This is somebody who is perfectly healthy otherwise, but because they're chronically exposed to these drugs, my anesthetic plan changed from IV sedation to general anesthesia,” Bryson says. “I'm not going to be able to keep him still without general anesthesia.”

His theory is that the chronic exposure to cannabis changes something about metabolism—that the speed at which the body eliminates drugs from the body is ramped up and increases tolerance. That might help to explain why cannabis use would affect with anesthetic drugs that interact with different parts of the brain and different receptors, he says.

Twardowski thinks that while that may be a factor, he believes it’s more than just metabolism. He can see the need for higher doses from the very beginning of a procedure, when he’s trying to put people under. “It seems to take longer to even accomplish that,” he says. “If it was wearing off quicker during the case then that may be part of it, but these folks are talking to me when I've given doses that would put you and me out.”

A small number of case studies have had similar findings: A study from Australia in 2009 found that more propofol was needed in people who used cannabis compared to those who didn’t when inserting a laryngeal mask, which keeps a person’s airway open during surgery.

In a case study from 2015, a 37-year-old man in Germany had shoulder surgery, and told his doctors that he smoked weed every week. After being given a slew of anesthetic drugs, he said that he was dizzy, but “the patient was still speaking with the anesthesia staff,” the authors of the paper wrote. After two more doses of propofol “the patient did not show any reduction of his conscious state.” Confused, the medical team ended up checking if his IV was attached correctly. It was, and eventually they were able to put him under with more medication, and his surgery went forward with no complications.

In a 2002 correspondence letter in the journal, Iris Symons from Barnet General Hospital in England recounted the case of a 34-year-old man who she had to give propofol, midazolam, Ketorolac, and local anesthetic. “Despite the high concentration of volatile and intravenous anaesthetic, the blood pressure and pulse rate remained high at the pre‐induction levels,” she wrote. When the man woke up later, he asked Symons, “How was it?”

“I said; ‘Actually you were very difficult to anesthetize,’” Symons wrote. He replied: ‘Well if I tell you something it might incriminate me.’ I said: ‘You may tell me anything in confidence.’ He replied: ‘I smoked cannabis last night.’

In these case studies and according to Bryson and Twardowski, it appears that if someone needs these high levels of anesthetic, they can’t tell afterwards. “Even though we've given them a high dose—and sometimes it's ridiculously high based on the patient's size—they're waking up just like everybody else a half hour later,” Twardowski says.

But there could still be potential harms: it is known that taking high amounts of these drugs can lead to breathing and blood flow problems, so the potential adverse effects need to be studied more closely. Twardowski says that since he uses conscious sedation, where a person isn’t assisted with their breathing while they’re unconscious, giving high doses of drugs like propofol is concerning– that’s what’s thought to have killed Michael Jackson after all.

Twardowski and his colleagues are now starting a second phase of their study. They’re going to look at all of anesthesia and sedation at their hospital to try and see where the effects of marijuana have the most effect. He’s hoping they’ll find an anesthetic that cannabis doesn’t increase the tolerance for.

Twardowski tells me they’ll also be looking into another troubling observation from the nurses: that people who use marijuana chronically have a harder time controlling their pain after surgery, which could mean higher amounts of painkillers prescribed. “Everybody's a little concerned about sending you home with way more pain medicine,” he says.

For now, Bryson and Twardowski say that if you can, try to abstain from smoking or eating edibles a month before your procedure— THC sticks around in the body for about 25 days after using.

And the best move is to be extremely upfront with your anesthesiologist about drugs and alcohol, whether you’re getting major surgery done or just getting your wisdom teeth out or an endoscopy. There’s no real point in lying, because your ability to be sedated will likely reveal your tolerance levels, and it’s best that your anesthesiologist know beforehand if you’ll need higher doses.

“The last thing you want to do is get your case canceled because the anesthesiologist is getting into doses of medicines that they're concerned with and don't feel comfortable with,” Twardowski says. “You have to be honest about that."


10 Quotes You'll Relate to If You or Someone You Love Has Alzheimer's Disease | killexams.com real questions and Pass4sure dumps

10 Quotes You’ll Relate to If You or Someone You Love Has Alzheimer’s Disease © The Mighty 10 Quotes You’ll Relate to If You or Someone You Love Has Alzheimer’s Disease

Alzheimer’s disease doesn’t just affect the person who is diagnosed — it also turns your world upside down if your loved one is grappling with the condition. Alzheimer’s disease is a progressive brain disorder that takes away memory and eventually the ability to do basic tasks. Feeling your own memories slip away or watching a friend or family member go further and further into the disease can leave you feeling alone, like no one else really understands the turmoil you’re going through.

But hearing how other people deal with the devastation of Alzheimer’s disease can help ease some of that isolation. Their wisdom can help light your way on the difficult days. So they rounded up some Alzheimer’s quotes — some relatable, some inspirational, some just purely honest — by people living with the disease and their loved ones. These quotes about Alzheimer’s, and dementia in general, reveal the strength of anyone enduring this difficult diagnosis.

1. “You have to be patient with [Alzheimer’s]. Once you understand that it’s a medical condition, you become a little more compassionate. You get less frustrated.” — Kim Campbell

Singer Glen Campbell, who died in 2017, revealed his Alzheimer’s diagnosis in 2011. His wife Kim told Country Weekly in 2013 that his symptoms started out as anxiety and panic attacks, not understanding questions and forgetting the words to his songs. She reflected on how she helps Campbell by being patient and compassionate and giving him instructions in stages so he can follow them.

2. “It is a strange, sad irony that so often, in the territory of a disease that robs an individual of memory, caregivers are often the forgotten.” — Karen Wilder

a close up of a persons hand: karen wilder quote about alzheimer's disease © Provided by mighty proud media, inc. karen wilder quote about alzheimer's disease

Gene Wilder was famously quiet about his Alzheimer’s diagnosis, but in 2018, 15 months after his death, his widow Karen wrote a powerful essay about their marriage and his final years of life. She explained how physically and emotionally taxing Alzheimer’s can be on caregivers and urged researchers not to forget their needs, too.

“Without [caregivers], those with Alzheimer’s could not get through the day, or die — as my husband did — with dignity, surrounded by love,” she added.

3. “I intend to live the remainder of the years God gives me on this earth doing the things I have always done.” — Ronald Reagan

the outside of a building: ronald reagan quote about alzheimers © Provided by mighty proud media, inc. ronald reagan quote about alzheimers

Former President Ronald Reagan’s response to his Alzheimer’s diagnosis was to sit down and write a letter to his fellow Americans. In it, he said he was sharing his diagnosis to encourage a “clearer understanding” of the people affected by it and acknowledged that families often bear a “heavy burden.”

“I only wish there was some way I could spare Nancy from this painful experience. When the time comes I am confident that with your help she will face it with faith and courage,” he wrote. Reagan died in 2004.

4. “Alzheimer’s is brutal. I mean, it’s associated with losing your memory, but you don’t just forget who people are; you also forget how to talk, how to eat, how to do everything. That’s hard to wrap your head around until you actually see it.” — Seth Rogen

In an essay for InStyle published in 2017, Seth Rogen explained that his now-wife, Lauren Miller, found out her mom had early-onset Alzheimer’s disease less than a year after they started dating. Rogen said he was “shocked” by what happened to her as a result of the disease. The couple founded Hilarity for Charity, a nonprofit organization that raises money for Alzheimer’s disease and caregiver resources (though he said his ultimate goal is to make the organization “obsolete”).

5. “I think this whole issue, whether it’s of Alzheimer’s or caregiving, has a long way to go, I think, as a national conversation. What do caregivers need? What do they look like? What do they as a country need? Why are two-thirds of the Alzheimer’s cases women?” — Maria Shriver

Inspired by her father, former First Lady of California Maria Shriver advocates for Alzheimer’s disease through her nonprofit, Shriver Report, and has also written a children’s book and produced films about Alzheimer’s disease.

In an interview with Miller-Rogen for Lenny Letter in 2017, Shriver raised the need for research into Alzheimer’s as a women’s issue, since women are more likely to get Alzheimer’s disease than breast cancer and often bear the caregiving responsibilities.

6. “For baby boomers, I feel like the canary in the coal mine while scientists search for a cure. I fear the day when I put my fingers on the keyboard and don’t know how to write anymore.” – Greg O’Brien

a close up of a bird © Provided by mighty proud media, inc.

Greg O’Brien, an investigative journalist, decided to take control of his own story after his Alzheimer’s diagnosis in 2009 at age 59. He wrote a book called “On Pluto: Inside the Mind of Alzheimer’s” about what it feels like to undergo the beginning stages of dementia. He later wrote an essay for The Washington Post detailing some of the changes he has noticed in his mind and urging others to keep up the fight.

“By documenting Alzheimer’s, I’m getting even with it,” he wrote.

7. “Alzheimer’s, while a horrible shroud that keeps out so many joys of life, also blanketed away the aggressive and shrill dimensions of modern life.” — Rick Steves

Travel writer and TV host Rick Steves shared an essay on his blog two weeks after his mother died of a heart attack in 2012. He revealed she also had Alzheimer’s disease and that he had come to discover a “silver lining” to her condition. In the later years of her life, she was still “cheery” and “a joy” and that the love between her and her husband more simple and, to Steves, inspiring.

8. “Never make [dementia] a secret. There should be no shame. Why feel ashamed of having a complex brain disease? People are afraid to talk about it.” — Wendy Mitchell

wendy mitchell quote about alzheimer's © Provided by mighty proud media, inc. wendy mitchell quote about alzheimer's

Like O’Brien, Wendy Mitchell also decided to write a memoir after being diagnosed with early-onset Alzheimer’s disease (she also has vascular dementia). That memoir, called “Somebody I Used to Know,” was published in 2018. Mitchell also blogs about her daily life with dementia, and in an interview with The Guardian, explained that she is open about her condition to reduce the shame that surrounds it.

9. “While the final chapter of my life with dementia may be trying, nothing has diminished my gratitude and deep appreciation for the countless blessings in my life.” — Sandra Day O’Connor

In October 2018, retired Supreme Court Justice Sandra Day-O’Connor wrote an open letter revealing she was in the “beginning stages of dementia, probably Alzheimer’s disease.” She said she would continue to live in Phoenix but would be stepping away from public life.

Her husband John also had Alzheimer’s, which according to a new biography was part of the reason why she retired from the Supreme Court in 2005.

10. “Alzheimer’s is me, unwinding, losing trust in myself, a butt of my own jokes and on bad days capable of playing hunt the slipper by myself and losing. You can’t battle it, you can’t be a plucky ‘survivor.’ It steals you from yourself.” — Terry Pratchett

a screenshot of a cell phone: terry pratchett quote © Provided by mighty proud media, inc. terry pratchett quote

Author Terry Pratchett was diagnosed with posterior cortical atrophy (PCA) in 2007. PCA is believed to be either a form of Alzheimer’s disease or possibly a unique disease. Before his death in 2015, he wrote an essay published by the Alzheimer’s Society and later in The Guardian reflecting on his diagnosis. He described PCA as having “extreme problems handling the physical world,” but still being able to “talk your way out of it.” He also expressed his belief that one day there would be a cure.

“It is a physical disease, not a mystic curse; therefore it will fall to a physical cure. There’s time to kill the demon before it grows,” he wrote.

Video: Alzheimer's symptoms reversed by compounds found in green tea and carrots (Cooking Light)

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    The Conventional Wisdom About Stock Buybacks Is Wrong | killexams.com real questions and Pass4sure dumps

    (Bloomberg Opinion) -- Here’s a simple math problem for you: If the companies in the S&P 500 Index have 289 billion shares outstanding, and they repurchase 82 billion in a decade, how many shares will they have at the end of those 10 years? The answer, of course, is 294 billion, 5 billion more than what they started with. I’m guessing that’s not the answer you came up with, right? But those are the real numbers for the past decade, and they point to the fact that investors, long thought to be the chief beneficiaries of buybacks, may not be.

    There has been a lot of debate recently about the worth of stock buybacks, sparked by the fact that it appears companies plowed a good deal of the money that they saved from Donald Trump’s corporate tax cut into repurchasing their shares. Buybacks, which have been rising for much of the past decade, jumped about 50 percent last year to nearly $800 billion for the companies in the S&P 500, a new annual high, according to S&P Global Inc.

    To a lot of people, that seemed not only like a bad outcome of the tax cuts, but also a poor outlet for corporate profits in general, and the groundswell could even lead to new regulation. Last month, Democratic Senators Bernie Sanders and Chuck Schumer proposed legislation that would restrict companies’ ability to buy back stock. Republican Senator Marco Rubio followed with his own proposal to limit repurchases by increasing the taxes on capital gains, leveling the advantage buybacks have over dividends, which are taxed as income.

    What everyone seems to agree on, whatever their opinion on buybacks, is that repurchases are a way companies hand money back to shareholders. The mechanics of it are that buybacks reduce the number of shares outstanding and therefore boost the per-share value of future earnings. Selling shareholders benefit by getting a slightly higher price than they would have had the companies not been buying. For investors who stick around, a higher stock price should follow. But that basic story could be wrong. Earlier this week, long-time stock strategist Ed Yardeni penned a mea culpa about buybacks, saying he was wrong to be a backer. Nearly all of the gains of stock repurchases, Yardeni now says, flow to top executives. “Buybacks are not designed ‘to return cash to shareholders’ as is widely believed,” he wrote in his regular newsletter. Yardeni says the companies in the S&P 500 have spent roughly $4.5 trillion on buybacks over the past 10 years, yet by his calculation, which include some adjustments, the shares outstanding of those companies has dropped by just 2 percent during that time. What accounts for the difference? Employee stock compensation.

    Buybacks haven’t returned cash to shareholders, or boosted share prices, Yardeni says. All they have done is bought back the shares that have been issued to employees, essentially enabling higher executive compensation by picking up the tab of stock options. Based on data from S&P Dow Jones Indices, the current members of the S&P 500 had 284 billion shares outstanding in early 2009, and have bought back bought 81.5 billion shares through the end of 2018. That means shares outstanding should have dropped by nearly 29 percent, instead of falling 2 percent, by Yardeni’s calculations – or rising slightly, as data from S&P show.

    Even after accounting for equity issuance and share-count changes due to acquisitions, I calculate that roughly two-thirds of what companies spent on buybacks appears to have gone toward offsetting executive compensation. And there’s more to the story.

    The tale usually told about buybacks is that companies have this pot of profits and they are choosing to use it to prop up their stock with buybacks. But back in 2005, the Financial Standards Accounting Board began forcing companies to expense the cost of option grants, even though they aren’t a cash outlay. That means buybacks aren’t really funding stock grants. Corporate bottom lines already include the cost of stock options. By the time you get to the bottom line, that money has effectively already been “spent.” Repurchases are just a way of squaring that accounting. Without buybacks, shareholders would effectively be paying for stock compensation twice – once when they are expensed and a second time from the dilution of additional shares. Executives get the options either way. And indeed, the growth of buybacks in the past decade-and-a-half correlates pretty closely with the 2005 accounting change for options. There is even some research to suggest causation.

    Story continues

    So do repurchases benefit executives or shareholders? They are like marketing or rent or any other expense. Spent on the right executives, stock buybacks benefit shareholders. More likely, the spike in executive compensation has probably led to some pretty wasteful buybacks. It also suggests that all of us, myself included, are spending a lot of time on the symptom, not the cause. Executive compensation is the issue, buybacks are just coming along for the ride.

    To contact the author of this story: Stephen Gandel at sgandel2@bloomberg.net

    To contact the editor responsible for this story: Beth Williams at bewilliams@bloomberg.net

    This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

    Stephen Gandel is a Bloomberg Opinion columnist covering banking and equity markets. He was previously a deputy digital editor for Fortune and an economics blogger at Time. He has also covered finance and the housing market.

    For more articles like this, please visit us at bloomberg.com/opinion

    ©2019 Bloomberg L.P.



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    Android [4 Certification Exam(s) ]
    APA [1 Certification Exam(s) ]
    APC [2 Certification Exam(s) ]
    APICS [2 Certification Exam(s) ]
    Apple [69 Certification Exam(s) ]
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    NI [1 Certification Exam(s) ]
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    Nokia [6 Certification Exam(s) ]
    Nortel [130 Certification Exam(s) ]
    Novell [37 Certification Exam(s) ]
    OMG [10 Certification Exam(s) ]
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    SASInstitute [15 Certification Exam(s) ]
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    SDI [3 Certification Exam(s) ]
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    Symantec [135 Certification Exam(s) ]
    Teacher-Certification [4 Certification Exam(s) ]
    The-Open-Group [8 Certification Exam(s) ]
    TIA [3 Certification Exam(s) ]
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    Trainers [3 Certification Exam(s) ]
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    VCE [6 Certification Exam(s) ]
    Veeam [2 Certification Exam(s) ]
    Veritas [33 Certification Exam(s) ]
    Vmware [58 Certification Exam(s) ]
    Wonderlic [2 Certification Exam(s) ]
    Worldatwork [2 Certification Exam(s) ]
    XML-Master [3 Certification Exam(s) ]
    Zend [6 Certification Exam(s) ]





    References :


    Dropmark : http://killexams.dropmark.com/367904/11585490
    Wordpress : http://wp.me/p7SJ6L-PJ
    Issu : https://issuu.com/trutrainers/docs/es0-002
    Dropmark-Text : http://killexams.dropmark.com/367904/12117599
    Blogspot : http://killexamsbraindump.blogspot.com/2017/11/never-miss-these-es0-002-questions.html
    RSS Feed : http://feeds.feedburner.com/NeverMissTheseEs0-002QuestionsBeforeYouGoForTest
    weSRCH : https://www.wesrch.com/business/prpdfBU1HWO000DOAM
    Calameo : http://en.calameo.com/books/004923526b234c1b090d4
    publitas.com : https://view.publitas.com/trutrainers-inc/pass4sure-es0-002-res-wisdom-2009-basic-exam-braindumps-with-real-questions-and-practice-software
    Box.net : https://app.box.com/s/qpn8ur6oeyml2o9l71hzp0o7kfkrspnq
    zoho.com : https://docs.zoho.com/file/5psib53d687fa7b714011853b5975ea329688






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