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Additionally cheap nizoral 200mg without a prescription, you need to be prepared to move citizens out of certain contaminated areas if the health situation deteriorates any further purchase nizoral 200mg without prescription. Stage 2 of the Disaster Donora purchase discount nizoral on line, a town of 14,000 people, now has 7,000 people ill from pollution inhala- tion. You will need to seriously consider relocating some citizens as well as heavily fning or shutting down any noncompliant factory owners. You will also need to bring in any medical assistance either within the state or external to state agencies. The federal agencies should be contacted and a request for assistance should be sent to agencies such as the Centers for Disease Control. Medical supplies and logistics will need to be inventoried before an implementation of any action plan can occur. If you decide to move some of the citizens, you will need to provide them with more than just shelter. Any displaced citizens will need food, water, and money to provide a stable means of living until the situation stabilizes and they are allowed to go home. Key Issues Raised from the Case Study The government is responsible for ensuring the health and well-being of its citi- zens. Tis case study clearly shows that inaction can lead to long-term issues for the community and its residents. The inability to control pollution is a fail- ure due to not having proper policies or enforcement mechanisms in place to contend with such an issue. Administrators and government ofcials were not proactive in keeping pollution levels down from the industrial areas, which resulted in severe air pollution. The consequences are potentially long term for many residents whose health has been impacted by the poor air quality of their community. Case Studies: Nuclear, Biotoxins, or Chemical ◾ 191 Items of Note The Donora incident resulted in legislation being passed for clean air and environ- mental protective acts (Gammage, 1998). Love Canal, Niagara Falls, 1970 Stage 1 of the Disaster You are the city manager of a large city. The citizens are blue-collar, industrial workers who work in the factories that comprise your city’s economy. The city’s population is expanding rapidly, which necessitates a large development program for new housing. The local school board needs additional land and has selected a site that was previously a chemical dump owned by a corporation (Stoss and Fabian, 1998). Even though the school board members were told that the land was not suitable for use, the corpora- tion sells the land since they are threatened with eminent domain confscation of the land by the school board. The city manager should be very concerned that chemicals could get into the water supply if construction is undertaken in the area of the former dump site. The city manager should not allow any type of residential construction in the area of the former chemical dump site by deny- ing permits to construction companies for new housing developments. The city manager should contact the school board and school district superintendent and voice his or her concerns about constructing a new school on the chemical dump site. In addition, the city manager should insist on an environmental impact study before any such construction is undertaken. The city manager may very well need to have legal representation to stop construction before it begins. The city manager may also need to voice concerns to state and federal agencies that oversee environmental and health concerns. The city manager should stay in close con- tact with the city council as well as school district ofcials. Stage 2 of the Disaster The school board has begun construction of a new school located on the property that was used as a landfll, even after the corporation that sold them the property stated sternly that it was not safe to build on the site (Zuesse, 1981). The school had to relocate the construction site of the new school due to the discovery of two pits flled with chemicals. You have also learned that chemicals have begun to seep into 192 ◾ Case Studies in Disaster Response and Emergency Management the sewer system that is next to the school construction site. If the school district keeps proceeding with the con- struction project, a legal injunction should be sought. In addition, the city man- ager should put more pressure on state and federal ofcials to be more involved with a project that appears to be impacting the sewer system as well as having the potential to contaminate the water supply for the entire municipality. The issues that are now being created by the construction of the school need to be communicated efectively to the elected ofcials and residents. The media needs to be involved in order to put public pressure upon the school district to abandon the project and that poisoned track of land. Stage 3 of the Disaster The residents of the homeowners association have begun to notice severe health problems with their children, including epilepsy and severe asthma (Turmoil and Fever, 2007). You now understand that the entire subdivision of housing was built upon 21,000 tons of chemical waste (Goldman Environmental Foundation, 2007). Due to the lack of action by city ofcials (your employees), residents have organized into a coalition to alert the media and government ofcials to the increasing num- ber of illnesses and birth defects that have occurred in the subdivision (Beck, 1979). City employees that have been reluctant to take action on this issue need to be reprimanded, reassigned, or terminated from their positions. The company that dumped the chemicals should be forced, through legal or legislative means, to clean up the chemical dumping site. The city manager should contact state and federal ofcials in a coordinated efort to resolve this issue. The public should be kept reassured that steps are being taken to resolve the issue and that the city will do everything in its power to correct a serious environmental oversight. Stage 4 of the Disaster The school that was built on top of the landfll has been demolished, but the school board and the corporation are refusing to admit any liability (University of Bufalo Libraries, 2007). The president of the United States has just declared the neighborhood a federal emergency and has relocated all residents out of Case Studies: Nuclear, Biotoxins, or Chemical ◾ 193 the subdivision (University of Bufalo Libraries, 2007). The city manager should be active in coordination of all activities in relocating residents to temporary housing that is satisfac- tory, as well as working closely with federal ofcials in resolving the crisis. Money will need to be allocated to a legal fund that will be used to not only hold the school district and com- pany liable for negligence, but also protect the city from lawsuits. The city manager needs to fgure out if the land can be used for any useful purpose other than residential. If the land can be used for something other than residential, a budget needs to be formulated in an efort to revitalize an area that has been so devastated by the chemical dumping incident. The city manager should provide government investigators any information that is needed. In the future the city manager should ensure city inspectors have a very strict building code that must be signed of on by the building inspection department as well as having an environmental impact study prior to construction. Key Issues Raised from the Case Study Administrators have an ethical and professional duty to protect their citizenry from items that can potentially produce health-related problems. Administrators and local ofcials should never ignore or deny that a problem exists.

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However order nizoral 200 mg on line, rehabilitation of branch pulmonary artery stenoses can be one of the most challenging tasks in congenital pediatric patients buy nizoral 200mg with mastercard. Transcatheter therapy has to strive to achieve the optimum possible outcome cheap 200 mg nizoral with visa, which sometimes requires repeated and staged procedures to achieve some improvement for an individual complex patient. The treatment modalities available include the use of cutting balloons, standard balloon angioplasty, or the placement of endovascular stents. A 23-year-old male who underwent GoreTex patch augmentation earlier in life and subsequently developed recoarctation with a 22 mm Hg peak systolic gradient and an associated posterior aneurysm. The individual success of treating these lesions is sometimes difficult to assess, but in patients with a biventricular circulation a reduction in the right ventricular to systemic pressure ratio is a good indicator for a successful outcome. Individual pressure gradients to branch pulmonary arteries may be less meaningful, and in fact angiographically significant branch pulmonary artery stenoses can be associated with surprisingly low-pressure gradients, especially for isolated lesions and in the presence of significant pulmonary insufficiency. The angiographic appearance of the vessel before and after transcatheter intervention is equally important, and while one should strive to aim to achieve a “normal” vessel diameter, frequently the percentage of improvement in the anatomic measured stenosis is a good outcome parameter. Rotational angiography with 3-D reconstruction is a new tool that is in particular suited for patients that require complex pulmonary artery rehabilitation. The 3-D reconstructions allow to visualize the complete pulmonary artery tree and the best angulations can be chosen to profile individual lesions P. This not only provides better imaging of individual lesions, but may also lead to a reduction in the overall amount of contrast needed, especially in patients who require multilevel pulmonary artery rehabilitation. The amount of contrast for individual rotational angiographies can be further reduced by using rapid right ventricular pacing during the rotational acquisition. The image can be rotated until the lesion is best profiled and the allowable angles are displayed (**) which then allows the operator to choose the same angulations for two-dimensional acquisitions. While standard balloon angioplasty can be performed using a normal balloon-over-the-wire technique, it is frequently helpful to place long sheaths toward the area of intended interventional therapy to facilitate simultaneous therapies of adjacent lesions, balloon exchanges, and subsequent placement of stents if required (Fig. In many patients, especially in adults, placements of long sheaths from a femoral venous approach may be difficult. Internal jugular venous or transhepatic approaches offer the advantages of eliminating some of the double-S-curves that have to be traversed from a femoral venous approach, while also requiring a shorter sheath length and allowing improved “pushability” of the catheter. Standard balloon angioplasty alone rarely achieves a sustainable long-term improvement to an individual stenosis and as such is usually only performed in situations where other forms of transcatheter treatment are not available or where the size of the patient or vessel prevents the use of endovascular stents that can be expanded to adult size. No absolute rules exist for determining the correct balloon size; however, it appears that the balloon should preferably be larger than two times the diameter of the stenotic segment while avoiding exceeding a diameter of three times the actual narrowing. However, when using standard balloon angioplasty “overdilation” of a vessel is frequently required to achieve an adequate outcome. In very resistant stenoses, the use of high-pressure balloons should be employed, rather than exceeding the size of the dilation balloons. Cutting balloon angioplasty is available for maximum diameters of up to 8 mm and is a suitable alternative to endovascular stenting especially in small distal pulmonary arteries (109,110). It is frequently beneficial to “score” very tight stenoses and can be followed either by standard balloon angioplasty or endovascular stent placement if required. In a randomized multicenter trial, Bergersen and colleagues demonstrated for cutting balloon angioplasty to be more effective to treat resistant pulmonary artery stenosis when compared to sole high- pressure balloon angioplasty (111). Standard balloon angioplasty of pulmonary branch stenosis has not been highly successful at correcting the lesions and many of the vessels that initially are dilated satisfactorily reconstrict immediately (recoil) with the deflation of the balloon or, if not immediately, a short time later. The true success rate at achieving a vessel of normal diameter with no gradient is less than 20%; at the same time, there is a definite morbidity and even mortality for the procedure. It is not possible to determine in advance which case will be successful, so the procedure is often performed as a therapeutic trial. Frequently, pulmonary artery rehabilitation is a staged procedure, where reinterventions are not necessarily a sign of procedural failure, but more importantly reflect a consciously chosen therapeutic strategy with frequent early reinterventions to achieve optimum pulmonary growth. The experience with stents in these lesions has significantly changed the approach to branch pulmonary stenosis. Results in eliminating any gradients and opening the vessels to their normal diameters have been excellent (8). The implant dilation does not require overdilation of the vessel to achieve a normal end diameter. In addition, it has been demonstrated that if the appropriate stents are implanted initially, these stents can be dilated further in the future up to the adult diameter of the vessel. In the 25 years since their introduction for this use, intravascular stents have become the primary mode of therapy for branch pulmonary artery stenoses in most large institutions that care for congenital heart patients. Implanting stents that may not be expandable to adult size (such as premounted stents) may be indicated in certain infants P. Holzer and colleagues presented a series of pulmonary arterial stent implantation in children weighing less than 15 kg and documented that stent implantation may prevent or defer the need for subsequent surgical intervention to a time when this can be performed with a lower risk (112). Similar results were documented in a larger series by Stanfill and colleagues (53). Furthermore, in situ stents may not necessarily present a major difficulty for the surgeons and can be excised or patched where required (53,112). While this may be challenging, it may present the preferred treatment alternative for selected patients. Furthermore, the meshwork of small-diameter stents can be potentially fractured using ultra–high-pressure balloons, as recently shown by Maglione and colleagues (52). This would then allow implantation of stents that can be expanded to adult diameter to accommodate growth of a child and vessel. The delivery and implantation of intravascular stents in the branch pulmonary arteries are performed through the use of long sheaths and these procedures are usually a fairly complex undertaking. An end-hole catheter is advanced well beyond the lesion to be treated and is replaced with a stiff exchange wire. Appropriate and diligent guidewire positioning is a key to successful stent therapy. A long sheath/dilator large enough in diameter to accommodate the stent mounted on the appropriate delivery balloon is passed over the wire beyond the area of stenosis. This is usually one of the most challenging parts of the procedure and may require changing the approach from femoral venous to internal jugular or transhepatic in selected patients. The balloon with the mounted stent is advanced over the wire and through the long sheath to the area of stenosis. The sheath is withdrawn off the balloon/stent; when the stent is verified to be in the exact position, the balloon is inflated, expanding the stent into the lesion and with deflation of the balloon, fixes the vessel at the dilated diameter (Fig. During stent positioning, angiography can either be obtained through the sidearm of the long hemostatic sheath, or by using an additional angiographic catheter advanced from a separate venous entry site. In order to achieve precise delivery and positioning of the stent, specialized balloon delivery catheters are often helpful. Pulmonary artery rehabilitation requires a high amount of technical expertise and is not without risks. Independent risk factors for high severity adverse events were age below 1 month, two or more indicators of hemodynamic vulnerability, use of cutting balloons, as well as operator experience of less than 10 years.

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In general buy nizoral 200mg online, athletes with mild-to-moderate elevation of blood pressure (prehypertension and stage 1 hypertension) who have no evidence of target organ abnormalities should be allowed to continue in competition (283) purchase 200 mg nizoral with visa. It is important for these patients to have ongoing monitoring of their blood pressure (every 1 to 3 months) nizoral 200 mg fast delivery. Athletes with stage 2 hypertension or with evidence or target organ abnormalities should be evaluated more extensively. In these patients, it is prudent to discontinue competitive sports until better control of blood pressure has been achieved. The role of exercise testing in the evaluation of athletes who have hypertension is controversial. Blood pressures recorded during testing may differ from blood pressures during actual competition (284). In addition, different sports require different amounts of aerobic and isometric activity. In general, resistance exercises such as weight lifting are associated with a higher acute rise in blood pressure during the event. When hypertension and other cardiovascular diseases are present concomitantly, the eligibility for competitive sports will depend on the type and severity of heart disease as well as the level of blood pressure. Careful assessment of the types of activity involved in both conditioning/practice and in competition will allow a more rational decision regarding the level of restriction. Pharmacologic Treatment of Hypertension It is well established that treatment of hypertension in adults is associated with a reduction in cardiovascular disease morbidity and mortality (285,286). The evidence base to support pharmacologic treatment of hypertension in children and adolescents is less well developed (286). However, there have been an increasing number of clinical trials in pediatric patients. These have been primarily short-term studies and have focused on the ability of pharmacologic agents to lower blood pressure as well as the evaluation of safety. The decision to use antihypertensive medication is best made on a patient-by-patient basis taking a number of factors into account including clinical features and the acceptance of antihypertensive medication by the family. However, the more severe the blood pressure elevation, the more urgent the use of blood pressure lowering with medication will be. The therapeutic goal for children and adolescents with hypertension is to lower the blood pressure below the 95th percentile for age and height percentile. However, for some children, such as those with diabetes or chronic renal disease, a more aggressive goal is appropriate. These patients should have blood pressure lowered below the 90th percentile for age, sex, and height as they are thought to be at highest risk for cardiovascular disease over time. As can be seen, several classes of antihypertensive medications are available for use. The results of that study support the preferential use of diuretics and β-adrenergic blockers as first-line agents in P. Pediatric trials have not focused on comparing different classes of agents in the treatment of hypertension. This means there is little or no evidence base to drive the decision regarding an initial agent in children. However, the choice of certain classes of medication is appropriate for some subsets of patients. There is one study that found that these medications can be teratogenic when used in the first trimester of pregnancy (288). A more recent analysis using a large population-based case-control study found that women who reported the use of any antihypertensive medication during pregnancy were at increased risk of having certain cardiovascular malformations. So, the use of these medications in adolescent females should be approached with caution regarding potential pregnancy. Beta-adrenergic blocking agents may be helpful in patients with comorbid migraine headaches. Check serum potassium, creatinine periodically mg/kg/d up to to monitor for hyperkalemia and azotemia. Cough and angioedema are reportedly less common with newer members of this class than with captopril. Benazepril, enalapril, and lisinopril labels contain information on the preparation of a suspension; captopril may also be compounded into a suspension. Check serum potassium, creatinine periodically to monitor for hyperkalemia and azotemia. Noncardioselective agents (propranolol) are mg/kg/d bid contraindicated in asthma and heart failure. A sustained-release formulation of propranolol is available that is dosed once daily. All patients treated with diuretics should have mg/kg/d electrolytes monitored shortly after initiating Maximum: 3 therapy and periodically thereafter. Useful as add-on therapy in patients being 50 mg/d treated with drugs from other drug classes. Furosemide is labeled only for treatment of edema but may be useful as add-on therapy in children with resistance hypertension, particularly in children with renal disease. Chlorthalidone may precipitate azotemia in patients with renal diseases and should be used with caution in those with severe renal impairment. Minoxidil is usually reserved for patients with hypertension resistant to multiple drugs. The approach to treatment in children and adolescents includes starting a low dose of the initial medication. Blood pressure should be monitored and the dose increased until the goal blood pressure is achieved, or intolerable side effects occur. If the first choice of medication is not as effective as desired, a medication from another class may be substituted. Again, the recommended approach is to start with a low dose and titrate upward until appropriate blood pressure control is achieved. Sometimes it is necessary to add a second agent from another class to the first medication to achieve desired blood pressure lowering. It is useful to consider combining drugs from classes with complementary mechanisms of action (243). In adults, the use of multiple antihypertensive medications to achieve goal blood pressure is increasingly recommended, sometimes even as first-line therapy (290). In addition to longitudinal follow-up of blood pressure in the clinic, it is important to follow patients for side effects associated with the class of medication being used. Treatment of Severe Hypertension Severe hypertension may occur in children and adolescents. These patients will have stage 2 hypertension and some may have blood pressure substantially >99th percentile for age, sex, and height percentile.

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What policies and procedures should you have in place for ships carrying this type of cargo? A ship carrying this type of cargo should declare its inventory to the city fre department buy nizoral 200 mg overnight delivery, type and amount effective 200mg nizoral. Furthermore generic 200mg nizoral free shipping, ships carry- ing this type of cargo should be berthed in an isolated area of the har- bor so that if something does go wrong, it will not impact other ships or infrastructure. The fre department should mobilize all of its resources immediately to combat the blaze. The city manager should stay in close contact with the fre department and alert hospitals that a crisis is currently unfolding. In addition, the city manager should seek out assistance from sur- rounding municipalities and state ofcials. If possible, the ship needs to be moved well away from any infrastructure and other ships. If the ship cannot be moved, then other ships that are in the vicinity need to be moved away from the area. Additionally, there is no telephone service since the telephone operators are on strike and there is no one to perform their function. You have dis- patched the city’s two fre trucks and the volunteer frefghters have arrived on the scene with an additional two fre trucks, but the fre cannot be contained with just water (Moore Memorial Public Library, 2007). The city manager needs to make sure that the area is cleared of workers and citizens to avoid casualties. If possible, an airplane equipped with fre-retardant chemicals needs to be obtained to help fght the blaze. Since you have no electronic communica- tions through the telephone system, other means will need be made available, such as setting up runners or getting volunteers with short-wave radios to assist with communication eforts. Since you have no hazardous materials team, local ofcials and state ofcials need to be contacted to obtain critical resources that can be used to fght a chemical fre. You need to make a public plea for the telephone operators to come back to work and of strike so that your communication system will be operable. Stage 5 of the Disaster The ship’s crew had only been able to remove 3 of 16 boxes of small arms ammuni- tion. In an attempt to douse the blaze, the captain of the ship has had steam poured into the cargo hold. Unfortunately, the steam turned the ammonium nitrate into poisonous nitrous oxide gas vapors, which fll the ship. The area needs to be completely evacuated since the fre is out of control and there is no viable means to fght the fre at this point. All ships need to be cleared of the harbor and chemicals that are in the dock area need to be relocated if at all possible. Additional frst responders will be needed to seal of the area and ensure that all of the evacuations have taken place. Stage 6 of the Disaster The steam has super heated the ammonium nitrate and has caused the ship’s fuel and oil tanks to leak, which is feeding the fre. The city manager needs to make sure that his police department keeps bystanders away from the disaster site by sealing of roadways leading to the harbor. Unfortunately there is not much that the city manager can do at this point since the fre is out of control and the city lacks proper frefghting equipment to take care of the situation. You should evacuate all of your frefghters from the area to avoid any of them getting hurt or killed. The explosion causes fooding around the initial area and also fattens a plant and several buildings in the nearby vicinity. You learn that the fre chief and 27 fre- fghters were killed, which leaves you with a huge shortage of trained frst respond- ers. In addition, you have no operational hospital in your city (Moore Memorial Public Library, 2007). The city manager needs to contact nearby cities with hospitals to manage anyone who has been injured in the fre or the blast. Search and rescue teams need to be formed to look for survivors in the buildings that were destroyed. The city manager will need to set up a makeshift hospital with as many medical volunteers as possible to assist with the wounded until those patients can be taken to a proper medical facility. Stage 8 of the Disaster The explosion killed hundreds of bystanders, pedestrians, and workers, and obliter- ated several buildings. The telephone operators have gone back on the job in this time of crisis and have telephoned a number of nearby agencies and municipalities for assistance. You have just received word that the military, local municipals, and medical centers are all sending personnel and resources to assist your city (Moore Memorial Public Library, 2007). The search and rescue eforts will need to be coordinated so that every survivor is found and treated. Coordinated communication will be essential between the other municipal frst respond- ers, your frst responders, and the military. The city manager will have to monitor how all of the eforts are being coordinated efectively. Medical facilities can easily become overloaded and medical supplies could quickly run out. Stage 9 of the Disaster Your city hall and chamber of commerce are now being used as makeshift medical centers. The military is setting up temporary housing and bulldozing as much of the debris as possible. The ship should be moved if possible and should be doused with a chemical fre retardant if available to the frst responders. What are the other risks that are in the port that should be addressed immedi- ately? You now know that 500 to 600 people have died and thousands more were wounded by the explosions and resulting fres (Moore Memorial Public Library, 2007). The plan of action should be to evacuate any people or ships that are still in the harbor. The city manager should now begin focusing on recovery of the bodies and getting any infrastructure repaired that will assist the frst responders in tackling fres or shoring up any buildings with structural damage. The city manager may want to con- sider bringing in engineers to determine the safety of some of the buildings that were hit with the explosions. In addition, pathologists are going to be needed to identify the bodies and families will need to be notifed. The American Red Cross should be contacted as well as the governor’s ofce to request assistance in cleaning up the disaster area. Key Issues Raised from the Case Study The main point that should be made in this case study concerns the issue of having proper rules and regulations in place to prevent a disaster from occurring. While it may be impossible to stop a fre from breaking out on a single ship, it is possible to limit the damage to that one particular vessel.