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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Additional findings include that: • telephone-based support combined with face-to-face sessions is beneficial (Dennis & Kingston 2008) • providing information (eg at ultrasound appointments) has a significant effect (Stotts et al 2009) • smoking cessation may be influenced by concern about weight gain (Berg et al 2008) discount 100 mg amantadine with mastercard antiviral foods list. Recommendation Grade B 12 Offer women who smoke referral for smoking cessation interventions such as cognitive behavioural therapy generic 100mg amantadine amex hiv infection symptoms after one year. At each antenatal visit purchase 100mg amantadine fast delivery stages of hiv infection video, offer women who smoke personalised advice on how to stop smoking and provide information about available services to support quitting, including details on when, where and how to access them. Recommendation Grade B 13 If, after options have been explored, a woman expresses a clear wish to use nicotine replacement therapy, discuss the risks and benefits with her. If nicotine replacement therapy is used during pregnancy, intermittent–use formulations (gum, lozenge, inhaler and tablet) are preferred to continuous-use formulations (nicotine patches). This can reduce nicotine concentrations and offer some measure of protection for the fetus, with a 50% reduction being associated with a 92g increase in birth weight (Li et al 1993; Windsor et al 1999). However, the greatest health benefits for the woman and baby are from quitting completely. Health professionals should reinforce quitting behaviours and continue to monitor all women who have recently quit about their willingness to stay smoke free. Partner smoking is highly correlated to relapse so it may be beneficial to extend the offer of smoking cessation support strategies to the woman’s partner. At each visit, congratulate the woman for having quit, review and reinforce the reasons for quitting, and encourage the non-smoker image. Discuss some high-risk times for relapse, such as late pregnancy, post partum and after breastfeeding has stopped. Continue to advise women who are trying to reduce their exposure to passive smoking. Smoking status should be monitored and smoking cessation advice, encouragement and support offered throughout pregnancy. The recommendations given in the preceding sections apply to all women in the antenatal period. This section outlines additional considerations and approaches that may assist in supporting Aboriginal and Torres Strait Islander women and adolescent women to quit smoking. Understanding community attitudes to smoking and language used when referring to tobacco products will support both assessment and intervention. Qualitative research into the context surrounding smoking among Aboriginal and Torres Strait Islander women has identified some factors that may affect motivation or ability to quit (Heath et al 2006; Wood et al 2008; Gilligan et al 2009b): • smoking provides an opportunity for ‘time out’ from social pressures and for ‘sharing with others’ • smoking is perceived as reducing stress, easing social interaction, relieving boredom and controlling weight • smoking may be seen as a less immediate problem relative to other issues • high levels of smoking by the woman’s partner or among family and friends make it harder to quit. Health care professionals involved in the care of Aboriginal and Torres Strait Islander women should be aware of the high prevalence of smoking in some communities, and take account of this social norm when discussing smoking and supporting women to quit. National action to reduce smoking in Aboriginal and Torres Strait Islander communities the Australian Government is funding a national network of regional tobacco coordinators and tobacco action workers to work with Aboriginal and Torres Strait Islander communities to reduce the number of people smoking. This workforce will implement a range of community-based smoking prevention, awareness raising and cessation support activities tailored to local communities. In discussing smoking and supporting Aboriginal and Torres Strait Islander women to quit smoking, health professionals should draw on the expertise of anti-tobacco workers where available. Adolescents who are pregnant and smoke may be at risk of other behaviours that compromise their health and that of the unborn baby (eg drinking alcohol) (Mohsin & Bauman 2005). Very few studies have investigated the effectiveness of interventions designed to help young people stop smoking and none are specific to pregnancy in this age group. Nicotine replacement has not yet been shown to be successful with adolescents (Grimshaw & Stanton 2006). Low birth weight is known to contribute to the development of coronary heart disease, type 2 diabetes and obesity in adulthood. They may also under report the amount that they smoke or answer in a way that does not really quantify their level of smoking (eg “half a pack a day”, “socially”). The important message to get across is that if they smoke, stopping smoking is the safest option. Explain that smoke-free environments give people of all ages the best chance to be healthy. Supporting women to stop or reduce smoking When: At subsequent antenatal contacts with women who smoke or have recently quit Be aware of local smoking cessation programs: Provide women with advice on locally available supports for smoking cessation. Depending on location this may include community support groups, Quitline or State/Territory quit services. It is helpful to continue enquiring about a woman’s smoking or passive smoking and to offer advice about quitting or reducing the family’s exposure to smoke. Briggs V, Lindorff K, Ivers R (2003) Aboriginal and Torres Strait Islander Australians and tobacco. Clausson B, Cnattingius S, Axelsson O (1998) Preterm and term births of small for gestational age infants: A population-based study of risk factors among nulliparous women. Gilligan C, Sanson-Fisher R, Eades S et al (2009a) Assessing the accuracy of self-reported smoking status and impact of passive smoke exposure among pregnant Aboriginal and Torres Strait Islander women using cotinine biochemical validation. Harvey D, Tsey K, Cadet-James Y et al (2002) An evaluation of tobacco brief intervention training in three Indigenous health care settings in North Queensland. Hauck Y, Rock D, Jackiewicz T et al (2008) Healthy babies for mothers with serious mental illness: a case management framework for mental health clinicians. Li C, Windsor R, Perkins L, Lowe J et al (1993) the impact on birthweight and gestational age of cotinine validated smoking reduction during pregnancy. Lumley J, Chamberlain C, Dowswell T et al (2009) Interventions for promoting smoking cessation during pregnancy. Nilsson E, Lichtenstein P, Cnattingius S et al (2002) Women with schizophrenia: pregnancy outcome and infant death among their offspring.

By stepping up your dose slowly generic amantadine 100mg hiv infection after 1 year symptoms, you can determine how much is optimal for you within this range buy generic amantadine on-line hiv infection dried blood. Remember that if you change your diet to buy amantadine canada antiviral reviews increase sodium intake from your food, you may not need as many salt tablets. Some of our patients report better tolerance of a buffered salt tablet (the commercially available brand, Thermotabs, contains 450 mg sodium chloride and 30 mg potassium chloride). Some drugs are given in combination with others, but rigorous studies of combination therapy have not yet been done. We recommend potassium supplements when people start on Florinef, regardless of the serum potassium level, and especially if individuals remain on the drug for several months. Once you are ready to start, begin with tablet per day for a week, then increase to a full 0. If the 1/4 tablet dose is tolerated for 4-7 days, increase to tablet for 4-7 days, then to 3/4 tablet or a full 0. By stepping up the dose gradually, you can better determine the right dose (some patients may only need tablet or tablet). Some patients report that splitting the dose (half in the morning and half with the evening meal) provides a more even effect, but occasionally people have to return to a once a day morning dose because the Florinef taken later in the day causes them to develop insomnia. Each patient’s tolerance of the drug and response to it is somewhat different, so we recommend regular visits while the doses are being adjusted. If there is no improvement, or more bothersome side effects appear (worse headaches, substantial weight gain, and certainly depressed mood) we recommend stopping the medication. If unsure about whether the drug is having a beneficial effect, it can be stopped for a few days to see if symptoms worsen. Comments: It is important to be sure that you are taking an adequate amount of fluid. We recommend checking the serum electrolytes periodically, but the optimal frequency for doing so is not established. Common side effects: Some individuals complain of headaches or fatigue after atenolol, and others have worse lightheadedness or worse symptoms in general. Like other beta-blocker drugs, atenolol can lead to constriction of the airways in individuals with a history of asthma. If cough or wheezing develops soon after starting the drug, it may need to be stopped. The activity of the drug can be decreased when it is used in conjunction with non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin). People are unlikely to tolerate higher doses if their resting heart rate is below 50 beats per minute. These medications may also exert their beneficial effects through actions on the central nervous system as well. Dextroamphetamine: Dexedrine spansules are the sustained release form of the medication, and because they usually contain no milk protein they are among the ones we use for patients with milk allergy. The average starting dose for adolescents and adults is one 5 mg Dexedrine spansule each morning for 3 days or so. If there is no apparent improvement at this dose by that time, we increase the dose to two of the 5 mg spansules in the morning (at the same time). After another 3-4 days, if there is no improvement, increase to 3 spansules (15 mg) in the morning. Methylphenidate: the dose of methylphenidate depends on the individual’s weight, but we usually try to keep the dose below approximately 0. One adolescent, for example, had her best response on a regimen of 15 mg per dose given three times a day. If the stimulant medications are working at a particular dose, we expect individuals to feel less lightheadedness, headache, or fatigue. The stimulants are controlled substances, so the prescriptions have to be written more frequently, and physicians cannot ask for refills on the same prescription. Some patients describe increased lightheadedness, agitation, and other bothersome symptoms. Action: the main effects of midodrine are to cause blood vessels to tighten, thereby reducing the amount of blood that pools in the abdomen and legs, shifting that blood volume into the central circulation where we want it to be. The drug has been used in thousands of individuals around the world, and appears to be well tolerated. Side effects: the main side effects from midodrine in those with orthostatic hypotension (a condition similar to, but not the same as, neurally mediated hypotension) are: high blood pressure when lying down in 15-20%, itching (also called pruritis) in 10-15%, pins and needles sensation in 5-10%, urinary urgency/full bladder in 5%. These changes are signs that the drug is working, and are not reasons to discontinue the drug. With Lexapro, the starting dose is 5 mg per day for 2-4 weeks, then increasing to 10 mg per day if needed. One of the recent areas of concern about this class of medications has related to the rare but serious risk of suicide in the first 1-2 weeks after starting these medications. The evidence suggests that this risk is primarily seen in those who are severely depressed. The risk of suicide and major personality changes drops markedly after 2 weeks or so. Be alert to the potential for unusual reactions, and stop the medication and check in with your physicians if you have concerns about how things are going. More data are appearing on these issues, so consult with your health care provider. Side effects: Some individuals complain of headaches or fatigue after Norpace, and others have worse lightheadedness. Use of the drug by those already taking beta-blockers or calcium channel blockers requires similar caution.

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Nerves from the bladder send signals to order cheap amantadine online hiv infection victoria the brain when the bladder is full discount amantadine american express hiv infection in zimbabwe, and nerves from the brain signal the bladder when it needs to order amantadine 100mg mastercard hiv infection more condition symptoms be emptied. All of these nerves and muscles must work together so the bladder can function normally. This type of leakage is called stress incontinence, due to the pressure that the un born baby exerts on the pelvic oor muscles, the bladder and the urethra. Stress incontinence may be only temporary and often ends within a few weeks after the baby is born. Before During Pregnancy Pregnancy 163 160 Pregnancy, the type of delivery and you should visit your doctor if they the number of children a woman persist for six weeks or more after has are factors that can increase the you have given birth. Women who idea to keep a diary to record your have given birth, whether by vaginal trips to the bathroom, how often delivery or cesarean section, have you experience urine leakage, and much higher rates of stress inconti when it occurs. The doctor will perform a physical examination to rule out various Loss of bladder control may be medical conditions and see how well caused by pelvic organ prolapse that your bladder is functioning. If the pelvic muscles • Urinalysis-You will be asked to do not provide adequate support, provide a urine sample to be ana your bladder may sag or droop. De • Bladder stress test-Your doctor livery with forceps can result in in will check for signs of urine leakage juries to the pelvic oor and anal when you cough forcefully or bear sphincter muscles. How can loss of bladder control In addition, changing your diet, due to pregnancy or childbirth be losing weight, and timing your trips prevented Labor and vaginal delivery have an Drinking beverages such as carbon impact on the pelvic oor muscles ated drinks, coffee and tea might and nerves that affect bladder make you feel like you need to uri control, so you should discuss your nate more often. Switching to decaf options with your health care feinated beverages or water can help provider. Limit your consumption of uids after dinner Cesarean sections are associated to reduce the number of trips to the with a lower risk of incontinence or bathroom during the night. You pelvic prolapse than vaginal deliver should consume foods high in ber ies, but they may present other to avoid being constipated, since risks. Large babies who weigh more constipation may also result in than nine pounds at birth may urine leakage. Exercising pelvic oor muscles with Losing weight after your baby is Kegel exercises can help prevent born can help to relieve some of the bladder control problems. Keeping a record of the times dur ing the day when you are most likely Talk to your health care team if this to experience urine leakage, you happens to you. If you are just childbirth classes or written about in magazine not sure that you are doing the exercises correctly articles. Unfortunately, because pelvic muscles ask your doctor or their nurse at a pelvic exam to are hidden from view, it is difcult to know if check if your squeeze is working the right muscles. Ask your doctor for a referral to succeed then you have identied the right a physical therapist with expertise in pelvic oor muscles to exercise. They are trained to evalu Do not stop your urine frequently as there ate your back and abdominal strength, your gait is concern that this may create problems and your posture. Start by pulling in and holding a pelvic muscle Exercising the muscles around the rectum squeeze for 3 seconds then relax for an equal will also strengthen those around the vagina amount of time (3 seconds). Squeeze as if you were trying • When you start, do the exercises while lying to stop urine from coming out. As you get stronger; do an exercise set your nger lifted and squeezed if you are correctly sitting and standing. Remember not to tighten your stomach and back muscles or squeeze your legs together. Postpartum depression is a complex mix of physical, emotional, and behavioral changes that occur after giving birth and are attributed to the chemical, social, and psychological changes associated with having a baby. As many as 50 to 75 percent of new moth ers experience the "baby blues" after delivery. Up to 15 percent of these women will develop a more severe and longer-lasting depression-called postpartum depression-after delivery. One in 1,000 women develop the more serious condition called postpartum psychosis. If you are experiencing the baby blues, you will have frequent, prolonged bouts of crying for no apparent reason, sadness, and anxiety. Although the experience is un pleasant, the condition usually subsides within two weeks without treat ment. The levels of estrogen experience alternating "highs" and and progesterone, the female repro "lows," frequent crying, irritability, ductive hormones, increase tenfold and fatigue, as well as feelings of during pregnancy but drop sharply guilt, anxiety, and inability to care after delivery. Symptoms tum, levels of these hormones drop range from mild to severe and may back to pre-pregnant levels. In appear within days of the delivery or addition to these chemical changes, gradually, even up to a year later. If you have had any of the following Postpartum psychosis - this is an symptoms, please notify your health extremely severe form of postpartum care provider right away: depression and requires emergency medical attention. This condition is • Thoughts of harming yourself or relatively rare, affecting only one in your baby 1,000 women after delivery. The symptoms generally occur quickly • Recurrent thoughts of death or after delivery and are severe, lasting suicide for a few weeks to several months. Postpartum psychosis • Difculty thinking, concentrating requires immediate medical atten making decisions, or dealing with tion since there is an increased risk everyday situations of suicide and risk of harm to the baby. Treatment will usually include • Loss of interest or pleasure in admission to hospital for the mother most of the activities during the and medicine.

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A major international conference on classification and diagnosis was held in Copenhagen cheap amantadine online visa antiviral and antiretroviral, Denmark buy amantadine 100mg otc antiviral ointment, in 1982 to 100 mg amantadine overnight delivery hiv infection prevalence united states review the recommendations that emerged from these workshops and to outline a research agenda and guidelines for future work (4). Several major research efforts were undertaken to implement the recommendations of the Copenhagen conference. In addition, several lexicons have been, or are being, prepared to provide clear definitions of terms (8). The work has gone through several major drafts, each prepared after extensive consultation with panels of experts, national and international psychiatric societies, and individual consultants. The draft in use in 1987 was the basis of field trials conducted in some 40 countries, which constituted the largest ever research effort of its type designed to improve psychiatric diagnosis (12,13). The Acknowledgements section is of particular significance since it bears witness to the vast number of individual experts and institutions, all over the world, who actively participated in the production of the classification and the various texts that accompany it. The classification and the guidelines were produced and tested in many languages; the arduous process of ensuring equivalence of translations has resulted in improvements in the clarity, simplicity and logical structure of the texts in English and in other languages. They were produced in the hope that they will serve as a strong support to the work of the many who are concerned with caring for the mentally ill and their families, worldwide. I hope that such revisions will be the product of the same cordial and productive worldwide scientific collaboration as that which has produced the current text. Norman Sartorius, Director, Division of Mental Health World Health Organization References 1. Mental disorders, alcohol and drug-related problems: international perspectives on their diagnosis and classification. Cooper and other consultants mentioned below, and involved a large number of centres (listed on pages xx-xx) whose work was coordinated by Field Trial Coordinating Centres. Dilling, Klinik fur Psychiatrie der Medizinischen Hochschule, Ratzeburger Allee 160, 2400 Lubeck, Germany Dr M. Mellsop, the Wellington Clinical School, Wellington Hospital, Wellington 2, New Zealand Dr Y. Pull, Service de Neuropsychiatrie, Centre Hospitalier de Luxembourg, 4, rue Barble, Luxembourg, Luxembourg Dr D. Wig, Regional Adviser for Mental Health, World Health Organization Regional Office for the Eastern Mediterranean, P. This increases the likelihood of obtaining homogenous groups of patients but limits the generalizations that can be made. There are a few unavoidable exceptions, the most obvious being Dementia, Simple Schizophrenia and Dissocial Personality Disorder. Many of the disorders in F8 and F9 are joint disturbances which can only be described by indicating how roles within the family, school or peer group are affected. The problem is apparent rather than real, and is caused by the use of the term "disorder" for all the sections of Chapter V(F). The term is used to cover many varieties of disturbance, and different types of disturbance need different types of information to describe them. General criteria that must be fulfilled by all members of a group of disorders (such as the general criteria for all varieties of dementia, or for the main types of schizophrenia) are labelled with a capital G, plus a number. Obligatory criteria for individual disorders are labelled by capitals only (A,B,C, etc. The two Appendices to this volume deal with disorders of uncertain or provisional status. Appendix 1 contains some affective disorders that have been the subject of recent research, and some personality disorders that although regarded as clinically useful in some countries, are of uncertain status from an international viewpoint. It is hoped that their inclusion here will encourage research concerning their usefulness. Appendix 2 contains provisional descriptions of a number of disorders that are often referred to as "culture specific". The considerable practical difficulties involved in doing field studies of persons with these disorders are recognised, but the provision of these descriptions may act as a stimulus to research by those with a knowledge of the languages and cultures concerned. For example, the individual has difficulty in registering, storing and recalling elements in daily living, such as where belongings have been put, social arrangements, or information recently imparted by family members. Moderate: A degree of memory loss which represents a serious handicap to independent living. The individual is unable to recall basic information about where he lives, what he has recently been doing, or the names of familiar persons. Evidence for this should be obtained when possible from interviewing an informant, supplemented, if possible, by neuropsychological tests or quantified objective assessments. Deterioration from a previously higher level of performance should be established. The decline in cognitive abilities causes impaired performance in daily living, but not to a degree making the individual dependent on others. The decline in cognitive abilities makes the individual unable to function without the assistance of another in daily living, including shopping and handling money. When there are superimposed episodes of delirium the diagnosis of dementia should be deferred. A decline in emotional control or motivation, or a change in social behaviour, manifest as at least one of the following: (1) emotional lability; (2) irritability; (3) apathy; (4) coarsening of social behaviour. For a confident clinical diagnosis, G1 should have been present for at least six months; if the period since the manifest onset is shorter, the diagnosis can only be tentative. Judgment about independent living or the development of dependence (upon others) need to take account of the cultural expectation and context.

Primary care provid ers also may perform medical record and clerical activities in this area amantadine 100mg fast delivery antiviral drug for hiv. Maintaining medical records should be considered an unclean procedure buy 100 mg amantadine with visa antiviral uses, and personnel who have been working on medical records should perform hand hygiene before they have further contact with a neonate buy amantadine with amex antiviral genes. In addition, patients’ medical records, computer terminals, and hospital forms may be located in the clerical area. General Considerations Disaster Preparedness and Evacuation Plan An overall disaster preparedness plan is essential for all areas of the hospital and all personnel. A plan addressing natural and terrorist disasters should be in place for each perinatal care area (ie, antepartum care, labor and delivery care, postpartum care, routine neonatal care, intermediate care, and intensive care). A floor plan that indicates designated evacuation routes should be posted in a conspicuous place in each unit. Safety and Environmental Control Because of the complexities of environmental control and monitoring, a hospital environmental engineer must ensure that all electrical, lighting, air composition, and temperature systems function properly and safely. The ventilation pattern should inhibit particulate matter from moving freely in the space, and intake and exhaust vents should be placed so as to minimize drafts on or near the patient beds. Filters should be located outside the infant care area so that they can be changed easily and safely. Care should be taken to ensure that only the patient and the area of interest being examined is in the primary beam and staff needed to assist in patient positioning should wear appropriate shielding. Both natural and artificial light sources should have controls that allow immediate darkening of any bed position sufficient for transillumination or ultrasonography when necessary. Artificial light sources should have a color rendering index of no less than 80, and a full-spectrum color index of no less than 55. Light should be highly framed so that new borns at adjacent bed stations will not experience any increase in illumination. Properly designed natural light is the most desirable illumination for nearly all nursing tasks, including updating medical records and evaluating newborn skin tone. At least one source of natural light should be visible from each patient care area. All external windows should be equipped with shading devices that are easily controlled to allow flexibility at various times of day. These shading devices should be either contained within the window or eas ily cleanable. Windows in neonatal care areas should have opaque shades that make it possible to darken the area to reduce inappropriate radiant heat gain or loss, or for procedures that require reduced light, such as transillumination or ultrasonography examination. Wall Surfaces Wall surfaces should be easily cleanable, provide protection at point of contact with moveable equipment, and be free of substances known to be teratogenic, mutagenic, carcinogenic, or otherwise harmful to human health. Oxygen and Compressed-Air Outlets Newborn care areas should have oxygen and compressed air piped from a central source at a pressure of 50–60 psi. An alarm system that warns of Inpatient Perinatal Care ServicesCare of the Newborn 5757 any critical reduction in line pressure should be installed. The ventilation system, monitors, incubators, suction pumps, mechanical ventilators, and staff produce considerable noise, and the noise level should be monitored intermittently. Mechanical systems and equipment in infant rooms and adult sleep rooms should conform to noise criteria 25. Staff members should take particular care to avoid noise pollution in enclosed patient spaces (eg, incubators). Care should be taken to avoid spaces shaped so as to focus or amplify sound levels, thus creating “hot spots” that exceed the maximum recommended noise levels. Electrical Outlets and Electrical Equipment All electrical outlets should be attached to a common ground. Current leakage allowances, preventive maintenance standards, and equipment quality should meet the standards developed by the Joint Commission. Personnel should be thoroughly and repeatedly instructed on the potential electrical hazards within the neonatal care areas. Joint statement of practice relations between obstetrician–gynecologists and certi fied nurse–midwives/certified midwives. American College of Nurse–midwives and American College of Obstetricians and Gynecologists. Nonphysician clinicians in the neonatal intensive care unit: Inpatient Perinatal Care ServicesCare of the Newborn 5959 meeting the needs of our smallest patients. Obstetric and neonatal services share many of the characteristics of high reliability organizations in other industries, such as the aviation industry and nuclear power plants. Individuals must feel comfortable drawing attention to potential hazards or actual failures with out fear of censure from management and peers. Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse) 3. Timely—reducing waiting times and sometimes harmful delays for those who receive and those who provide care 61 62 Guidelines for Perinatal Care 5. Quality improvement accepts that good care depends upon more than just the judgment of the individual. Larger departments may benefit from designation of a patient safety officer and qual Quality Improvement and Patient SafetyCare of the Newborn 6363 ity reporting directly to the department chair. Peer Review Peer review is a quality assessment process in which a retrospective analysis of cases is undertaken using outcomes data to assess adherence to guidelines or other standards of care. A departmental peer review committee should be multidisciplinary and may include the following members, with consideration given to the vice chair of the department who serves as the committee chair: • Representative physicians with varying levels of clinical experience (junior and senior staff) within the department • Representative subspecialists, when available • House staff member, when appropriate • the department chair (ex officio) Small hospitals may face difficulty conducting peer review because of competi tive interests or interpersonal problems that have a real or perceived effect on the efficacy of the review. Therefore, it may be helpful to develop a relationship with another hospital or outside independent reviewer or consultant to conduct peer review. Care has been monitored and improved by focusing on specific outcomes, such as maternal, newborn, and neonatal mortality. Significant progress has been made in methods for collecting data and gathering vital statistics (eg, prenatal records, linked birth and death certificate data, linked birth and hospital dis charge data).


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