Foul odor from the nose may indicate sinus infections from dehorning or tumors cholesterol range chart uk effective 20 mg vytorin, abscesses in the throat or severe pneumonia cholesterol levels good or bad generic vytorin 20 mg overnight delivery. Mouth/Throat Cows should always breathe through their noses unless it is extremely hot and they open mouth breathe to cool off cholesterol levels european purchase 20mg vytorin fast delivery. Jo hn so dito r providin g livesto c k cholesterol measurement chart vytorin 20mg with visa, trees cholesterol yellow eyes quality vytorin 30mg, trin in g a n d otherresoures to help strugglin g f m ilies A risha W ebb C re tiveServies ssist n t m ovetowa rd gre terself relin c e n d build sust in a blefutures reduce cholesterol food chart purchase discount vytorin online. P rtn ers le rn to c refo r n im a ls n d grow L uise tgo ery Glossa ry n d Referen c e dito r rops in wa ys tha t n besust in ed fo rfuturegen ertio n s cholesterol levels europe 20mg vytorin fast delivery. Heifer dds expertise in a n im a lhe lth a n d husba n dry cholesterol medication kidney function buy vytorin 30mg low cost, wa terqua lity, gen derequity, a gro e olo gy a n d c o m m un ity developm en t C opyri g h t by H ei fer I nternati onal llri g h ts reserv ed. T h i s book, i n partor i n i ts enti rety, m ay be copi ed, reproduced oradapted to m eetlocalneeds w i th out O vertheye rs, Heiferha s developed a setofguidin g prin c iples lled the per i ssi on from th e auth ors orpubli sh er, prov i ded credi t C o rn ersto n es fo r ust n d Sust in a bleD evelopm en t. TheC o rn ersto n es fo rm the i s g i v en to H ei fer I nternati onaland th e auth ors. Sin c e, this o m m o n sen se ppro a h to sust in a ble developm en tha s en a bled Heifer P ri nted i n th e U ni ted S tates of eri ca to pa rtn erwith m illio n s off m ilies H ei fer I nternati onal in m o retha n 1 o un tries to 1 W orld A v enue im provetheirqua lity oflife L i ttle Rock R 7 w w w. A k now le d g e m e nt xi xii P ro vidin g Fo rges n d C o n c en trteto K ids I nt od u ion xiii Ha n d Feedin g K ids H ow o U e T h is ook xiv xvii C prin e rthritis n c epha litis (C) P reven tio n P ro grm. S t or y F om C m b od ia oa od ion M it ig ov I m xviii xix Feedin g M a tureGo a ts E x m ples o fFeeds Usin g O ts n d W he t rn. Go a ts n d E n viro n m en t lM a n a gem en t D eterm in in g the geo fGo a ts Grzin g M a n a gem en t E stim a tin g the o dy W eighto fGo a ts Fo rgeM a n a gem en t D esired C ha r teristis P ln tM a n a gem en t n d So ilIm pro vem en t B o dy C o n ditio n Sc o rin g. T h e L e a ning id e Sem i In ten siveSystem s the L e s on xten siveP ro duc tio n. W a rn in g Sign s o fD ise sein M a tureGo a ts Gest tio n C ha rt C o m m o n Sign s o fIlln ess in Go a tK ids C rin g fo rtheP regn a n tD o e P reven tiveHe lth P ro grm. Ho w to P ss Sto m a h Tube B irthin g K it Ho w to Give n A n im a l o lus P repa rtio n fo rK iddin g in In ten siveSystem s Ho w to Give n In je tio n. P repa rtio n fo rK iddin g in E xten siveSystem s P reven tio n a n d Tre tm en to fIn tern a lP rsites Sign s o fP rturitio n (K iddin g). A bn o rm a l irth P o sitio n s L ife yc leo fTypi lL iverFluke (Illustrtio n). P reven tio n a n d Tre tm en to f xtern a lP rsites Go o d Gen erlRules L ife yc leo f O n e ho stTik (Illustrtio n). M ilkin g E quipm en t n d Supplies tivity a n d L a bo rP ro f le P ro perM ilkin g P ro c edures ess n d D e isio n T ble Ho w to C refo rtheM ilk. T h i s uni que approach creates a i n L i v estock ev elopm ent W prog ram the L e a ning id e ri pple effectth attransfor s li v es and com uni ti es. T h e pooresti n th e com uni ty sh ould be Ha n dlin g o fGo a ts P rio rto Slughter ow n needs, setg oals and plan appropri ate strateg i es to i ncluded and recei v e pri ori ty forassi stance. T h ey are also responsi ble forsubm i tti ng are eli g i ble reg ardless ofcreed oreth ni c h eri tag. O ne of soi lferti li ty, sani tati on, forestati on, bi odi v ersi ty, G los y our ost portant ornerstones, sh ari ng and cari ng polluti on, w i ldli fe and w atersh ed condi ti ons. A ppe nd ix B e a oe R e c or d S h e e t t e, proj ectg roups m ustdev i se strateg i es H ei fer i s com i tted to i nv olv i ng all em bers i n A ppe nd ix B k R e c or d S h e e t for i ts conti nui ty. I n ourexperi ence, selfreli ance i s deci si on ak i ng, w or i ng w i th g rassroots g roups A ppe nd ix C d g e t ing osteasi ly ach i ev ed w h en a g roup h as v ari ed acti v i ti es to dev elop strong leadersh i p and org ani zati on. Trai ni ng i ncludes for alsessi ons as w ellas I nt e r ne t S it e s i n successfulli v estock anag em ent. I n addi ti on be an appropri ate breed forth e area and sh ould to trai ni ng i n li v estock h usbandry and env i ronm ental be a v i talpartofth e far acti v i ti es w i th outplaci ng conserv ati on, g roups h av e requested trai ni ng i n an extra burden on th e fam i ly orresources food processi ng, m ar eti ng and h um an nutri ti on. I ti s expressed i n prov i de draftpow erforculti v ati on and transportati on, as th ei rv alues, sense ofconnecti on to th e earth and sh ared w ellas m anure forsoi lferti li ty. O ften spi ri tuali ty creates a strong bond foreducati on, h ealth care and h ousi ng, and as li v i ng am ong g roup m em bers, g i v i ng th em fai th, h ope and a sav i ng s accounts, prov i de long ter econom i c stabi li ty. HeiferIn tern a tio n a lis ple sed to presen tthis n ew, revised editio n of a is ing a ts fo ilk a nd M e a t Sin c ethe f rsteditio n wa s prin ted in 1 literlly hun dreds ofgo o d texts the hin g m a terils n d Terry W l l en V M is theD ire to rof n im a lW ell ein g n d St ffVeterin a rin with Heifer bo o ks o n go a thusba n dry ha veem erged. This versio n lso in c ludes sto ries illustrtin g Fo llowin g two ye rs in the rm y Veterin a ry C o rps hewo rked in four m a n da iry, beef n d how go a ts ha ve o n tributed to theliveliho o ds ofsm a llsc lef rm ers roun d thewo rld. In thoseo lden da ys, Iha n dled pro c urem en t da ily reofthe n im a ls wa itin g fo r shipm en t prepa rtio n fo rshippin g, he lth tests n d rrn gem en ts fo r irtrn spo rt tio n. In n d 1 It ught o urses in da iry go a thusba n dry in C m ero o n, W est fri When husba n d, operted sm a ll sc lego a tda iry c lled lo o m D iry in to n Rouge L o uisin a I rrived, Ifoun d lim ited the hin g m a terils with ba si in fo rm a tio n n d sim plesuggestio n s bout whih pro duc ed fuid m ilk, heeses n d ie re m. Go a ts Un lim ited, begun in is K iko go a tbreedin g c en ter n d f rm tha tpr ties holisti m a n a gem en t pa sture browse M y o a utho rPaul R uden berg, V M ha s served s volun teerfo rHeiferIn tern a tio n a lsin c e s m a n a gem en t n d sust in a ble ltern a tive griulture D rP eisc helha s t ughtSm a llRum in a n t theHeiferIn tern a tio n a lC o un try D ire to rfo rHa itifro m 1 un til hehelped in ititepro je ts P ro duc tio n ttheUn iversity ofHa wa ii tHilo, Un iversity ofC lifo rn i tC hio, n d is n ow the fo c usin g o n sm a llrum in a n t n d c ttlehusba n dry, soil o n serv tio n, refo rest tio n, liter y n d Sm a llRum in a n t xten sio n Spe ilistfo rTen n esseeSt teUn iversity n d theUn iversity pa rtiipa to ry trin in g. Fro m 1 to t tin a wo rked in theC ribbe n s sm a llrum in a n tspe ilistthro ugh the B arbara arterst rted drwin g when shewa s a youn g hild. C rterlives o n sm a llf rm in rum in a n tin tegrted pa rsitem a n a gem en t n d pa sturem a n a gem en tfo rgo a ts. Given Ho listi n im a lHe lth, in P ririeGrove rka n sa s whereshedevelops sust in a ble n im a l theirsm a llst ture o m pa red to otherlivesto c k, go a ts n berised o n lrgeo rsm a llln d welln ess pln s a n d trin s pro duc ers a n d educ to rs. Sheha s been in volved with o rga n i holdin gs Furtherm o re pproxim a tely two thirds ofthefeed en ergy used to risethese livesto c k pro duc tio n o n herown f rm n d wo rkin g with othero rga n i pro duc ers fo r ye rs. D r n im a ls o m es fro m subst n c es whih a reun desirble in digestible n d in edibleby hum a n s. W ells c urren tly a dvises thest ff tHeiferRa n c h in P erryville rka n sa s rese rhin g pa rsite m a n a gem en tstrtegies to reduc ethen eed fo r n thelm in tis. She lso wo rks with Heifer Itis littlewo n dertha tgo a ts were m o n g thee rliestdo m esti ted n im a ls re o rds in this pro je ts in theU. This m a y beexplin ed by the f ttha tgo a ts ha vegen tletem perm en ts m a kin g them ide lhousehold n im a ls. Trditio n a lly rised fo rm ilk n d m e t go a ts rethesoureofthem ostwidely o n sum ed M arie M cC abe, V M join ed HeiferIn tern a tio n a lin J un e s D ire to rofC o m m un ity E duc tio n. Go a tpro duc ts ha vebe o m esought fter o m m o dities in developed c o un tries. Fo r en turies go a tskin s ha vebeen used fo rdrum s lothin g, pa rhm en t n d s In a dditio n wewish to kn owledgethe o n tributio n s ofthefollowin g in dividua ls who ha ve o n t in ers fo rwa ter n d m ilk. In m o dern da y, go a tskin s been a tivein the f elds ofgo a thusba n dry, sust in a bledevelopm en t n d trin in g. A e ssi W al l ace R o by C even dra W i l l iam R o se, Sin c etheirdo m esti tio n over ye rs go, go a ts Jam es e V ries S tarbard ha veheld spe ilpl ein thehe rts n d ultures G eo rge W aen l ei S usan S tewart ofm a n y people With theirm a n y ben e f ts itis G rdo atcher l sa S wen so le rtha tgo a ts will o n tin ueto ha ve n im po rt n t Jo sep h wel l R o Tem est ro lein sust in a ble griulturldevelopm en t L g ushen g l l en Zep n d fo o d pro duc tio n ro un d thewo rld. In the seofgo a ts wo m en often re eive design ed s a tool fora facil itatorto usewhen trin in g group off rm ers in terested in thein c o m efro m m ilk o rsa leofkids. Itis lwa ys m o reeffe tiveto trin theperso n who st rtin g o rim provin g go a tpro duc tio n. Thebo o k is o rga n ized in to ha pters n d e h c ha pter wo rks with the n im a ls so in fo rm a tio n is n otlost n d they n sk relev n tquestio n s. How thetrin in g is o rga n ized depen ds o n Therefo re itis im po rt n ttha tthewo m en, hildren o rwo rkers rein vited, n d theown ers theexperien c e n d n eeds ofthegroup. W ebegin ourpln n in g with who will tten d be usethepeoplewho tten d should Thef ilit to rwillwa n tto kn ow s m uc h boutthegroup s possible Ifthere rein terested setthe gen da fo rthetrin in g. W ha tdo thepa rtiipa n ts wa n tto le rn a bout W ha t go a tf rm ers butthey ren otyeto rga n ized in to go a tpro duc ers group, fo rm in g group retheissues thepa rtiipa n ts rede lin g with in risin g livesto c k, in theirvillge n d should be prio rity. Trditio n a ltrin in g st rts with thete her n d groups le rn to seto bje tives ele tof ers a n d o rga n ize f n a n c es. In f t ex item en t bout wha tthete herwa n ts to the h o rthin ks thele rn ers should kn ow. How willthey useit W hy rethey in vestin g Ifyou a rewo rkin g with n existin g group, you willwa n tto kn ow then um ber ge in c o m e n d v lua bletim eto tten d the o urse this should in fuen c ethe o n ten tofthetrin in g. Fin d outthelevelofliter y, n d theln gua gepreferen c es go a ts they willn otbeha ppy ifthewholetrin in g is a boutn utritio n n d pa stures (even ofthegro up. When they o m eto getherwha tdo they t lk m o resuc essfulitwillbe a bout How is itrelted to go a tpro duc tio n Thef rm do es a n d in c ludethem in yourtrin in g design a s pl es to stim ultedisc ussio n n d pro blem solvin g n otn eed to be m o del in f t them o ren eeds thebetterThegroup c n n a lyze a boutthere l ha llen ges thef rm ers ref in g. If n existin g o m m un ity buildin g is m o re o n ven ien tdueto a en trllo c tio n, besureto rrn geha n ds o n R V W R R S E S S I tivities with live n im a ls tua lfeedstuffs et Iftherewilln otbeen ough go a ts fo r Theseven steps ofpln n in g fo r n y go o d pa rtiipa to ry trin in g even t re W ho, W hy, W here everyo n eto do ha n ds o n pr tie o n sider f n din g a differen tlo c tio n wherethere re When, W ha t W ha tFo r n d How. The gen da should in c lude le ro rder a n im a ls a tten ds lthough hem a y n otbethe tua lda ily ret ker n c o urgeboth own er ofeven ts a n d plen ty oftim eto seethef rm n d ddress questio n s. In developin g o un tries them a lehe d of lrify pln s fo rm e ls tthebegin n in g ofe h sessio n. Thetim eshould be o n ven ien tfo rthef rm ers n d n otjustthef ilit to r so sm a llgroups n touttypi lsitua tio n s n d le d disc ussio n boutdifferen t A lso, m en n d wo m en m a y bebusy tdifferen ttim es ofda y, so sepa rtetrin in g tim es solutio n s. Fa rm in g ha s se so n a lwo rklo a ds so trin in g m a y n eed to stop durin g o rifthem en help thewo m en n d preven tthem fro m le rn in g to give n in je tio n o r thepln tin g o rha rvestse so n, n d pik up ga in durin g theslow se so n. Thin k bouthow to o rga n izesm a llgroups fo rpr tie n d disc ussio n se so n is thetim ewhen f rm ers ha vethem osttim eyet ess to villges m a y bedif ult sessio n s so tha two m en o ryoun g people regiven voie n d m en do n otdo m in a the C refulpln n in g to llow thetrin in g to ha ppen when thef rm ers refree n d go a ts a re ll D isc overthelo c lln gua gefo rbo dy pa rts dise ses n d lo c lm ediin es n d use a v ilbleis very im po rt n t them. In the seofdise ses tha t n bepreven ted by v in a tio n, disc overthelo c l M ostoftheselesso n s m a y be da pted fo rdifferen ttim efrm es fro m two to four n a m e n d the h the ppropriten a m eto en a blethef rm erto buy the o rre tv in e hours. If residen tiltrin in g o urseis offered, f n d outifthem en a n d wo m en in thegroup prefertwo da ys threeda ys o rtwo weeks. C ostoftrn spo rt fo o d n d housin g n eeds to be M a kesureyou pln plen ty oftim ein yoursessio n s fo rthele rn ers to refe to n wha tthey ha ve a rrn ged wellin a dv n c e le rn ed n d pr tied. Fo rex m ple ifthey pr tiegivin g in je tio n s sc hedule tim e ttheen d of thepr tien oto n ly to review wha tthey ha vele rn ed but lso to refe to n it W ha twa s surprisin g W hatis thetopi ofthelesso n, suc h a s go a tn utritio n o rrepro duc tio n. W ha twa s useful W ha tdo they kn ow tha this differen ttha n wha tthey kn ew befo re W ha t a rerelev n t n d n be pplied right wa y by f rm ers. Fin d out urren tlevels ofkn owledge n d very powerfulle rn in g experien c e m o repowerfultha n justpr tie lo n e pr tie eitherbefo rethesessio n o r tthest rt Ifthere redifferen tlevels ofexperien c e you m a y wa n tto dividethegroup, o rdesign sessio n s so tha tm o reexperien c ed f rm ers St rt trin in g sessio n by skin g fo rtheirexpe t tio n s n d c urren tbeliefs o rpr ties. Still rem em berto ha llen gef rm ers to o n siderthebig im provetheirpro duc tio n, you c n a lwa ys offerm o re dv n c ed trin in g in thefuture piture bouthow they wa n ttheirlives to be n d thepr ti lsteps tha t n brin g bout ha n ge W hatforrefers to thele rn in g o bje tives. Itis very helpfulin pln n in g to st the le rly wha t a is ing a ts fo ilk a nd M e a t provides n experien c ed ba sed trin in g m o delo n theba si thepa rtiipa n ts will tua lly D O by theen d of sessio n. This helps f ilit to rs to refrin re n d m a n a gem en tofda iry n d m e tgo a ts. O n ly when wedo it So, st tewha tthele rn ers will tua lly do in is ofim m editepr ti lv lue n d they n sha retheirexperien c es n d skills with others a sessio n. Fo rex m ple B y theen d ofthesessio n, pa rtiipa n ts willha vedesign ed n d built m o delgo a tpen. L e rn in g groups fro m differen t lsses ultures o rsexes m a y determ in ehow we c lrif es thepln n in g pro c ess n d is very helpful t f rstitis ha llen gin g to do this but ppro a h thetrin in g sessio n s. Thegroup n help in determ in in g a epted st n da rds ofbeha vio r in theen d itwillhelp in c re setheben e f ts ofthetrin in g. The o urse n lso beused by in dividua ls utilizin g the dvie n d ssist n c eofothergo a t ow m e n s wha this your tua llesso n pln, n d wha tm a terils do you n eed to prepa re breeders exten sio n perso n n el n d lo c lveterin a rin s. Duch Sakhorn, his wife and fve children S H ouseh old G oatP roducti on, are a poor family living in Prek Taong village. They a proj ectsupported by H ei fer joined the project and received two breeding goats I nternati onal am bodi a and th e along with training. The two original placements F ar ers G oat ssoci ati on i n P rek produced eight goats of which four were passed Ta O ng V i llag e, P eam O h a on to other poor families in the community. We also make compost T h ey recei v ed trai ni ng i n H ei fer fertilizer from goat manure for fertilizing our one-half hectare feld. Duch Sakhorn said: I am inspired by the Cornerstone g oats w ere to assi stth e fam i ly i n Gender and Family Focus because my family members always share household i m prov ed nutri ti on, m ar eti ng g oatproducts and g enerati ng i ncom. Her li v estock speci es k eptforfood by th e m aj ori ty offar ers i n C am bodi a, w h o k eptcow s and family earns their living by growing banana trees, beans, and maize. H ow ev er, th e proj ecth as been successful i n assi sti ng poorfar ers i n rai si ng have three goats, 13 chickens and two pigs. She saves goat and pig manure for fertilizing g oats forfood and to dem onstrate th e adaptabi li ty ofg oatproducti on forsm allfar s. Since participating in the E ach fam i ly recei v ed tw o fem ale breedi ng g oats and a m i cro credi tloan forsetti ng project, she has sold three goats for other supplies needed for her family. Kim trai ni ng courses on feedi ng g oats, com on di seases, g oat anag em ent, zero g razi ng and Sonem. T h e proj ectprom otes th e carefulensi li ng ofcassav a leav es Although goat production in the community is progressing, the market for goat and foddertrees i ncludi ng k apok and L eucaena. Goat meat and milk are not common at local markets in Cambodia, around th ei rland forleav es as a protei n source. To i nsure g oath ealth, a k ey far er i n th e yet the Farmer Goat Association is sharing ways that goats can help poor families with com uni ty w as selected fortrai ni ng by a V i llag e A ni m alH ealth W or er limited farm land. They encourage the use of goat meat to improve family nutrition, which F orth e pasttw o years, th e F ar erG oat ssoci ati on h as dem onstrated th e si g ni fcant is low in protein. The Farmer Goat Association of Lvea Em Commune works together to i m pacts and di rect prov em entoffam i ly i ncom e from sale ofg oat eat. The association offers dishes of goat meat for ceremonial or reci pi entfam i li es h av e passed on th e g i ftofoffspri ng to oth erfam i li es i n th e com uni ty celebration events in the community, as they share information about how goats can help a w h i le rem ai ni ng offspri ng h av e been sold forcash to supportth ei rfam i ly needs and pay family have a competitive advantage and generate additional income for the family. O therwiseusehe vy pa per C o lo red pen c ils o r ryo n s fip c ha rto r bl k bo a rd Threero pes o rbelts fo rho ldin g thego a ts in skit D iry a n d m e tgo a ts fo rthe f rst tivity tle stthreego a ts o fdifferen t ges fo rthese o n d a tivity m e surin g t pefo re h pa rtiipa n t rum in a n tsto m a h fro m a slughterho use (if v ilble Ha n do uto f o dy C o n ditio n Sc o rin g C ha rt A V S S I T Sele ttwo c lss m em bers to dis uss theskit n d presen titto thegro up. In troduc ethef ilit tors who willha ve lre dy m in utes iden tify he rtgirth prepa red a n a m et g. E h person willdesign his herown n a m e dividein to groups, determ in eweightofgoa ts n d 3 m in utes t g with a drwin g of goa ton it. Get qua in ted with on e om pa re n swers a n otherby tellin g a boutthen a m et g, som ethin g a boutf m ily Refe t: W ha t retheben e f ts to weighin g a goa tthis wa y G et very on e T hi i g an d T al k i g A boutthe S k it ody C on dition S cori g (S) Sees m ples ript ten d ofthis le rn in g guideof the ter Review B C S c ha rt skit boutgettin g st rted in risin g goa ts. In theskitpeople D ividein to the m s oftwo with a n otherte m o bservin g 2 m in utes m a y begoa ts orthey m a y beim a gin a ry. A tors a d lib som e x m in e n d pa lpa tegoa t n d n otes ore ofthe on vers tion on c ethey kn ow theskit dd or ha n ge Swith the m s n d repe t 6 m in utes c on vers tion to dis uss the ha llen ges ofrisin g goa ts in rin g the m s together the om m un ity. S hare U derstan di gs rom the S k it W ha this thebests ore When willyou usethis m ethod W ha tha ppen ed here W ha twereC rm en a n d M a ri n d in form a tion P rtiipa n ts a pproa h goa ts in the m s oftwo orthreeperson s n d iden tify a ge. There n besm a llrewa rds forthosewho a re orre t U derstan di g the R um i an tS tom ach Two c lss m em bers willpresen tin form a tion on therum in a n t 3 m in utes stom a h. W here T a reyou goin g, to thevet C arm en l ook sirritated: N o wa y, Ijustgot gre tde l tthelivesto c k m a rket these rethe S W st rtofm y n ew herd. Ide ided yesterda y tha tIwa n tto riseda iry goa ts so I n sen d m y da ughterto s hoolin thef ll. Theldy who sold them s id this on eis threeye rs old, a n d is n d is lo w in c ho lestero l. P ro tein in o urdietbuilds stro n g bo n es, teeth, ha ir, m us les n d a n tibo dies to f ghtoffin fe tio n.
In swine cholesterol medication contraindications buy 30 mg vytorin mastercard,tetanus is m ostly seen as a resultofwound infection cholesterol pills glass order vytorin,castration orum bilicalinfection in new born anim als cholesterol test particle size 20 mg vytorin visa. Clostridium tetaniform s spores which are extrem ely resistantand m ay rem ain viable foryears ifprotected from lightand heat cholesterol medication pdf buy discount vytorin 30mg on line. Clostridium tetaniproduces toxins which are responsible forthe clinicalpicture oftetanus cholesterol vaccine discount vytorin 20mg on-line. Neurom uscularactivity favours m igration of tetanus toxins through peripheralnerves which reach the lum barand cervicalregion ofthe cord and the brain stem cholesterol medication in canada vytorin 30mg line. In this ascending form ofthe disease cholesterol reduction cheap vytorin 30 mg amex,tetanus develops firstin the lim bs cholesterol value in eggs purchase vytorin pills in toronto,followed by the m uscles ofthe trunk. Toxins circulate in the blood and lym ph and cause tetanus in the m uscles ofthe forelim bs,uppertrunk and hind lim bs. The firstsym ptom s are the protrusion ofthe nictitating m em brane,and the involvem entoffacialand jaw m uscles leading to lock jaw. The m usculature is usually grey yellow in colourand the carcass is inadequately bled. Differentialdiagnosis:Strychnine poisoning,hypocalcem ia (eclam psia)ofm ares,cerebrospinal m eningitis,lactation tetany ofcattle,enzootic m usculardystrophy,enterotoxaem ia oflam bs, polioencephalom alacia Glanders Glanders is a bacterialdisease ofhorses and othersolipeds characterized by lesions in lym ph glands,lym ph vessels,respiratory tractand skin. Transm ission:Ingestion offood and drinking ofwatercontam inated with secretions and excretions ofsick anim als. W ound infection and the respiratory route in acute glanders, contam inated needles,groom ing equipm ent,urine,nasaldischarges,purulentskin lesions are also associated with the transm ission ofthis disease. Granulom atous nodules along the lym phatics underthe skin,especially on the legs. Necrosis in the internalorgans and testicles Judgem ent:Carcass ofan anim alaffected with glanders is condem ned. Differentialdiagnosis:Epizootic lym phangitis,ulcerative lym phangitis,strangles,dourine and m elioidosis Strangles (Distem per) Strangles is a contagious disease ofequines characterized by inflam m ation ofthe upper respiratory tractand purulentlesions in the regionallym ph nodes. Transm ission:Source ofinfection is nasaldischarge from infected anim als and contam inated food and water. Infection is spread by ingestion orvia respiratory route by inhalation of droplets. Itm ay spread foratleast4 weeks afterthe initialattack due to organism developing resistance to diverse environm entalconditions. The spread ofinfection is also caused by parasites and infected anim als during copulation. Purulentinflam m ation ofthe brain followed by excitem ent,neck rigidity and term inal paralysis 11. Lam eness and difficultbreathing Atypicalform ofstrangles is m anifested by subclinicalinfection and m ild disease. Abscesses in the m esenteric lym ph nodes Bastard stranglesdenotes m ultiple abscessation in the vitalorgans and generalized system ic infection. Judgem ent:Carcass ofan anim alaffected with strangles is condem ned ifthe anim alshows signs ofacute infectious disease accom panied with feverand system ic generalized lesions. Differentialdiagnosis:Epizootic lym phangitis,ulcerative lym phangitis,dourine,m elioidosis, equine viralrhinopneum onitis,equine influenza and equine viralenteritis Parasitic diseases file:///C:/versam m elt/index m eister. Transm ission:Transm ission by coitus and rarely by bloodsucking flies (Tabanidae and Stom oxys) Antem ortem findings: 1. Acquired loss in cutaneous pigm entation (vitiligo)noted as white discrete patches of various shapes and sizes in the skin and externalgenitalia. Transitory urticarialplaques which do notulcerate,appearon the m ucosa and skin, particularly on the flanks. Edem a ofthe scrotum,prepuce and penis in stallions and the udderedem a in m ares 10. Nervous signs are m anifested by incoordination,irregularm uscularcontractions,facial file:///C:/versam m elt/index m eister. Em aciation,anaem ia and characteristic depigm entation in the skin and externalgenitalia 3. Edem atous fluid in the pleural,pericardialand peritonealcavities Judgem ent:Carcass ofan anim alshowing chronic lesions oftrypanosom iasis without system ic involvem entand the carcass ofrecovered anim als is approved. Horse carcass affected with the disease is condem ned ifclinicalsigns are accom panied with em aciation and edem a oranaem ia. Itis seen as an occupationalhazard,prim arily to those associated with varied activities in the poultry industry;em ployees in abattoirs,vaccinators,laboratory staff and otherpersonnel. In m ostcases the clinicalpicture is thatofconjunctivitiswith rare system ic reactions. Transm ission:Secretions from infected birds,by wild birds and contam inated feed,equipm ent and people. Seabirds and m igratory waterfowlcom prise the m ain reservoirforavian influenza virus. The m orbidity and m ortality rates can reach 100 % in cases ofhighly pathogenic strain of the viruses. Diffuse haem orrhages between the hocks and feet file:///C:/versam m elt/index m eister. In highly pathogenic influenza virus,fibrinous exudate is found in airsacs,oviduct, peritoneum and pericardialsacs. Edem a ofthe head with congestion,haem orrhages and cyanosis ofthe com bs,wattles and sinuses 8. Petechialand ecchym otic haem orrhages in abdom inalfat,various serosaland m ucosal surfaces,heart,gizzards,proventriculus and sm allintestine. Judgem ent:Carcasses affected with avian influenza in any form should be condem ned. Differentialdiagnosis:Fowlcholera,chlam ydiosis,m ycoplasm osis,velogenic viscerotropic Newcastle disease file:///C:/versam m elt/index m eister. Transm ission:Transm ission is by directcontact,fom ites,and by aerosols through coughing, gasping and respiratory fluids. The virus has a wind borne potentialforspread creating quite a challenge forcontroland prevention. Paralysed wings and twisting ofthe head and neck (torticollis) Postm ortem findings: Acute form 1. Peracute deaths willoften show no discernible lesions in som e ofthe firstbirds dying in an file:///C:/versam m elt/index m eister. Haem orrhages are throughoutthe gastrointestinaltractwith a tendency to ulcerate and becom e necrotic as the disease progresses. The m ucosallining ofthe proventriculus is a frequentsite ofhaem orrhage,especially at the junction between the oesophagus and proventriculus. In hens thathave survived the disease,there is a tendency to lay m isshapen eggs or develop egg yolk peritonitis. Ifconfirm ed,carcass is condem ned and prem ises with equipm entshould be disinfected. In case thatlaboratory confirm ation is not possible,suspected carcasses should be also condem ned. Acute form:Haem orrhage in the m ucosa ofthe trachea (upper),large intestine, particularly caecaltonsils (m iddle),proventriculus (bottom)and gizzard. Som e birds becom e carriers and shedders ofthe virus through file:///C:/versam m elt/index m eister. Serous,catarrhaland caseous exudate in the upperrespiratory tractincluding nasal passages,trachea,sinuses and bronchi 2. Occasionally swollen and pale kidneys containing urolith deposits (uric acid crystals)(Fig. Sm allcystic oviducts Judgem ent:Affected birds are treated as suspects on antem ortem inspection. A carcass showing acute signs ofclinicaldisease accom panied with em aciation is condem ned. Laryngotracheitis spreads slowly in a flock although respiratory signs are m ore severe than in infectious bronchitis. The transm ission from acutely infected birds is m ore com m on than from recovered orvaccinated birds. The latterm ay shed the virus fora prolonged period of file:///C:/versam m elt/index m eister. Inflam m ation ofthe larynx and trachea leading to necrosis and haem orrhage ofm ucosa 2. Ifan acute condition is associated with generalsystem ic changes,the carcass is condem ned. Differentialdiagnosis:Newcastle disease,Infectious bronchitis and infectious coryza file:///C:/versam m elt/index m eister. Ithas a worldwide distribution and affects birds ofall age groups,exceptthe recently hatched. Itis resistantto environm entalfactors and persists in the environm entform any m onths. Antem ortem findings:Two form s oflesions are recognized,-the cutaneous (dry form)and the diphtheric (wetform) Cutaneous form 1. Nasaland oculardischarge Postm ortem findings:The following stages ofthe pox lesions papules,vesiclesand pustules m ay be observed. Occlusion oftrachea,and death due to asphyxiation Histopathology shows characteristic intracytoplasm ic inclusion bodies (Bollingerbodies)in the infected epithelium. Judgem ent:Carcass affected with fowlpox is condem ned ifprogressive generalized lesions in a bird are accom panied with em aciation. Fowls with localized lesions and recovered birds are approved afterthe rem ovalofscales. Differentialdiagnosis:Pantothenic acid and biotin deficiency,vitam in E deficiency,infectious laryngotracheitis and otherrespiratory diseases in poultry,injuries caused by external parasites and cannibalism. Avian leucosis com plex Avian leucosis com plex occurs in fourseparate disease entities: 1. In horizontaltransm ission,chicken which contractthe virus afterhatching develop antibodies;som e willrem ain shedders,som e willdevelop tum ours and die,and others willovercom e the infection. Infection from flock to flock is unlikely as the virus does not survive a long tim e in the environm ent. Lym phoid leucosis is a B celltum ourwhich starts in the bursa and,before sexualm aturity,m ay spread to otherorgans. M ale birds are also affected in lessernum bers than fem ale due to the earlier regression ofbursa in m ale birds. Otherorgans such as lung,heart,proventriculus,gonads,bone m arrow and m esentery are som etim es affected. Ecchym otic haem orrhages around the skin follicles ofthe wing Judgem ent:The carcass ofa bird affected with lym phoid leucosis is condem ned. Transm ission:Itis spread by airborne infection involving follicle cells called chicken dander. Infected birds willstartto shed the virus in the second orthird week afterinfection and willcontinue to do so throughouttheirlife,although they do develop antibodies againstthe virus. Itis m anifested with tum ours in the liver,spleen,kidneys,brain,spinalcord and dorsalrootganglia and with sudden death. Noted in broilerchicken on postm ortem exam ination in abattoirs as enlargem entoffeatherfollicles and associated lym phoid infiltrations. Localized skin lesions require the condem nation of file:///C:/versam m elt/index m eister. Differentialdiagnosis (forskin lesions):Lym phoid leucosis (see Table 7),erythem a,derm atitis, pigm entation and norm allarge follicles. In both cases follicular enlargem entis noted;however,the lesion m ay differin colour. Ornithosis (Psittacosis,Avian chlam ydiosis) Ornithosis is an acute orchronic disease ofturkeys,ducks,chicken,pheasants and pigeons. Transm ission:W ild carrierbirds and cage birds transm itChlam ydia to theirnestling which m ay survive and becom e carriers. M ild cases m ay be unobserved orshow m ild respiratory signs and diarrhoea file:///C:/versam m elt/index m eister. Inflam m ation ofthe lungs,airsacs,liver,heart,spleen,kidneys and peritoneum In turkeys 2. Congestion ofthe lungs and an enlarged congested spleen In pigeons file:///C:/versam m elt/index m eister. In cage birds enlarged spleen and liver,inflam m ation ofthe airsacs and pericardium and intestinalcongestion. Judgem ent:Ifthe disease is suspected on antem ortem,birds are treated as suspects and sam ples should be shipped to the Laboratory. Ifthe disease is suspected on postm ortem,delayed slaughterof the birds from the sam e source should be required. Ifthe disease is notconfirm ed the carcass m ay be approved ifotherwise wholesom. Salm onella infections in this M anualinclude pullorum disease,fowltyphoid,arizona infection and paratyphoid. Pullorum disease occurs in chicken and turkeys and is caused by Salm onella pullorum. Differentialdiagnosis:Liverand heartlesions should be differentiated from infections due to othersalm onellae and from cam pylobacteriosis,colibacillosis and om phalitis. Nervous lesions should be distinguished from nervous signs observed in Newcastle disease. Respiratory tract lesions should be differentiated from aspergillosis and jointlesions with synovitis and bursitis caused by otherbacteria orviruses. Inflam m ation ofthe anteriorpartofthe intestine Judgem ent:Carcass and viscera affected with fowltyphoid are condem ned. Enlarged,bronzed to the m ahogany colourliverand enlarged,m ottled and brittle spleen in a turkey Diseased liverand spleen are shown in contrastto the norm al ones atleft. Paratyphoid infection Paratyphoid infection is an acute and chronic infection ofpoultry and m am m als. Swollen eyelids Judgem ent:Carcass and viscera affected with paratyphoid infection are condem ned. Differentialdiagnosis:see pullorum disease file:///C:/versam m elt/index m eister. Arizona infection (Arizoonosis,Paracolon infection) Arizoonosis occurs in young turkey poults. Cloudiness and enlargem entofthe eye causing blindness Antem ortem findings:Antem ortem findings in young birds are sim ilarto those ofparatyphoid. Purulentexudate in the brain Judgem ent:Carcass and viscera affected with arizoonosis are condem ned. Differentialdiagnosis:The causative organism m ustbe isolated and identified for differentiation from salm onellosis. Fowlcholera (Pasteurellosis) Fowlcholera is an infectious disease affecting alm ostallclasses offowland otherpoultry. Itoccurs m ore frequently in stressed birds associated with parasitism,m alnutrition,poorsanitation and otherconditions. This organism is easily destroyed by sunlight, file:///C:/versam m elt/index m eister. However,itwillsurvive severaldays ofstorage or transportation in a hum id environm ent. Transm ission:Ifbirds are bitten by infected anim als such as rodents and carnivores,the disease could be dissem inated in the flock. Contam inated feed,water,soiland equipm entare also considered as potentialfactors in the spreading ofthe disease. M iddle earinfection is rare butoccurs when the bacterialagentreaches the m iddle ear through the nasalcavity. The bird m ay lose its sense ofbalance with the head and neck twisted to one side. Petechialand ecchym otic haem orrhages on the heart,serous and m ucous m em branes,on the gizzard and abdom inalfat. The liveris swollen and is streaked with white areas and associated sm allgrey areas of necrosis (corn m ealliver,Fig. Darkened breastm uscle is frequently noted and haem orrhagic lesions are often m issing. Judgem ent:Localized lesions ofpasteurellosis such as infection ofwattles,joints ortendon sheaths require the condem nation ofthe affected parts;the restofthe carcass is approved. Differentialdiagnosis:Acute colibacillosis and erysipelas in turkeys,salm onellosis, tuberculosis,listeriosis. Pasteurellosis is differentiated from septicem ic and virem ic diseases by culture ofP. Hum ans m ay becom e infected with this disease,and then they m ay also infectpoultry with exudates from the nose and m outh. Sm allareas ofnecrosis in the liver(corn m ealliver) Tuberculosis Tuberculosis is a chronic granulom atous disease ofpoultry caused by M ycobacterium avium. Irregulargreyish yellow orgreyish white nodules ofdifferentsizes in the liver(Fig. Differentialdiagnosis (on postm ortem):Aspergillosis,typhoid and paratyphoid,salm onellosis, fowlcholera,cam pylobacter,colibacillosis,chlam ydiosis,histom oniasis and neoplasm. Prim ary factors associated with the etiology ofairsac disease are poorairquality and dust,associated with eitherviralorm ycoplasm alagents. Postm ortem findings:Postm ortem exam ination ofaffected chicken reveals inflam m ation of trachea and frothy exudate in the airsacs.
The acknowledgment of parentage form and information shall clearly state that completion of the form is voluntary on the part of the mother and father cholesterol in eggs nutrition facts vytorin 30mg with visa, and shall include all of the notices as provided in section 7 of the acknowledgment of parentage act cholesterol test diy purchase discount vytorin online. The hospital shall provide the information whether or not the hospital provides hospice care cholesterol definition simple buy genuine vytorin on line. This subsection does not apply if the hospital does not have electronic access to the information described in section 21541(1)(a)(i)(A) and (B) cholesterol lowering diet and lifestyle buy vytorin 20 mg with visa. A hospital shall retain a copy of the notice required under this subdivision for not less than 7 years cholesterol levels in child buy cheap vytorin on-line. You may be responsible for the costs of the transportation that is not covered by your health benefit plan cholesterol medication pdf buy 20 mg vytorin free shipping. We have conducted a good-faith search to determine whether your health benefit plan provides coverage for this transportation and cholesterol medication dangers purchase 20 mg vytorin fast delivery, if so cholesterol estimation test purchase vytorin cheap, to order this transportation from a provider that participates with your health benefit plan. You have a right to be transported by a method other than transport by an aircraft transport vehicle or ambulance that is a rotary aircraft. The hospital and the ordering physician are immune from civil liability for injuries or damages arising out of your decision to use a form of transportation other than the one ordered by the ordering physician. A hospital shall not deny an aircraft transport vehicle or ambulance that is a rotary aircraft the right to land at the hospital for the purpose of allowing an aircraft transport vehicle that is a contracted provider with the hospital or ambulance that is a rotary aircraft that is a contracted provider with the hospital to remain on standby. The department shall grant an extension under this subsection unless the department determines under part 222 that there is a demonstrated need for the delicensed beds in the subarea in which the hospital is located. If the department does not grant an extension under this subsection, the hospital shall request relicensure of the beds pursuant to subsection (7) or allow the beds to become permanently delicensed pursuant to subsection (8). Upon receipt of a complete application under this subsection, the department shall temporarily delicense the beds indicated in the application. The department shall not grant an extension of temporary delicensure under this subsection. The form shall contain all of the following information: (a) the number and location of the specific beds to be delicensed. Along with the application, an applicant for delicensure under subsection (1) or (3) shall submit to the department plans that indicate to the satisfaction of the department that the space occupied by the beds proposed for temporary delicensure will be used for 1 or more of the following: (a) An alternative use that over the proposed period of temporary delicensure would defray the depreciation and interest costs that otherwise would be allocated to the space along with the operating expenses related to the alternative use. The department shall indicate in the bed inventory which beds are licensed and which beds are temporary delicensed under this section. The feasibility study shall include at least all of the following information: (a) the outstanding hospital bonded indebtedness and associated interest for all the hospitals in this state and the amounts payable in principal and interest per year until the bonds are retired. The committee shall be composed of 15 members equally divided among representatives of health consumers, health providers, and purchasers of health care. The advisory committee established under subsection (5) shall submit its report to the governor and the legislature not later than 4 months after the advisory committee receives the feasibility study. As used in this subsection, "medicaid" means that term as defined in section 22207. In developing recommendations under this subsection, the ad hoc advisory committee shall review the provisions of the code pertaining to hospital licensure in order to determine those provisions that should apply to rural community hospitals. The director shall direct the committee to report its recommendations to the department within 12 months after the committee is appointed. The director shall submit proposed rules, based on the recommendations of the committee, for public hearing not later than 6 months after receiving the report under section 21562(5). Except as otherwise expressly provided in this part or in rules promulgated under this section, a rural community hospital shall be licensed and regulated in the same manner as a hospital otherwise licensed under this article. The provisions of part 222 applicable to hospitals also apply to a rural community hospital and to a hospital designated by the department under federal law as an essential access community hospital or a rural primary care hospital. This part and the rules promulgated under this part do not preclude the establishment of differential reimbursement for rural community hospitals, essential access community hospitals, and rural primary care hospitals. The department may impose conditions upon a waiver under this section to protect the public health, safety, and welfare. A hospital that has entered into a contract with a community mental health board may establish a mental health crisis stabilization program for voluntary admission with a maximum length of stay not to exceed 72 hours. The center for rural health created under section 2612, as part of the development of the biennial rural health plan required under section 2223, shall develop a plan that provides for the creation of a set of rural health networks. Each rural health network shall consist, at a minimum, of 1 essential access community hospital, rural referral center, or regional referral center described in section 21566, and 1 rural primary care hospital as described in section 21567. Other rural health care providers including, but not limited to , primary care centers, community health centers, licensed nursing homes, and local public health departments may also be included in a rural health network for the purpose of developing a continuum of patient care. Population is to be determined according to the official 2000 federal decennial census. The purpose of a memorandum of agreement is to have a written understanding of the agreement between the parties. A memorandum of agreement serves as a legal document that is binding and holds the parties responsible to their commitment along with describing the terms and details of the cooperative agreement. A memorandum of agreement may be used between agencies, the public, the federal or state government, communities, and individuals. A permit application that is not timely filed is subject to a late fee in an amount determined by the department as the additional cost of processing the late renewal, but not more than a dental license late renewal fee. If the operator of the mobile dental facility changes, the permit is no longer valid. However, if an application for a new permit to continue operating the mobile dental facility is submitted not later than 30 days after the change of operator, the former permit is valid as an interim permit until the application is approved or denied, but not longer than 90 days. The memorandum of agreement shall state that the contracting dentist or party will accept referrals of patients treated at the mobile dental facility. The agreement to accept a referral does not require the dentist or party to treat the patient. A dentist licensed under this act need not be present at a mobile dental facility when only preventative dental services are being provided. If the patient is a minor or incapacitated person, the operator or his or her designee shall also attempt to contact a parent or guardian and inform him or her of the referral. Failure of the operator or his or her designee to comply with this subsection is cause for disciplinary action by the department. Upon request of the dentist or party who accepts the referral, the operator shall transmit all imagery records taken of the patient at the mobile dental facility. If the operator has a memorandum of agreement due to its status as a state of Michigan designated or funded oral health prevention program with oversight from the department, the operator is exempt from any requirement concerning a memorandum of agreement under this part. The residents, patients, personnel, or employees, other than food handlers, of the home are not required to submit to a medical or physical examination. However, the nursing home shall be inspected and licensed under laws pertaining to fire, safety, sanitation, and building construction. However, a nursing home may use the term "health center" or "health care center" or "rehabilitation center" or a term conveying a meaning substantially similar to those terms as long as those terms do not conflict with the terms prohibited by this subsection. The owner, operator, and governing body of a nursing home licensed under this article: (a) Are responsible for all phases of the operation of the nursing home and quality of care rendered in the home. A nursing home, regardless of its status as a legal entity, may employ or contract with an individual licensed or otherwise authorized to engage in a health profession under part 170 or 175 to provide the program of planned and continuing nursing care and medical treatment under this subsection, which care and treatment include direct clinical services to residents. A nursing home, regardless of its status as a legal entity, may employ or contract with a dentist who is licensed under part 166. However, if the hospital determines that it has reached surge capacity, this subdivision does not apply. A nursing facility that is not concurrently certified for the title 18 program on March 30, 1979 shall make application for concurrent certification not later than its next application for licensure and certification. A failure to make application shall result in the skilled nursing facility being decertified or refused certification as a provider in the title 19 program. Skilled care certification shall not be renewed unless the requirements of this subsection are met. A nursing home shall not be licensed under this part unless the nursing home has formulated, and is prepared to implement, insofar as possible, a plan to provide immediate access to acute care facilities for the emergency care of patients. If a nursing home changes nursing home administrators, the nursing home immediately shall notify the department of the change. The nursing home shall have at least 1 licensed nurse on duty at all times and shall employ additional registered and licensed practical nurses in accordance with subsection (2). Nursing personnel employed in the nursing home shall be under the supervision of the director of nursing. A licensee shall maintain a nursing home staff sufficient to provide not less than 2. The ratio of patients to nursing care personnel during a morning shift shall not exceed 8 patients to 1 nursing care personnel; the ratio of patients to nursing care personnel during an afternoon shift shall not exceed 12 patients to 1 nursing care personnel; and the ratio of patients to nursing care personnel during a nighttime shift shall not exceed 15 patients to 1 nursing care personnel and there shall be sufficient nursing care personnel available on duty to assure coverage for patients at all times during the shift. An employee designated as a member of the nursing staff shall not be engaged in providing basic services such as food preparation, housekeeping, laundry, or maintenance services, except in an instance of natural disaster or other emergency reported to and concurred in by the department. In a nursing home having 30 or more beds, the director of nursing shall not be included in counting the minimum ratios of nursing personnel required by this subsection. A nursing home shall not be licensed under this part unless that nursing home has entered into an agreement with the county community mental health program, if available, that will service the mental health needs of the patients of the nursing home. Upon termination of the deposit, the applicant shall account for all funds received, expended, and held on hand. The bond shall insure the department of public health, for the benefit of the patients. The department may require an additional bond, or permit the filing of a bond in a lower amount, if the department determines a change in the average balance has occurred or may occur. An applicant for a new license shall file a bond in an amount which the department estimates as 1-1/4 times the average amount of patient funds which the applicant, upon the issuance of the license, is likely to hold during the first year of operation. This section does not constitute a basis for increasing nursing home staffing levels. A licensee of a nursing home operated for profit is considered to be the consumer, and not the retailer, of the tangible personal property purchased and used or consumed in the operation of the home. A nursing home shall offer the option to new residents upon admission and to other residents upon request. For purposes of this subsection, "medical symptoms" includes the following: (a) A concern for the physical safety of the resident. The department shall consider the recommendations of the hospital bed safety work group established by the United States Food and Drug Administration, if those are available, in determining what constitutes an acceptable bed rail. This subsection does not preclude the department from citing specific state or federal deficiencies for improperly maintained bed rails, improperly fitted mattresses, or other hazards created by improperly positioned bed rails, mattresses, or beds. The department shall provide to the applicant or licensee professional advice and consultation related to the quality of institutional or agency aspects of health care and services provided by the applicant or licensee. The court may grant the petition upon a finding that the health or safety of the patients in the nursing home would be seriously threatened if a condition existing at the time the petition was filed is permitted to continue. A major structural alteration shall not be made to the nursing home, unless the alteration is necessary to bring the nursing home into compliance with licensing requirements. The department may refuse to issue a license to establish or maintain and operate, or both, a nursing home to an applicant: (a) Whose occupational, professional, or health agency license has been revoked during the 5 years preceding the date of application. As used in this subdivision, "good moral character" means that term as defined in Act No. At the time a provisional license is granted, specific deadlines for the correction of each physical plant violation shall be established. If the department finds a violation of rights enumerated in this section, the department shall direct the administrator of the nursing home to take the necessary action to assure that the nursing home is, in fact, operated in accordance with the rights listed in this section. Assistance may be provided individually or on a group basis and may include organizational activity and counseling and litigation. A representative shall use only patient areas of the home to carry out the activities described in subsection (1). Communications between a patient and the representative are confidential, unless otherwise authorized by the patient. Upon receipt of a complaint, department staff shall investigate the allegations made in the complaint. The task force shall make a determination regarding proper resolution of the complaint based on the results of the investigation. Written notification of the task force determination and of recommendations adopted by the task force shall be given to the complainant and the individual or organization against whom the complaint was made. This subsection does not prohibit constitutionally protected activity or conduct that serves a legitimate purpose including, but not limited to , activities or conduct allowed under subsection (1). The director shall approve or disapprove the organization within 30 days after receiving the application. The policies shall include a procedure for the investigation and resolution of patient complaints. The policies and procedures shall be clear and unambiguous, shall be printed in not less than 12-point type, shall be available for inspection by any person, shall be distributed to each patient and representative, and shall be available for public inspection. A patient of a nursing home at the time of the implementation of this section shall be given a copy of the rights enumerated in section 20201 as specified by rule. In the case of a developmentally disabled individual, the rights shall be explained in a manner that the person is able to understand and the explanation shall be witnessed by a third person. In the case of a minor or a person who has a legal guardian, both the patient and the parent or legal guardian shall be fully informed of the policies and procedures. As used in this subsection, "hospice" means that term as defined in section 20106(4). A written receipt shall be given to a patient whose money or other property is received by a nursing home. Upon request, but not less than once every 3 months, the nursing home shall furnish the patient a complete and verified statement of the funds or other property received by the nursing home. The statement shall contain the amounts and items received, the sources, the disposition, and the date of each transaction. The nursing home shall furnish a final statement not later than 10 days after the discharge of a patient. The department may require the individual making the report to submit a written report or to supply additional information, or both. The owner, administrator, employee, or representative of a nursing home shall not interfere with the right of a person to bring a civil or criminal action or to file a complaint with the department or other governmental agency with respect to the operation of the nursing home, nor discharge, harass, or retaliate against a person who does so or on whose behalf the action is taken. If you think you should not have to leave this facility, you may file a request for a hearing with the department of consumer and industry services within 10 days after receiving this notice. If you request a hearing, it will be held at least 7 days after your request, and you will not be transferred during that time. If you lose the hearing, you will not be transferred until at least 30 days after you received the original notice of the discharge or transfer. If you have any questions, call the department of consumer and industry services at the number listed below. The discussion shall include an explanation of the reason for the involuntary transfer or discharge. The prohibition against transfer or discharge imposed by this subsection continues unless the patient falls within 1 or more of the exceptions described in subsection (1). The hearing shall be in accordance with fair hearing procedures prescribed by rule. The department of social services shall continue medicaid funding during the appeal, transfer, or discharge period as provided in section 21774 for those medicaid patients affected by section 21773. The licensee, with the approval of the department, shall develop a plan to effectuate the orderly and safe transfer or discharge of a patient. The patient shall receive counseling services before the move to minimize the adverse effects of transfer trauma. The department shall assure that counseling will be available if the patient requires counseling after transfer or discharge. A licensee shall conspicuously post in an area of its offices accessible to patients, employees, and visitors: (a) A current license. The copy of the notice or order shall be retained for not less than 3 years after its date of issuance or not less than 3 years after the date of the resolution of the subject matter of the notice or order, whichever is later. A nursing home shall take all reasonable measures to ensure the comfort of a patient in the terminal stages of an illness. The notice shall be sufficient to make suitable arrangements for the transfer and care of the patient. The licensee and the department of social services shall keep the department of public health informed of their efforts and activities in carrying out this responsibility. The department of social services shall make available to the licensee and the department of public health assistance necessary to assure the effectiveness of efforts to secure a suitable relocation. In the case of an emergency closing of a nursing home, or when it is determined by the department that a nursing home is suddenly no longer able to provide adequate patient care, the department shall do both of the following: (a) Assure that the department of social services has been notified to make arrangements for the orderly and safe discharge and transfer of the patients to another facility. The department may also contract with the Michigan public health institute for the performance of specific functions required or authorized by this article, if determined necessary by the director of the department. A licensee shall not use false or misleading information in the advertising of a nursing home or its name. For a patient who is assigned a dining assistant and experiences an emergent change in condition, the charge nurse shall perform a special assessment to monitor the appropriateness of continued utilization of the dining assistant. The department and the long-term care stakeholder advisory workgroup designated under section 20155(24) shall develop a dining assistants training curriculum. The department shall approve a dining assistants training curriculum that meets the requirements of this subsection. In order to be approved by the department, the dining assistants training curriculum must include, at a minimum, 8 hours of course material that covers all of the following: (a) Dining assistants program overview. A nursing home shall not employ or allow an individual who is less than 17 years of age to provide feeding assistance as a dining assistant. A dining assistant is not nursing personnel and a nursing home shall not include a dining assistant in computing the ratio of patients to nursing personnel or use a dining assistant to supplement or replace nursing personnel. A dining assistant who is providing feeding assistance to a patient in his or her room as provided under this subsection must not be assigned to assist another patient at the same time. The nursing home shall include in the written record, at a minimum, the complete name and address of the individual, the date the individual successfully completed the dining assistants training curriculum, a copy of the written record of the satisfactory completion of the training curriculum, and documentation of the criminal history check.
Shown in Figure 13 is a representative gas chromatogram for this confirmation analysis cholesterol lowering diet for vegetarian generic 30mg vytorin with visa. Gas chromatogram for confirmation of valproic acid (A) with internal standard (B) cholesterol oxidation eggs vytorin 20 mg overnight delivery. Screening for all Drugs in Hair For each sample cholesterol numbers chart canada cheap 30mg vytorin overnight delivery, 50 mg of the pulverized hair was weighed out and placed into a test tube cholesterol test in walgreen buy cheap vytorin 20mg line. If the sample weighed less than 50 mg it was completely used for the screening method cholesterol oatmeal proven 30 mg vytorin. To each test tube cholesterol in eggs not bad discount vytorin 30 mg fast delivery, 1 mL of methanol was added and the tubes were capped and sonicated for one hour cholesterol levels new zealand cheap 30mg vytorin. The samples were then centrifuged and the supernatant was transferred to a clean test tube and refrigerated lower cholesterol definition cheap vytorin 30 mg without prescription. The samples were then centrifuged, and the supernatant was pooled with the previous supernatant. Confirmation in Hair of Chlordiazepoxide, Codeine, Cocaine, and Sertraline Sample Preparation the internal standard (d6-paroxetine) was first added to 50 mg of pulverized hair to give a final concentration of 4 ng/mg. Shown in Figure 14 is a representative gas chromatogram for this confirmation analysis. Gas chromatogram for confirmation of cocaine (A), codeine (B), sertraline (C), and chlordiazepoxide (D) with internal standard (E). It is fair to say that a completed sexual assault (as against an attempted one) includes sexual penetration by one person (usually a man) of another (usually a woman) against her will, i. Below the age of consent, which varies among the different states, a person is legally incompetent to consent. However, the quantity of drug(s) confirmed in urine or hair after the fact does not permit a toxicologist to determine either the dose of the drug(s) or the time of administration. Further, it does not permit a toxicologist to know with certainty whether the drugs found were clandestinely administered to a victim, or taken recreationally or therapeutically. One school of thought believes that a sexual assault is only drug-facilitated if the perpetrator gave the drug surreptitiously to the victim to render them unconscious or impair their memory to such a degree that would facilitate sexual assault (42, 173, 174). The second school of thought believes that 86 if the victim was rendered unable to consent to sexual acts by surreptitious drugging or by their own recreational drug use, the sexual assault is drug-facilitated (36, 40, 175). Illinois) make clandestine drugging a separate crime or an aggravating factor to the crime, potentially increasing penalties for those convicted. Explicit criteria for each definition have been developed which rely on toxicological findings and case history. It must also be noted that subjects are placed into one of the categories based on likelihood judgments considering these factors. If the subject stated on the questionnaire that she was given drugs before the assault. If the subject states (or thinks) a drug was surreptitiously given to her, and states that she did not take the drug voluntarily, and a drug capable of producing sedation was found. If the subject admitted to using the drug and it was found on both visits, we assume that she is recreationally using the drug. If the patient reported to the clinic greater than 72 hours after the alleged assault = No 88 3. If any drugs being analyzed for were found that, either alone or in combination, could have reduced the mental competence of the subject to consent to sexual acts = Yes these criteria were developed to help in aiding a toxicologist in determining what they are willing to testify to regarding their analysis. Fourth, a cut-off of 72 hours post-assault is used because most toxicology laboratories would not be able to detect drugs used greater than 72 hours ago, and any results may suggest post-assault drug use by the subject. There is a caveat to this criterion; if the drug is found in the second visit also, we assume that the subject is a recreational user who did not admit to using the drug. Statistical Analysis All statistical analyses were done using Microsoft Office Excel 2003. Correlations between time interval and age were calculated by using a one-tailed, two sample unequal variance, Student t-Test. All submitting subjects were female and their ages ranged from 18 to 56 with a mean age of 26. One prior study of 1,076 sexual assault complainants had subjects with a mean age of 25 years, which is similar to the subject population in this study (10). The first group, 18-20 years, only contains three years, but is important when considering the drug profiles of subjects below the legal drinking age. One hypothesis is that subjects above the drinking age are more likely to frequent bars and clubs where drugs can be easier to give surreptitiously. If a subject identified with a race different from these three, or the race was not identified, they fall into the fourth category (Other/Unknown). Census data from 2000 (Table V), the racial distribution of the subjects in this study corresponds well with the racial distribution of the U. When this study was first initiated, efforts were made to 91 insure that the racial make-up of the subjects in this study would generally reflect the racial make-up of the entire U. The further distribution of the races into the six age cohorts is shown in Figure 17. The racial distribution among the age cohorts was unremarkable with White always outnumbering any of the other categories. It is difficult to draw any conclusions about the Other/Unknown category as the race of the subjects in this population was not always identified; thus, most analyses are done on the three identifiable races. However, for total sample analyses that do not involve race breakdown, the Other/Unknown group subjects were included. The time interval between when the alleged assault occurred and when the subject reported to the clinic ranged from 1. For example, if the subject reported to the clinic six hours after an assault, the drugs that were found will most likely represent the drugs that were exerting their pharmacologic effect at the time of the assault. However, if a subject reported after three days and drugs were found, it was difficult to determine if the drugs that were found were pharmacologically active at the time of the assault. The time intervals for subjects who returned for the second visit and subjects who believed they were given something are not statistically different from all of the subjects. Therefore, the length of time between the alleged assault and the subject reporting to the clinic did not appear to affect whether a subject returned for a second visit or if they 92 believed that they were given a drug. If someone was given a drug that rendered her unconscious, it would be expected that she would report to the clinic much later than someone who was completely cognizant at the time of the assault. However, nearly 25% of the subjects who believed they were given a drug reported to the clinic within eight hours of the assault. However, for the 18 to 20 age cohort, there was a statistically significant difference (p = 0. Subjects in this age cohort had a mean time interval for reporting more than 50% shorter than for all of the subjects. Subjects in this study under the age of 21, were more likely to report to the clinic in a shorter time period after the sexual assault incident than subjects above the age of 20. For White, Hispanic, and the Other/Unknown subjects, there was no statistical difference (p > 0. As in the 18 to 20-age cohort, Black subjects had a shorter reporting time interval to the clinics of more than 50%. Thus, at least in this study population, Black complainants reported sexual assault much faster than those who identified themselves as another race. There were no statistically significant differences for the time interval and whether drugs were found or not. Washington took the longest time to start enrolling subjects, and they did so towards the end of the study. Texas, although running the entire length of the study, had to stop enrolling subjects for a time in the middle of the study due to problems involving nurse training at the clinic. Two sites were able to enroll the minimum number of subjects we desired (35): California and Minnesota. Second Visit Analysis Fifty-nine subjects (41%) returned to the clinic for the second visit, which was considerably lower than would have been desirable. The reasons cited in that study as to why the subject did not return for a follow-up visit included a lack of time and the inability to find a babysitter. Loss of sexual assault complainants to follow-up after an initial clinic visit is a chronic problem, even when the follow-up is by phone. Shown in Figures 18 and 19 are the race for the returning subjects and the distribution of those subjects into the six age cohorts, respectively. There were no observed trends indicating any racial group or age cohort bias in the returning group. Distribution into the six age cohorts of all subjects returning for the second visit. Originally, the protocol called for completion of the questionnaire during the second visit. This step was changed, however, in accordance with the practices of the particular site. The questionnaire could best be completed in connection with the taking of the history. In those cases where the questionnaire information was to be gathered on the second visit, and the subjects did not return, a self-reported drug history and the circumstances of the alleged assault were never provided. In some subjects, the racial group was not recorded either, even though there was a checkbox on the urine collection container itself in addition to the questionnaire. Thus, a few of the races listed as Other/Unknown were due to the race of the subject never being noted. With experience, it was decided to have the questionnaires completed at the first visit to insure that as much information as possible was gathered for patients who did not return for the second visit. Had this change not been implemented, only 59 questionnaires would have been completed, instead of the 119 that were ultimately returned. Self-reporting of drug use is discussed later, but subject belief about surreptitious drug administration is discussed here. As to whether the subject believed that she was given a drug surreptitiously, 28 (23. Subjects below the age of 30 comprised more than 80% of those who believed they were given a drug. No Hispanic subject 98 believed that she was given a drug and only two thought that it was a possibility. This suggests that women complainants in the Hispanic community are less likely to think they were drugged. The second visit urine specimen helps in determining if the subject is a regular user of the drug that was found or if they changed their drug usage after the assault. No specimens were presumptively positive for barbiturates or methadone, and confirmations were not done for these compounds. Confirmations were then done on all of the presumptive positives, and 66 of the 81 (81. These results include patients that were positive for more than one drug/drug class and thus the number of positive samples do not add up to the number of positive subjects. The ranges of concentrations for the confirmed samples are shown in Figures 20-29. Confirmed Benzoylecgonine Concentrations (Low) 900 800 700 600 500 400 300 200 100 0 N=12 Figure 21. Low concentrations for samples (N=12) that were positive for the metabolite of cocaine (benzoylecgonine). Middle concentrations for samples (N=7) that were positive for the metabolite of cocaine (benzoylecgonine). Confirmed Benzoylecgonine Concentrations (High) 1200 1000 800 600 400 200 0 N=7 Figure 23. High concentrations for samples (N=7) that were positive for the metabolite of cocaine (benzoylecgonine). Concentrations for samples (N=5) that were positive for the common metabolite of most benzodiazepines (oxazepam). Low concentrations for samples that were positive for either amphetamine or methamphetamine. Confirmed Amphetamines Samples (High) 250 200 150 100 50 0 Amphetamine (N=5) Methamphetamine (N=8) Figure 29. High concentrations for samples that were positive for either amphetamine or methamphetamine. The 29 specimens with multiple confirmations had 23 with 2, 4 with 3, and 2 with 4 (specimens with drugs (or drug classes)). For the amphetamines and opiates, any specimen that tested positive for more than one drug in the class was treated as positive only for the drug class. Oxazepam was found only in combination with other drugs, which suggests that a benzodiazepine is used to enhance the high of other drugs, as in marijuana or alcohol; or it is used to lessen the anxiety caused by stimulant abuse, as in cocaine or amphetamines. Marijuana was the most commonly detected drug, whether alone (17 subjects) or in combination (21 cases). Drug Combination # of Samples Ethanol 10 Cocaine 3 Marijuana 17 Opiates 5 Amphetamines 2 Ethanol + Cocaine 1 Ethanol + Marijuana 1 Ethanol + Amphetamines 1 Cocaine + Marijuana 12 Cocaine + Opiates 3 Cocaine + Oxazepam 1 Marijuana + Oxazepam 3 Opiates + Oxazepam 1 Cocaine + Marijuana + Oxazepam 2 Cocaine + Marijuana + Amphetamines 2 Cocaine + Marijuana + Oxazepam +Amphetamines 1 Ethanol + Cocaine + Opiates + Amphetamines 1 i. Of these 73 subjects, the use of ethanol, either alone or in combination, had the highest number of admissions at 66 (90. The cocaine, marijuana, and amphetamine data were used to evaluate the truthfulness of self-reporting of drug use among sexual assault complainants. These drugs were examined because they would not 107 be given to someone to cause sedation or amnesia. They also would not normally make someone more compliant and less resistant to a sexual assault. It is also difficult to surreptitiously give these drugs, as they are most commonly used by smoking the drug. There were many cases where the subject admitted to using alcohol, but it was not found. This is due partly to the short half-life of ethanol and to the delay in reporting for some of the subjects. In cases where the subject did not complete a questionnaire, the value was considered unknown, as well as when the subject completed the questionnaire but the box was not checked. Any sample that did not fall into the three races studied was not included in this meta-analysis. White subjects did not have a 100% correlation between admitting to using a drug and being found positive. However, Black and Hispanic subjects did not admit to using cocaine, heroin, or amphetamines, but had 20 cases where a urine was positive. This suggests that while there is underreporting for all races, Blacks and Hispanics demonstrate a higher rate of underreporting. This corresponds with previous work done by Fendrich and Vaughn that showed that Hispanics underreport more than Whites and that Blacks underreport twice as much as Whites (177). The validity of self-reporting among this sexual assault complainant population is further discussed below. These data suggest that women over the age of 31 abuse fewer drugs than women under the age of 31. Also, stimulant use was favored in the younger group, while depressants were found more in women above the age of 31. However, we cannot be sure about this because the depressants may have been given surreptitiously. Analysis of Subjects Who Returned for the Second Visit Of the 59 subjects who returned for the second visit, 29 were positive for at least one of the drugs of abuse. The drugs that were found in the first visit do not appear to predict whether the subject would return for the second visit. If both visits were positive for a drug, it was assumed that the subject commonly used the drug in question. If only the first visit was positive, it was assumed that the subject was either given the drug surreptitiously or had not used that drug since the alleged assault. If only the second visit was positive, it was assumed that the subject had used the drug in the interval between the first and second visit. Marijuana and amphetamine use were not extremely different and two subjects began using marijuana after the assault. The subjects who were only 111 positive on the first visit could have been given the depressants surreptitiously and this will be examined below. TheDate-Rape Drugs For the next two sections, only the first visit urine samples were considered. Second visit urine samples were most important for analyzing intra-individual drug usage and if a date-rape drug was found only in the second visit, it would skew data on drugs found after the assault to include more cases. Ketamine is used clinically for surgical procedures and prescriptions for it are not normally given. For all subjects who completed a questionnaire, three claimed to have a prescription for clonazepam and it was only found in these three subjects. Ketamine and scopolamine were not admitted to by any of the subjects and were not found. The specific cases where flunitrazepam and clonazepam were found are discussed below in the results from individual sites.
