what are some examples of debate in the story of Didache?

A clinical documentation improvement program has been up and running for six months. Initial training of the CDI staff covered the following:

• Overview of CDI program and goals

• MS-DRGs including CCs and MCCs and their impact on MS-DRG assignment

• The top 10 MS-DRGs for the organization

• What documentation is used for code assignment and where to find in the paper and electronic medical record

• Review of clinical indicators for specific diagnosis such as respiratory failure and protein-calorie malnutrition

1. After reviewing the training program, recommend 4 additional topics that should be covered.

2. Why are these topics important to the CDI program

C. A., a 63 year old Filipino male with hormone-refractory prostate cancer is your clinic patient. C. A. was diagnosed with benign prostatic hypertrophy (BPH) several years ago and was taking alpha blockers for this condition.

A year ago, his BPH symptoms worsened despite maximal therapy. At that time, his primary physician performed a digital rectal examination and noted that he had a new hard nodule (1cm x 1cm) in the right lobe of his prostate and a PSA of 2.4 (PSA in the year prior to that was 2.2). A prostate biopsy revealed high-grade adenocarcinoma. A bone scan showed a small focal abnormality in the lumbar spine at the level of the L2 vertebra. The prostate cancer was staged as T2b.

1. What are the risk factors of prostate cancer?
2. How is prostate cancer diagnosed?

C. A.’s past medical history includes the following:

• Hormone-refractory metastatic prostate cancer per HPI (history of present illness)
• Severe Gastroesophageal Reflux Disease
• Coronary artery disease status post myocardial infarction two years ago with a history of left circumflex percutaneous transluminal coronary angioplasty
• Pulmonary nodules 2 mm , stable per CT for the last 5 years
• Hypertension
• History of depression
• Current tobacco abuse
• Hyperlipidemia

At the time of diagnosis, the patient was seen by the oncologist and then by radiation oncologist. Their recommendation was for the patient to undergo radiation therapy (external beam Intensity Modulated Radiation Therapy) followed by hormonal therapy and possible Taxotere trial.

1. Based on this information, what aspect of C. A.’s history do you think will have an implication in his nursing care?

Six months post-cancer diagnosis, C. A. was treated with radiation therapy (external beam Intensity Modulated Radiation Therapy) to his prostate and pelvic lymph nodes and placed on hormonal therapy and a Taxotere trial. He complained of increasing low back pain. An MRI scan showed bony metastasis to the L2 and L3 spine. The PSA was increasing at 18.6. He received radiation therapy to the spine.

1. What will be your priority concern at this time?
2. What changes in the plan of care will you recommend?

Eleven months post-cancer diagnosis, C. A. is here with his wife to see this physician for routine follow-up. He reports moderate pain control on his current pain regimen. He also states that his appetite is poor and that he tires easily. He is independent in his ADLs and IADLs, and even working occasionally on his good days. You note that he has lost 2 pounds since his last clinic visit 2 months ago. (BMI= 25.6).He is alert and oriented. His recent labs show a PSA = 70.7

1. You assisted C. A. for an interval history (wt loss, fatigue, Taxotere, etc). He lies down on the examination table for the physician to do a routine examination. What questions will you ask C. A.?
2. C. A. is looking anxious and asks: “How much time do I have?” What will be your response?

The physician’s progress notes read: C. A. is a 63 year old male with hormone refractory prostate cancer, KPS = 70%, anorexia, weight loss, increasing pain and fatigue. His PSA is increasing despite multi-modal therapy. He is alert and oriented. He has no other reported symptoms.

1. Which of these findings is your priority concern at this time? Why?

You researched that patients with hormone refractory prostate cancer who have indices similar to C. A. (age 63, PSA 70.8, Albumin 2.6, Alkaline Phosphatase 219, Hgb 11.5, LDH 680), who are tracked through the database at Memorial Sloan Kettering Cancer Center. They show a median survival of 3 months at a Karnofsky Performance Scale (KPS) of 70 (which is C. A.’s KPS score at the present time) and a 1yr survival probability of 2% with 2-yr survival probability of < 1%. (These estimates don’t directly consider presence or extent of metastases, PSA doubling time or patient ethnicity).

As for the patient’s health care goals, his primary objective is to remain pain free. He realizes that despite his young age, metastatic prostate cancer is an uncurable disease with treatments being primarily palliative with rather modest survival benefit at the current stage.

1. With this new development, what changes will you expect in C. A.’s plan of care?
2. What recommendations will you include for C. A.’s benefit?

Though his wishes are to continue considering available chemotherapy/radiation, C. A.’s primary goal is to be pain free, and to be able to spend quality time with his family, and to stay active. Though he would prefer to have CPR and intubation as treatments for acute issues, he would not like prolonged life support and would wish to have them withdrawn if they only served to prolong his life artificially.

1. What are the available resources that you can recommend for C. A. so he can achieve these goals?

She (Patricia Keely, 1963-2017 )was a 21-year-old undergraduate at the University of Minnesota when she discovered a lump near her neck. It was Hodgkin's lymphoma, a cancer of the lymphatic system. She underwent radiation therapy and later also chemotherapy.

Despite a cancer recurrence in grad school, she earned a doctorate in cell biology from Minnesota and embarked on the research career that brought her to Madison after stints at Washington University in St. Louis and the University of North Carolina.

Doctors aren't sure what causes Hodgkin's lymphoma. But it begins when an infection-fighting cell called a lymphocyte develops a genetic mutation.

Prior infection with Epstein-Barr virus is associated with increased risk of getting cancer later on.


The mutated cells to multiply rapidly, causing a large number of oversized, abnormal lymphocytes to accumulate in the lymphatic system, where they crowd out healthy cells and cause the signs and symptoms of Hodgkin's lymphoma.

Symptoms are vague:
•Painless swelling of lymph nodes in your neck, armpits or groin
•Persistent fatigue
•Fever
•Night sweats
•Unexplained weight loss
•Severe itching

The main treatments for Hodgkin lymphoma are chemotherapy alone, or chemotherapy followed by radiotherapy.

Dr. Patricia Keely first became a group leader at the University of Wisconsin-Madison and later became the Chair of the Department of Cell and Developmental Biology. She studied the mechanisms driving breast cancer development and metastasis. She was particularly interested in how the microenvironment in the vicinity of tumor cells influences cancer development

In 2006, Dr. Patricia Keely was diagnosed with esophageal cancer, probably caused by the radiation that cured her lymphoma. She underwent surgery in January 2006. Doctors removed two-thirds of her esophagus and the top of her stomach.
After surgery, "my prognosis for being without disease was only 50-50," Dr. Keely said. If the cancer came back, it would mean it has spread and there would be no cure.

She got different opinions from doctors. She was told that chemotherapy would be effective only if accompanied by radiation, but she could not have any more radiation therapy because of her earlier treatment.

She plunged into medical literature and found a clinical trial at the Mayo Clinic for an experimental drug called Iressa intended to prevent a recurrence of esophageal cancer.

"I understand the mechanism" of the drug, she said. "It made intellectual sense to me. It blocks a signaling pathway that is found to be increased in metastatic esophageal cancer."
Question 1:
Dr. Keely chose to enter a clinical trial where cancer patients were treated with IRESSA. IRESSA is a targeted EGF receptor drug. What type of mutation involving the EGFR might thus have been present in Dr. Keely’s metastatic tumor? List 2 possible oncogenic EGFR alterations.





Question 2:
How does the EGF receptor inhibitor IRESSA act (What domain in EGFR does IRESSA target?). What alternative anti-EGFR drugs would be available that would act differently than chemical inhibitors?






Question 3:
How might IRESSA have helped Dr. Keely to increase her survival chances once diagnosed with esophageal cancer? What would IRESSA do in terms of pathway effect and cellular processes affected?







Question 4:
IRESSA needs to be taken continuously by patients undergoing treatment. Often, tumor cells develop resistance after a while. What type of resistance mutants are frequently observed in the EGF receptor?












Question 5:
IRESSA (Geftinib) is one approved drug that targets the EGFR. Tarzeva (Erlotinib) and Gilotriv (Afatinib) are others. Are these targeting the same EGFRs? How about their mechanism? And what about Erbitux (Cetuximab)?









Question 6. Particular receptor tyrosine kinases (RTKs) that promote excessive cell division are found at high levels on various cancer cells. A protein called Her2 is a version of EGFR involved in tumor development. Choose the best statement about Her2 action.

A. Activation of Her2 causes cells to undergo apoptosis.
B. Activation of Her2 promotes progression through the cell cycle.
C. Activation of Her2 has no effect on the cell cycle.
D. Activation of Her2 causes cells to enter the G0 (quiescent) phase of the cell cycle.
E. All of the above



Question 7. Knowing how receptor tyrosine kinase signaling through the EGF type family of receptors works, what additional pathway molecule would you target for effective anti-cancer therapy to eliminate cancer cells that acquired resistance to IRESSA? Choose the most effective way to target.

A. Drugs that inhibit Raf kinase
B. Agents that inhibit EGFR activation, such as the monoclonal antibody drug herceptin
C. Drugs that inhibit mTOR
D. Drugs that inhibit Ral-GDS
E. Drugs that inhibit both, Raf and PI 3-kinase activity

Why do you think this is the most promising approach? Explain inn 1-2 sentences

answer only first 3 questions please according to the text

Q) Draw A table with 20 Medical terms Total

1. 20 word roots+ suffixes+ interpreting the meaning + giving Medical Term examples with interpretation
2. 10 prefixes+ interpreting the meaning of these prefixes+ Medical Term example for each prefix with interpretation

Hand written not allowed

Select three common combinations of medicinal preparations and outline the possible side and adverse effects of these combinations for the patient. Discuss the actions the practitioner should take to support the patient in this type of situation.

How will you address these 3 issues?

Three very traditional barriers to new or expanding roles for nurses in clinical practice or health system management are:

(1) physician resistance to what they perceive to be incursions into the “medical” domain;

(2) patient reluctance to shift their confidence to what they may see as a new category of health worker; and

(3) legal limitations to the type of businesses or practices that may be run by nurses.

How does inflammatory edema form?

what are the intervention for overweight related to inappropriate food choices and serving size as evidence by body mass index of 28.5

What a Good Study quide forATI RN Ptogram

ARTICLE REFLECTION ASSIGNMENT

The reflection assignment must include:

a) a one paragraph comprehensive summary of the article including the primary objective (PLEASE GIVE A DETAILED EXPLANATION THAT MAKES SENSE)

b) a one paragraph reflection of your own personal response to the reading. (PLEASE GIVE A DETAILED EXPLANATION THAT MAKES SENSE)

Read the article provided below and complete the assignment

Who should get the Covid-19 vaccine first? The equality vs. equity debate, explained.

When we finally find a safe and effective Covid-19 vaccine, every nation in the world will want it. But for a while, there won’t be enough to go around. So who should get access to the first doses?

One way to answer that question is to say: The nations that discover the vaccine — or that can pay those who discover it — will get first dibs. All the other nations will just have to wait until more doses can be manufactured.

This is “vaccine nationalism,” where every nation just looks out for itself, prioritizing its citizens without regard to what happens to the citizens of lower-income countries that can’t afford to buy up doses. It’s a path that most ethicists think is wrong. It’s also the path the United States is currently on.

September 18 was the deadline for governments around the world to join the Covax Facility, a unique financing mechanism that asks countries to pool their resources together so that humanity has a better shot at discovering a successful vaccine quickly. In return, all participating countries are promised that when that day comes, they’ll get equal access to the vaccine.

Some 156 countries signed agreements with Covax, representing 64 percent of the global population. The US did not.

“Bad! Bad!” is how Ezekiel Emanuel, a medical ethics expert at the University of Pennsylvania, characterized America’s decision. “This is an opportunity for low- and middle-income countries to get a vaccine and not just have it as a rich boys’ club,” he told me.

Ruth Faden, founder of the Johns Hopkins Berman Institute of Bioethics, also bemoaned the decision. “It’s just incredibly shoot-yourself-in-the-foot,” on two levels, she said.

Economically, Faden argues, it’s in America’s self-interest to help ensure every other country’s population is vaccinated because until the fear of Covid-19 dissipates, trade and travel won’t go back to normal. And health-wise, nobody is safe until everybody is safe. That’s because any Covid-19 vaccine we find is not going to be 100 percent effective. It can’t fully protect everyone from getting infected, so one infected traveler entering the US can still cause an outbreak.

For these moral and pragmatic reasons, ethicists generally reject vaccine nationalism (though some think it’s fine for a government to prioritize its citizens within certain limits). Instead, they say we should think about distributive justice, figuring out how to get lifesaving resources to every human being in a fair way.

But that unobjectionable-sounding notion actually obscures a key question, one that ethicists are now fiercely debating: When we say we want to distribute a vaccine fairly, do we care more about equality or about equity?

Equality would mean each country gets the same proportion of vaccine doses relative to its population size, and at the same rate. Equity would mean we drive more vaccine doses to the countries most in need.

The distinction between these two approaches — and which one wins out — will shape who gets a vaccine quickly and who’ll have to wait around, hoping they don’t get sick in the meantime. Let’s get clear on each approach, and understand why groups like the World Health Organization are pushing for equality right now, while some ethicists say that’s a mistake.

Why the WHO is focusing on equality

The WHO is one of three groups leading the Covax Facility. The other two are Gavi, a public-private partnership that spearheads immunization efforts in developing countries, and the Coalition for Epidemic Preparedness Innovations, an international collaboration (formed as a Gates Foundation initiative after the West African Ebola epidemic) to make vaccines available quickly when outbreaks happen.

Covax is kind of like a mutual fund, but for vaccines. It’s creating a diversified portfolio of vaccine candidates (currently, nine are in development and a further nine are under evaluation), the idea being that it’s better to back many candidates, knowing that some won’t pan out.

“Very few countries can do what the US is doing: We’re backing seven horses at this point, so we can create our own diversified portfolio,” Faden said. “But many countries don’t have the resources to do that for themselves. This is the answer to that problem.”

Covax asks wealthier countries to fund the development and manufacturing of the vaccine candidates. Lower-income countries don’t have to pay; they’ll be supported through voluntary donations to a dedicated Covax mechanism called the Advance Market Commitment. Covax aims to buy and make available 2 billion doses by the end of 2021.

If that happens, it’ll be a huge deal. Covax’s effort to get countries to work with each other instead of against each other could save many lives worldwide. According to Gavi CEO Seth Berkley, it’s the biggest multilateral effort since the Paris climate agreement; certainly, it’s a big step in the right direction.

Here’s how the WHO says Covax allocation should work: Once a safe and effective vaccine is discovered, there should be an initial phase where all participating countries get doses in proportion to their population, at the same rate. Essentially, 3 percent of every country’s population would get access to the vaccine before any country moves on to 4 or 5 percent. This proportional allocation would continue until every country has enough doses to vaccinate 20 percent of its population.

The WHO suggests the initial tranche of doses, aiming to cover 3 percent, would likely go to health care workers. The tranche covering 20 percent would likely go to high-risk adults, like older people and those with underlying conditions. (The WHO says 20 percent would be enough to cover these groups in most countries, though some countries have older populations and might need more. They can request enough doses for up to 50 percent of their population, but they won’t receive doses for more than 20 percent until all other countries have been offered that amount.)

Soumya Swaminathan, the WHO’s chief scientist, explained the rationale to a panel of reporters on September 15.

“What we’ve done in the Fair Allocation Framework, at least in the first phase, is to go with the principle of equality,” she said. “Because in this case, the disease has spread across the world. It has not spared any country, high-income or low-income, whereas diseases like TB and malaria disproportionately affect low- and middle-income countries.”

However, she said that after countries have received enough doses to vaccinate 20 percent of their populations, she expects to shift toward “more allocation to those countries which appear to be needing it much more than other countries” — that is, equity.

Pressed as to why Covax doesn’t adopt an equity model right from the get-go, Swaminathan candidly explained that the reason is pragmatic: If wealthier countries are told they’ll have to wait in line for vaccine doses behind poorer countries, they may reject Covax.

“There’s a big, big risk that if you propose a very idealistic model, you may be left with nothing,” she said. She recalled the 2009 swine flu pandemic, when wealthy countries like the US scooped up most doses of the H1N1 vaccine. Low-income countries couldn’t get access until later, by which point the acute phase of the pandemic was already over.

“That’s the historical reality. We are trying to create a new reality,” Swaminathan said. “But you cannot leave behind the high-income countries. To say to them, ‘You don’t have a big problem right now and therefore you don’t need the vaccine,’ may not be acceptable to them because the virus is there and waiting to spring back the moment people go back to normal. … Without their agreement, it’s not going to be successful.”

In other words, the WHO is conscious of the politics at play here.

Faden co-drafted the WHO’s Values Framework for vaccine allocation, which does list equity among its guiding principles, even though it wouldn’t kick in till later. “Look, there is a real-world problem,” she told me. “We currently live in a global order that is profoundly unjust. We need a strategy that appeals to and works for high-income countries. The Covax Facility’s principle of simple equality for the first 20 percent is this strategic attempt to incentivize countries to get in — the kind that can pay.”

Why some ethicists say we should focus on equity

Other ethicists are pushing for a more idealistic framework, one that prioritizes equity from the start. Chief among them is Emanuel, the University of Pennsylvania expert. Even as he participates in several WHO working groups on Covid-19, he’s trying to get the international body and other players to rethink their model.

There’s a very obvious problem, he says, with the WHO’s approach: Two countries can have similar-size populations but very different Covid-19 case counts. Should they really both get enough doses to vaccinate 3 percent of their populations right off the bat? Or should we drive more help toward the country with the greatest disease burden so we save as many lives as possible?

Emanuel explained the problem with the former approach via analogy. “Imagine you’re an ER doctor,” he told me. “You’re very busy, so you walk into the ER and say each person gets five minutes of time irrespective of how sick they are. That makes no sense.”

In a paper published September 11 in Science, he and a diverse group of experts propose an alternative framework called the Fair Priority Model. (Though there are a couple of other proposals out there putting forward frameworks for vaccine distribution, this is the only one that offers as substantive a model as the WHO’s.)

The experts lay out a plan for distributing the vaccine in three phases. Positing that our main goal should be to avert premature deaths, they suggest using standard expected years of life lost (SEYLL) averted per dose as the criterion in phase one. They say we should give priority to countries that would reduce more SEYLL per dose.

In phase two, which aims to reduce pandemic-induced economic deprivation, they give priority to countries that would reduce more SEYLL and reduce more poverty. In phase three, which aims to end community spread, they give priority to countries with higher transmission rates.

This model offers a concrete way to reduce serious harms and prioritize disadvantaged people on an international scale. Emanuel said it’s more ethical than the WHO’s current approach.

“I wasn’t born yesterday. I understand that sometimes you can’t do exactly what’s ethical because you need to get people to the table,” he told me. “But political expediency is one thing and ethics is another thing. What I object to is claiming this [WHO approach] is an ethical position. And they do claim that — they use the ethics language of ‘we’re being equitable’ and all this. But that’s not transparent; that’s actually false advertising.”

Some might object that Emanuel’s own proposal is not equitable to countries with more elderly citizens: Saving them will save fewer years of life (thus netting less SEYLL per dose), but older citizens are still morally valuable.

Emanuel told me that he’s heard this ageism critique “a million times” but that it’s ill-founded.(He has, it may be worth noting, idiosyncratic personal views about aging.) He noted thatmany surveys conducted around the world suggest that, all things being equal, the public prioritizes youth over older adults in the distribution of health resources. As a global society, we seem to value investing in youth, both because investing in them when they’re young yields greater dividends later on and because we don’t want to cheat them of the chance at significant life experiences — a deprivation that arguably constitutes a moral harm.

Emanuel contends that his group has arrived at the best way to enshrine three fundamental values: benefiting people and limiting harm, prioritizing the disadvantaged, and equal moral concern.

“We met every week, arguing, and we had a very diverse group,” he said. “You had utilitarians, you had people who are more Rawlsian, you had cosmopolitans who believe national borders are basically ethically irrelevant, and you had people who believe borders are very relevant. I think our position represents the best of ethics and a consensus about principles that transcends lots of different specific moral commitments.”

Ultimately, is this proposal better than the WHO’s? How you answer that depends somewhat on your specific moral commitments. From a utilitarian’s standpoint, for example, whichever proposal will do the best job at maximizing benefit and limiting harm to all people is the best approach. If the WHO’s realpolitik enables it to get more paying countries into the Covax Facility, thus eventually enabling more vaccines for people who couldn’t otherwise afford them, it might actually be the most ethical model.

Either way, Covax is now in business, and its multilateral, cooperative approach comes as a welcome counterpoint to the vaccine nationalism we’ve seen in other quarters. For countries that have signed agreements with the Facility, the next step is to cough up the cash: Payments are due October 9. This money will hopefully accelerate the development and manufacturing of the vaccine we’re all awaiting.