dralmanza.memoria

Sickle Cell Anemia

2017-02-08T10:33:00.000-08:00

The Sickle Cell Anemia is a autosomal recessive disorder caused by a change in the 6 codon of the B-globin gene from A to T, results in a modified hemoglobin structure. The results is Hemoglobin S which polymerizes under low oxigen conditions, causing distortion of red blood cells leading to the associated clinical phenotype.

Thr Pro Glu Glu beta A chain
ACT CCT GAG GAG beta A gene
codon # 4 5 6 7
ACT CCT GTG GAG beta A gene
Thr Pro Val Glu beta A chain
The mutation in the gene coding for the B-chain of hemoglobin results in RBCs assuming a sickle shape when deoxygenated which them precipitate out of circulation and may occlude the microvasculature.

Mutation in both B-chain define the Sickle Cell disease, a single affected chain is Sickle cell trait.

HbS mutation is a single amino acid replacement in B-chain, substitution of normal glutamic acid with Valine. Low oxigen or dehydration precipitates sickling. Heterozygotes (sickle cell trait) are relatively malaria resistant.
Complivation in Homozygotes include aplastic crisis, due to parvovirus B19 infection, autosplecnectomy, inrease risk of encapsulated organism infection, Salmonella osteomyelitis, painful crisis, and splecnic squestration crisis.
Acute chest pain due to occlusion of bone marrow can cause a fat embolus to the lungs, resulting in hypoxemia anf possibly cardiovascular collapse.
8% of African-Americans carry the HbS trait, 0,2 % have the disease.
Sickled cells are crescent-shape RBC.
"Crew cut" in skull x-ray due to marrow expansion from increase erythropoiesis.
New-Born initially asymptomatic owing to high HbF and low HbS

Therapic for SCA include Hydroxyurea and bone marrow transplantation.
Because Ribavirin may cause a hemolytic anemia, it should be avoided in pte with hematologic disorder such as Sickle cell anemia and Thalasemia major.

retrieved from: First Aid for the USMLE step 1 2016, First Aid for Basic Sciences and General Princeples 2012.

Miscellaneous Echo finding (brief notes)

2016-03-30T09:51:00.000-07:00

Ehlers-Danlos Syndrome:

A heterogeneous group of connective tissue disorders with simple Mendelian inheritance. The cardinal manifestations of EDS are hyperextensible (stretchy) skin, hypermobile joints and easy bruising.

Echo/Doppler: Aortic root dilation, sinus de Valsalva aneurysm, Dilation of the proximal innominate artery, MVP, AVP, VSD, ASD, Tetralogy of Fallot, Aortic coarctation, Bicuspid AV, and Dextrocardia.

Fabry’s Disease:

An X-linked recessive inborn error of glycosphingolipid metabolism.

Echo/Doppler: MVP, increased LV wall thickness/mass, Aortic root dilation, MR, diastolic dysfunction.

Friedreich’s Ataxia:

Cardiac abnormalities are a characteristic feature of the autosomal recessively inherited spinocerebellar degeneration known as FA, which is the most common hereditary ataxia.

Echo/Doppler: Concentric Hypertrophy, Globally decreased LV systolic function, EF and FS. Increased left Atrial dimension.

Glycogen storage disease:

A group of inheritable disorders of glycogen metabolism, resulting from specific enzymatic defects; Pompe’s disease (GSD type IIa) is a classic form of infantile GSD and is autosomal recessive.

Echo/Doppler: severe thickness of the IVS, free wall and LVPW with a tumor-like appearance of the papillary muscles with small LV cavity. Poor global LV systolic function.

Holt-Oram (Heart-Hand) Syndrome:

An autosomal dominant syndrome characterized by skeletal abnormalities and congenital cardiac defects.

Echo/Doppler: ASD (ostium secundum), dilation of the right heart and paradoxical motion of IVS consistent with RVOL. VSD (trabecular type), may present with complex congenital heart disease/vascular malformations, Nonobstructive CM and MVP.

Loeys-Dietz syndrome (Aortic Aneurysm Syndrome):

Autosomal dominant aortic aneurysm syndrome characterized by the triad of arterial tortuosity and aneurysms, hypertolerism and cleft palate. Aggressive arterial aneurysm (mean age of death 26 years of age), vascular disease may be widespread, and increased pregnancy related complications.

Marfan’s Syndrome:

A hereditary condition of connective tissue, bones, muscles, ligaments and skeletal structures.

Echo/Doppler: Proximal aortic dilatation, multivalvular prolapse, dilated mitral annulus, MAC, left Atrial compression, LVVOL, AI, MR, aortic dissection (most common cause of death) and CAD.

Lyme disease:

Caused by tick-borne spirochete, Borrelia burgdorferi, initial infection marked by rash, followed by weeks to months by involvement of other organ systems, including the heart, neurologic system and joints.

Echo/Doppler: severe AV node block associated with syncope; DCM.

Noonan’s Syndrome:

A inherited autosomal dominant manner and is characterized by congenital heart disease, short stature, abnormal facies and somatic features of Turner’s Syndrome but normal karyotype.

Echo/Doppler: PV stenosis, Secundum ASD, VSD, PDA, and localized anterior septal hypertrophy.

Phen-fen:

The appetite suppressants phentermine, fenfluramine and dexfenfluramine, alone or in combination, have been implicated as causing valvular disease; complication uncommon with less than 6 months of use.

Echo/Doppler: thickened MV/Chordae Tendineae, thickened AV, mild or greater AR, mod or greater MR, pulmonary HTN.

Bibliography

Armstrong, W. F., & Ryan, T. (2010). Feigenbaum's Echocardiography. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

Reynolds, T. (2013). The Echocardiographer's Pocket Reference. USA: Arizona Heart Foundation.

PREDICTION OF INTRACARDIAC PRESSURES (Reynolds, 2013)

2016-03-27T18:30:00.000-07:00

2-D echocardiography combined with cardiac Doppler may be utilized to predict intracardiac pressures.

Right Atrial Pressure (RAP)

v Normal 2 to 5 mmHg, to approximate the RAP, examine the IVC by 2-D and substitute one of the following values for the actual RAP.

Variable	Normal (0-5(3)mmHg)	Intermediate (5-10(8) mmHg)		High (15 mmHg)
IVC diameter	Less than 2.1 cm	Less than 2.1 cm	More than 2.1 cm	More than 2.1 cm
Collapse with sniff	More than 50 %	Less than 50 %	More than 50 %	Less than 50 %

Secondary indices of elevated RAP:

ü Restrictive filling

ü Tricuspid E/E’ more than 6

ü Diastolic flow predominance in hepatic veins (systolic filling fraction less than 55 %).

v Dilated hepatic veins with a dilated inferior vena cava suggest increased right Atrial pressure.

v A dilated coronary sinus (normal 4 to 8 mm as measured in the A4C with a posterior tilt) suggests increased RAP; it may be dilated also with persistent left superior vena cava, coronary artery AV fistula, anomalous hepatic vinous drainage to the left coronary sinus, and total anomalous pulmonary venous return or severe tricuspid regurgitation.

v In the absence of significant tricuspid regurgitation (TR), a right atrium that is increased in dimension especially when compared to the left atrium, suggests increased RAP.

v A right atrium maximal volume measured at end-systole of more than 45 +/- 14 cm3 suggests a mean RAP of more than 8 mmHg.

v A right Atrial maximal volume measured at end-diastole of more than 30 +/- 15 cm3 suggests a mean RAP of more than 8 mmHg.

v Interatrial septal deviation towards the left atrium may indicate increased RAP.

v A PW Doppler tricuspid valve E/A ratio of equal or more than 1.1 may indicate a mean RAP of > 8 mmHg, assumes the absence of right ventricular inflow tract obstruction.

v A dagger shaped CW tricuspid regurgitation velocity spectral display suggests increased RAP.

v A decreased right ventricular IVRT (normal 54 +/- 3.55 msec) suggests increased RAP.

v A patient with left heart disease and pulmonary hypertension may eventually develop elevated right heart pressures.

Bibliography

Reynolds, T. (2013). The Echocardiographer's Pocket Reference. USA: Arizona Heart Foundation.

PERICARDIAL DISEASE (my class notes)

2016-01-27T10:57:00.000-08:00

The pericardium is made up of two layers. The epicardium (visceral pericardium) is a serous membrane which lies directly adherent to the heart and the outer layer is called the fibrous (parietal) pericardium. The normal thickness of the parietal pericardium is approximately 2 mm. there is approximately 10 to 50 mL of fluid normally between the epicardium and the fibrous pericardium. This normal pericardial fluid may be seen as an echo-free space during ventricular systole. When the echo-free space persists throughout the cardiac cycle, a pericardial effusion is considered present. When quantitating the amount of pericardial fluid by echocardiography the fluid should be measure during ventricular diastole. Intrapericardial stands or fibrin strands within pericardial effusion most likely indicate inflammation or long-standing pericardial effusion.

The most common presenting symptom of acute Pericarditis is Chest pain; other symptoms include dyspnea, fever and cough. The chest pain associated with acute Pericarditis may be relieved by the patient sitting up and leaning forward.

The expected echocardiographic finding for Pericarditis is a pericardial effusion but patients may have Pericarditis without pericardial effusion (dry Pericarditis). Additionally pericardial effusion can occur in the absence of pericardial inflammation such as in post-operative cardiac surgery, chronic renal disease, collagen vascular disease, cardiac trauma, malignancy, AIDS and hypothyroidism.

The best guideline for differentiating pericardial effusion from pleural effusion by two dimensional echocardiography is: pericardial effusion is located anterior to the descending aorta; pleural effusion is present posterior to the descending aorta; in addition, a large pericardial effusion usually surrounds the heart.

Pulsus paradoxus is present when there is an exaggerated inspiratory decline in arterial blood pressure of more than 10 mmHg. Pulsus paradoxus is associated with cardiac tamponade for two reasons: filling of both ventricles against a common stiffness and respiratory changes in the venous pressure differential (systemic versus pulmonary) alternately favoring right and left ventricular filling. Respiratory variations of the cardiac Doppler signal of the atrioventricular valves suggest pulsus paradoxus.

In cardiac tamponade the right ventricular diastolic collapse occurs in early diastolic when the right ventricular volume and pressure are at lowest levels. Right ventricular diastolic collapse can be observed in the parasternal long axis view, parasternal short axis view, apical four chambers and the subcostal four chamber view.

With a large anterior and posterior pericardial effusion the heart may move freely within the pericardial cavity. This type of motion called the swinging heart syndrome tends to occur in large pericardial effusions. The swinging may cause the phenomenon of electrical alternant.

Marked (more than 25%) respiratory variation of tricuspid valve (increase in inspiration; decrease with expiration) and mitral valve (decrease in inspiration; increase with expiration) peak flow velocities and/or velocity time integrals is a strong indicator for the presence of cardiac tamponade. The orders in which changes occur are fairly predictable. Changes in the tricuspid occur first, followed by changes in the mitral valve with right atrial collapse being the next change and right ventricular diastolic collapse occurring last. Hepatic vein flow in cardiac tamponade mimics the flow changes of the tricuspid valve. The hepatic vein will have a reduction or reversal of diastolic flow expiration.

Constrictive Pericarditis results in the impairment of diastolic filling of the heart which may result in diastolic heart failure. Diastolic filling is impaired because of the constraint the pericardium places on the heart. Intracardiac filling pressures are usually increased in patients with constrictive Pericarditis. Constrictive Pericarditis should be a differential diagnosis in patients who present with congestive heart failure and normal global ventricular systolic function. Virtually all filling of the ventricle occurs in very early diastole. This abnormal pattern of diastolic filling is reflected in the characteristic dip-and-plateau (square root sign) waveforms in both the right and the left ventricles. The rapid rise in pressure after the early diastolic correspond to the period of rapid diastolic filling while the plateau phase correspond to the period of mid and late diastole when there is little additional expansion of ventricular volume. This can be expressed by the inflow patterns of the mitral valve and tricuspid valve with increased E/A ratio (more than 1.5) and shortened deceleration time ( less than 140 msec).

Causes of Constrictive Pericarditis include prior pericardiotomy, idiopathic, Pericarditis, radiation, infection and collagen vascular disease. Tuberculosis was at one time considered the leading cause of constrictive Pericarditis but idiopathic and prior pericardiotomy are the most common reason for Constrictive Pericarditis currently.

A thickened pericardium more than 2 mm, interventricular/inter-Atrial septal bounce (shudder), bound-down appearance of the ventricular walls with lack of pericardial slide, inferior vena cava plethora, normal Atrial dimensions, normal ventricular dimensions and normal global ventricular systolic function are the echocardiographic findings associated with constrictive Pericarditis.

Pulsed wave Doppler in Constrictive Pericarditis:

Ø Mitral flow: restrictive pattern (increase E/A ratio, shortened DT)

Ø Increased peak velocity across the mitral valve with expiration

Ø Hepatic flow vein: expiratory flow decrease or reversal

Ø Tissue Doppler in mitral valve annulus is Normal E’ wave peak velocity (more or equal to 8 cm/s) and the E/E’ ratio is normal (more than 8), it is called annulus paradoxus

FARMACOTERAPIA EN LA INSUFICIENCIA CARDIACA (I):

2016-01-26T12:17:00.000-08:00

El objetivo de la Farmacoterapia en el fallo cardiaco es reducir la morbilidad y prevenir las complicaciones. Dentro de los medicamentos que ayudan a aliviar los síntomas, junto al uso del oxigeno, se encuentran los siguientes (Dumitru, 2014):

· Diuréticos: reducen el edema mediante la reducción del volumen sanguíneo y la presión venosa.

· Vasodilatadores: reducen la pre y post-carga.

· Digoxina: puede causar un leve incremento del gasto cardiaco.

· Agentes Inotrópicos: ayudan a restaurar la perfusión del órgano y reducir la congestión.

· Anticoagulantes: reducen el riesgo de tromboembolismo.

· Beta-Bloqueadores: por modificación neurohormonal, mejoran la fracción de eyección del ventrículo izquierdo (LVEF), previenen arritmias, y controlan la frecuencia ventricular.

· IECA: por modificación neurohormonal, vasodilatación y mejoramiento de la LVEF.

· Bloqueadores de los receptores de la angiotensina II: también por modificación neurohormonal, vasodilatación y mejoramiento de la LVEF.

· Analgésicos: manejo del dolor.

Medicamentos que pueden exacerbar la insuficiencia cardiaca y que deben ser evitados:

· Anti-inflamatorios no esteroideos: pueden causar retención de sodio y vasoconstricción periférica, además pueden atenuar la eficacia y elevar la toxicidad de diuréticos y IECAs.

· Bloqueadores de los canales de calcio: pueden empeorar el fallo cardiaco e incrementar el riesgo de eventos cardiovasculares, solo los bloqueadores de los canales de calcio vasoselectivos han demostrado no tener efectos negativos en la supervivencia.

· Drogas anti-arrítmicas excepto las de Clase III: pueden tener efectos cardiodepresivos y facilitar las arritmias, solo la amiodarona y el dofetilide han demostrado no tener efectos negativos en la supervivencia

Bibliography

Dumitru, I. (2014, Apr 23). medscape.com. Retrieved from emedicine.medscape.com: http://emedicine.medscape.com/article/163062-medication

INFECTIVE ENDOCARDITIS: (my class notes)

2016-01-26T12:09:00.002-08:00

Fever is the most common symptom (80 to 85%) of infective endocarditis. Additional symptoms include chills, sweats, anorexia, weight loss, malaise, dyspnea, cough, stroke, headache, nausea/vomiting, myalgia/arthralgia, abdominal pain, back pain and confusion. The onset of symptoms is estimated to be less than two weeks in patients with native valve endocarditis. The perioperative period post-cardiac valve replacement is two to five months or longer. Heart murmurs are noted in 80 to 85% of patients with infective endocarditis. The classic triad of infective endocarditis is fever, new murmur and positive blood cultures. The classic echocardiographic findings in infective endocarditis are valvular vegetation and valvular regurgitation.

Complications of infective endocarditis include:

Ø Congestive heart failure

Ø Embolization

Ø Valve ring abscess

Additional complications include valve leaflet vegetation, disruption (e.g. flail) with resultant regurgitation, perforation, aneurysm, fistula, dehiscence of prosthetic valve, pericardial effusion and hemodynamic compromise (e.g. valvular regurgitation, premature mitral valve closure, restrictive mitral valve inflow pattern, valvular stenosis (rare) and shunt).

Infective endocarditis is a greater risk in patients with prosthetic heart valve; the classic clinical setting for infective endocarditis is pre-existent valvular heart disease (e.g. rheumatic, myxomatous, congenital, prosthetic heart valve, intravenous drug abuse). A mode of infection (e.g. dental, surgical, and traumatic) is often identifiable. If a patient is an intravenous drug abuser normal right sided cardiac valves can be affected.

Vegetations are common to all types of infective endocarditis. They are situated most frequently on the valvular leaflets and less often on the endocardium of the ventricles or of the left atrium (McCallum’s patch of rheumatic carditis) and on the pulmonary or other arteries. The expected cardiac Doppler finding for infective endocarditis is valvular regurgitation. Approximately 15 % of patients do not have a new murmur due to valvular regurgitation with one possible explanation being that the vegetation is located on the base of the leaflet which may not disrupt valve closure. Valvular stenosis is a rare complication of native valve infective endocarditis.

The usual site of attachment for vegetation is on the atrial side (low pressure side) of the mitral and tricuspid valve leaflets. Aortic and pulmonary valve vegetations are usually found on the ventricular (low pressure side) of the valve. When the diameter of the vegetation exceeds 10 mm 50 % of patients develop at least one complication of infective endocarditis. In tricuspid valve endocarditis, pulmonary embolism is the most common complication.

Valve ring abscess is an uncommon but a serious typical complication of infective endocarditis and usually involves the aortic valve ring. Rupture of aortic ring abscess can occur creating a fistula.

Valve ring abscess usually presents as an area of echolucency (if cystic) or echoreflectant (if solid) around the valve ring or myocardium. Abscesses may be found in the aortic posterior annulus, peri-annular area, aortic-mitral intervalvular fibrosa, posterior aortic root and interventricular septum. For prosthetic heart valves, abscesses are usually seen around the sewing ring.

The sensitivity of detecting a vegetation with transthoracic two-dimensional echocardiography (TTE) is 65 to 80 % and with transesophageal echocardiography (TEE) it is95 %. It has been proposed that all patients with suspected infective endocarditis should undergo TEE examination. The clinical utility of cardiac magnetic resonance imaging has not been determined but has been useful in determining the presence of perivalvular extension of infection, aortic root aneurysm and fistulas.

PULMONARY REGURGITATION (my class notes)

2016-01-26T08:24:00.000-08:00

By far the most common cause of pathologic pulmonary regurgitation is dilation of the valve ring secondary to pulmonary hypertension. The second most common cause is infective endocarditis. Iatrogenic significant pulmonary regurgitation may be present in patients following treatment for pulmonary valve stenosis or tetralogy of Fallot.

Isolated pulmonary regurgitation may lead to right ventricular volume overload. Right ventricular volume overload (RVVO) is diagnosed by the echocardiographic findings of right ventricular dilatation and paradoxical interventricular septal motion. RVVO may be diagnosed with two-dimensional echo as right ventricular dilatation and flattening of the interventricular septum during diastole with restoration of the normal circular configuration during ventricular systole best seen in the parasternal short-axis of the left ventricle at the level of the papillary muscles.

Color Doppler findings indicate significant pulmonary regurgitation:

Ø Wide jet width at origin

Ø Jet width/Right ventricular outflow tract width more than 70 %

Ø Holodiastolic flow reversal in the main pulmonary artery

Ø Jet length more than 10 mm

Pulmonary artery end-diastolic pressure can be calculated by the formula:

PAEDP (mmHg) = 4xend-diastolic velocity PR2 + RAP (mmHg)

Normal PAEDP is 4 to 12 mmHg

The estimation of the PAEDP reflects the pulmonary artery wedge pressure.

Mean Pulmonary Artery Pressure may be calculated by the formula:

MPAP (mmHg) = 4x peak velocity PR2

The normal range for the MPAP is 9 to 18 mmHg.

MITRAL VALVE STENOSIS (my class notes)

2016-01-21T07:41:00.000-08:00

Classic M-mode findings for Mitral Stenosis:

v Thickened mitral valve leaflets

v Decreased mitral valve E-F slope

v Anterior motion of the posterior mitral valve leaflet

Two dimensional echo finding for rheumatic MV stenosis:

v Hockey-stick appearance of the anterior mitral valve leaflet

v Increase left Atrial dimension

v Thickened MV leaflets and subvalvular apparatus

Other Two dimensional echo/Doppler finding include:

v D-shaped left ventricle

v Left Atrial thrombus

v Abnormal interventricular septal wall motion

v Increase right heart dimension

v Increased TV regurgitation jet velocity

v Increased E velocity

v Increased Pressure half-time

v Turbulent flow

MVA: Severe stenosis = less than 1.0 cm2

Moderate = 1.1 to 1.5 cm2

Mild stenosis = 1.6 to 2.5 cm2

Normal MVA = 4 to 6 cm2

MVA (cm2) = 220/PHT (msec)

The abnormal range for PHT in patient with MV stenosis is 90 to 400 msec. MV stenosis is considered severe when PHT is 220 msec or longer.

PHT (msec) = Deceleration Time x 0.29

Mean Pressure gradient (tracing CW Doppler spectral wave form)

v Severe stenosis = more than 10 mmHg

v Moderate = 4 to 10 mmHg

v Mild stenosis = less than 4 mmHg

SEVERE MITRAL VALVE STENOSIS:

Ø MEAN PRESSURE GRADIENT MORE THAN 10 mmHg

Ø MITRAL VALVE AREA LESSN THAN 1.0 cm2

Ø PRESSURE HALF TIME MORE THAN 220 msec

MANEJO DEL SINDROME DE DIFICULTAD RESPIRATORIA AGUDA

2015-07-09T11:11:00.000-07:00

Recientemente se han producido cambios en el manejo del síndrome de dificultad respiratoria aguda. El presente trabajo brinda una revisión acerca de la nueva definición propuesta para esta enfermedad y de los hallazgos clave respecto de distintas estrategias terapéuticas evaluadas en los últimos años.

Autor: Duggal A, Mireles-Cabodevila E, Krishnan S, Arroliga A Cleveland Clinic Journal of Medicine 81(11): 683-690, Nov 2014

Introducción
El síndrome de dificultad respiratoria aguda (SDRA) se caracteriza por la presencia de daño en la arquitectura alveolar, hipoxemia grave y opacidades parenquimatosas bilaterales. Los avances en la comprensión de la fisiopatología de este síndrome han derivado en modificaciones en el diagnóstico y en el manejo de la enfermedad.
En las últimas dos décadas, el bajo volumen corriente, la presión positiva al final de la espiración (PEEP, Positive End-Expiratory Pressure) y la restricción de líquidos se han convertido en las terapias de elección. El enfoque multidisciplinario también ha introducido cambios en el manejo del SDRA, que incluyen el uso de sedantes específicos, la movilización temprana y distintos protocolos para la interrupción de la ventilación mecánica.

El objetivo del presente trabajo fue llevar a cabo una revisión de los principales artículos publicados sobre el SDRA en los 5 últimos años, en los cuales se debate una nueva definición para la enfermedad y las distintas terapias, con ventilación mecánica o sin ella, que han tenido reciente repercusión sobre el manejo de los pacientes.

Una nueva definición
En 1994, la Conferencia del Consenso Americano-Europeo elaboró una definición para el SDRA sobre la cual se basaron todos los ensayos clínicos y observacionales llevados a cabo durante los últimos 20 años. Sin embargo, esta definición fue considerada como limitada en términos de confiabilidad y validez. Es por eso por lo que en 2011, la Fuerza de Tareas para la Definición del SDRA actualizó la definición con el fin de mejorar su viabilidad, confiabilidad y validez en la predicción de resultados. Aunque esta nueva definición, conocida como definición de Berlín, no difiere significativamente de la anterior, logra definir los criterios con mayor especificidad. Estos criterios son:

1) Opacidades bilaterales en la radiografía de tórax o en la tomografía computarizada, las cuales no pueden ser explicadas por la presencia de nódulos, atelectasias o derrame pleural.

2) Nuevos síntomas respiratorios, empeoramiento de los ya presentes, o evento clínico asociado con SDRA dentro de los 7 días del diagnóstico.

3) Evaluación objetiva de la función cardíaca (por ejemplo, mediante ecocardiograma) a fin de excluir edema pulmonar cardiogénico.

4) Hipoxemia con una presión parcial de oxígeno arterial dividido por el porcentaje de oxígeno inspirado (relación PaO2/FiO2) de 300 mm Hg o menos a pesar de la ventilación mecánica con PEEP o de una presión positiva continua en la vía aérea (CPAP, Continuous Positive Airway Pressure) de al menos 5 cm H2O.

Asimismo, la nueva definición clasifica la gravedad de la enfermedad según el grado de hipoxemia, es decir, según la relación PaO2/FiO2, en tres categorías: leve (relación PaO2/FiO2 > 200 y < 300 mm Hg), moderada (relación PaO2/FiO2 > 100 y < 200 mm Hg) y grave (relación PaO2/FiO2 < 100 mm Hg).

La Fuerza de Tareas evaluó la confiabilidad y validez de la definición de Berlín en un metanálisis que incluyó a 4 400 pacientes y en el que se demostró que la nueva definición logra predecir el riesgo de mortalidad mejor que la definición anterior. No obstante, si bien la nueva definición ha logrado subsanar algunas de las limitaciones de la más antigua, aún debe ser validada en la práctica clínica, especialmente en relación con su capacidad de predecir la mortalidad.

Estrategias de soporte ventilatorio en el SDRA
La ventilación mecánica en posición prona ha sido descripta hace casi 30 años, pero su uso ha sido inconstante en la práctica clínica. Si bien los resultados respecto de este tipo de terapia han sido contradictorios, algunos metanálisis han sugerido que podría ser beneficiosa en pacientes con SDRA grave.

En consecuencia, se llevó a cabo el estudio PROSEVA (Proning Severe ARDS Patients study), ensayo aleatorizado y controlado diseñado para determinar si la ventilación mecánica en posición prona es capaz de mejorar los resultados en pacientes con SDRA grave. Del estudio participaron 466 pacientes de España e Italia con SDRA grave, los cuales fueron colocados en posición prona por al menos 16 horas o fueron dejados en posición supina luego de 12 a 24 horas de ventilación mecánica convencional inicial.
La tasa de mortalidad a 28 días fue del 16.0% para el grupo en posición prona comparado con un 32.8% para el grupo en posición supina. La tasa de mortalidad a 90 días también resultó ser más baja en el primer grupo. Asimismo, la ventilación en posición prona obtuvo una tasa más elevada de extubación exitosa y no se vio asociada con una mayor incidencia de complicaciones.
En conclusión, el uso temprano y prolongado de la ventilación mecánica en posición prona mejoró significativamente las tasas de mortalidad en pacientes con SDRA grave. Los hallazgos del mencionado estudio han convertido a este tipo de ventilación en una de las estrategias posibles para el manejo de pacientes con SDRA grave.

Por otra parte, estudios observacionales y experimentales han sugerido que la ventilación de alta frecuencia oscilatoria (VAFO) es superior a la ventilación mecánica convencional en pacientes con SDRA. No obstante, la ausencia de protocolos definidos y la falta de aval científico de alta calidad que justifique su uso han limitado su aplicación en la práctica clínica. En los últimos años, la aceptación de la VAFO ha ido en aumento debido a los resultados prometedores informados en algunos ensayos clínicos preliminares. Por lo tanto, se diseñaron dos estudios, uno en Canadá y otro en el Reino Unido, con el fin de comparar la VAFO con la ventilación mecánica convencional en pacientes con SDRA.

El estudio OSCAR (Oscillation in ARDS study) incluyó a 795 pacientes que fueron distribuidos aleatoriamente para recibir VAFO o ventilación convencional. De acuerdo con los resultados de este estudio, no se hallaron diferencias significativas en la tasa de mortalidad en cuidados intensivos, en la tasa de mortalidad durante la internación o en la de mortalidad a 30 días.
La duración de la ventilación mecánica fue similar en ambos grupos, al igual que el uso de drogas vasoactivas y antibióticos. Sin embargo, el uso de sedantes y bloqueantes neuromusculares fue más frecuente y prolongado en el grupo que recibió VAFO, comparado con el otro grupo. En conclusión, el ensayo no logró demostrar ningún beneficio del uso de la VAFO para el manejo del SDRA en la práctica clínica.
El estudio OSCILLATE (Oscillation for Acute Respiratory Distress Syndrome Treated Early study) evaluó la eficacia y seguridad de la VAFO para el tratamiento del SDRA moderado a grave de comienzo temprano. Del ensayo participaron 548 pacientes distribuidos aleatoriamente para recibir VAFO o ventilación mecánica convencional.
El estudio debió ser interrumpido tempranamente luego de que un análisis provisional hallara que la VAFO podía ser perjudicial. La tasa de mortalidad durante la internación fue del 47% para el grupo con VAFO y del 35% para el grupo control. A su vez, el primer grupo recibió más vasopresores, sedantes y bloqueantes neuromusculares que el segundo. Como conclusión, los autores informaron que la VAFO resultó ser perjudicial para el manejo del SDRA en la práctica clínica.

Los resultados de los estudios OSCAR y OSCILLATE hicieron que mermara el entusiasmo por el uso de la VAFO en el SDRA. Aunque se ha postulado que el tipo de protocolo implementado, más que la técnica en sí misma, podría ser responsable por los malos resultados, hasta el momento no hay nada que avale su uso de rutina en la práctica clínica. Hacen falta más estudios para definir si la VAFO sigue siendo una alternativa válida como terapia de rescate.
Por último, se ha planteado si la oxigenación por membrana extracorpórea (ECMO, Extracorporeal Membrane Oxygenation) podría ser una opción viable en el SDRA. Esta técnica utiliza una tecnología de bypass cardiopulmonar a fin de brindar el intercambio gaseoso, y se emplea en pacientes con hipoxemia grave para asegurar una adecuada oxigenación y ventilación. Si bien los primeros resultados del uso de ECMO en pacientes con SDRA no han sido muy alentadores, las mejoras tecnológicas implementadas últimamente en esta técnica han llevado a un incremento en su aceptación.

El estudio CESAR (Conventional Ventilatory Support Versus Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure trial) se llevó a cabo en Inglaterra con el fin de evaluar la seguridad, eficacia y costo-efectividad de la ECMO en el manejo del SDRA grave. Un total de 180 pacientes con SDRA grave fueron distribuidos aleatoriamente para recibir ECMO o tratamiento convencional.
El criterio principal de valoración, es decir, la mortalidad o incapacidad grave a los 6 meses, ocurrió en el 37% de los pacientes del grupo que recibió ECMO y en el 53% de los del grupo convencional. Aunque sobrevivió un mayor número de pacientes del primer grupo, la diferencia no fue estadísticamente significativa. Asimismo, la duración de la hospitalización y los costos fueron significativamente mayores en el grupo que recibió ECMO. De todos modos, los autores concluyen que la ECMO parece mejorar las tasas de supervivencia en pacientes con SDRA por lo que señalan que, a medida que mejore la tecnología y se incremente la experiencia, esta técnica irá ganando aceptación como terapia para el SDRA grave.

Farmacoterapia en el SDRA
Una gran variedad de drogas ha sido estudiada en pacientes con SDRA; no obstante, la farmacoterapia efectiva aún sigue siendo extremadamente limitada para esta enfermedad.

Se sabe que la ventilación mecánica produce lesiones en el parénquima pulmonar, las cuales pueden exacerbarse debido a la asincronía respiratoria que se observa en los pacientes sometidos a este tipo de terapia. Teóricamente, los bloqueantes neuromusculares podrían minimizar la asincronía respiratoria, lo que brindaría un mejor control del volumen corriente en pacientes con SDRA y reduciría las lesiones asociadas con la ventilación mecánica. También se ha sugerido que el cisatracurium, un bloqueante neuromuscular, tendría un efecto directo sobre el nivel de inflamación pulmonar en pacientes con SDRA.

El estudio ACURASYS (ARDS et Curarisation Systématique) fue un ensayo aleatorizado que incluyó a 340 pacientes sometidos a ventilación mecánica por SDRA grave, cuyo objetivo consistió en evaluar el efecto del bloqueo neuromuscular dentro de las primeras 48 horas en dicha población. Los participantes fueron divididos aleatoriamente en dos grupos; un grupo recibió una infusión continua de cisatracurium por 48 horas, mientras que el otro recibió placebo. De acuerdo con los resultados del estudio, la tasa de mortalidad a 90 días fue más baja en el grupo que recibió el fármaco. La tasa de paresia adquirida en la unidad de cuidados intensivos no difirió significativamente entre los grupos.
En conclusión, la administración del bloqueante neuromuscular mejoró la tasa de supervivencia, aumentó el tiempo sin necesidad de ventilación mecánica y no incrementó el nivel de debilidad muscular. Si bien estos resultados aún deben ser interpretados con cautela, el cisatracurium parece ser un tratamiento promisorio para el SDRA moderado a grave, por lo que amerita ser investigado en ensayos controlados y aleatorizados más amplios a fin de confirmar estos hallazgos.

Otras drogas han sido estudiadas en pacientes con SDRA, entre las que se incluyen agonistas beta, estatinas, suplementos nutricionales, corticoesteroides, N-acetilcisteína y surfactante. En ningún caso se han hallado resultados satisfactorios. De hecho, un reciente estudio con salbutamol intravenoso en pacientes con SDRA ha debido interrumpirse en forma precoz dada la elevada incidencia de arritmias y acidosis láctica asociadas con la droga. Este hecho reafirma la necesidad de considerar cuidadosamente la farmacoterapia en enfermos críticos, así como de evaluar los efectos perjudiciales potenciales antes de introducir el uso de drogas en la práctica clínica.

Conclusión
El SDRA continúa siendo un desafío, tanto en su diagnóstico como en su tratamiento. La nueva definición de la enfermedad permite clasificar su gravedad según el grado de oxigenación del paciente. La ventilación mecánica en posición prona y el bloqueo neuromuscular utilizados en forma temprana en casos de SDRA moderado a grave han obtenido resultados prometedores, aunque aún quedan dudas sobre su aplicación en enfermos críticos. La VAFO no es recomendada como terapia primaria para el SDRA, pero podría ser considerada como terapia de rescate en pacientes con hipoxemia refractaria. También la ECMO podría considerarse una opción en casos de hipoxemia refractaria.

♦ SIIC - Sociedad Iberoamericana de Información Científica
Retrieved from: http://www.intramed.net/contenidover.asp?contenidoID=87084&uid=817594&fuente=inews

Introduction to the Brewing Process

2014-08-03T10:39:00.003-07:00

Laisy Almanza
Pre-Med Student at USFSP
Due: July 25^th, 2014
Even though beer was brewed from the earliest colonialtimes the lager style of beer was widely introduced by German immigrants and due to the lighter color and flavor profile became the dominant American choice by the mid 19th century and for this reason most people believe that beer started in Germany (Murray, 2009). The number of small specialty brewers in the U.S. has augmented dramatically since 1980. This sea change is linked to President Jimmy Carter’s signing, in 1976, of legislation allowing home brewing, though it is still illegal in some states and In 1997 the number of U.S. breweries exceeded that of Germany. Surprisingly craft beer has become a five billion dollar annual market (Murray, 2009). The majority of people who drink beer think of it as a simple alcoholic beverage they buy at the liquor store to enjoy at any gathering with family, friends, or both. However, they usually don’t stop and think about how it is made or how long it may take to make each batch especially in a microbrewery. Many also don’t stop and consider the microbiology, chemistry, and the scientific steps involved in the entire process of brewing or how important quality assurance is throughout each step. Each batch made is analyzed thoroughly so that it not only tastes its best but also has nothing that should not be there. Every aspect of the beer is observed and measured from the alcohol content to bitterness and even the pH and oxygen content. It is an extremely complex process but it can be simplified so that people who truly enjoy their beer can understand the method behind it. Only true beer lovers will enjoy understanding the difference between the color, taste, smell, etc. of each particular beer and once they know the difference they will be able to differentiate between a truly good beer and it probably won’t be the one they always considered the best. Brewers take their jobs very serious and really attempt to make the best product. Some brewers choose to not send their product overseas simply because of its shelf life, or how long it takes for it to loose it’s special characteristics, and its quality even though this may mean a loss of income and expansion. Beer is made from four crucial ingredients: water (90% of beer is water), fermentable sugars (malted barley), hops and yeast. With the right settings, the yeast will ferment the fermentable sugars to alcohol, carbon dioxide and the taste we know as beer. Once the beer is bottled it can be aged anywhere from a week to 3 months depending on the style of beer the brewer wants to make. Of course there are other optional ingredients that can be added to the beer to make it unique such as sugars (white or brown), syrups, honey, other sweeteners, fruits, vegetables, grains, herbs and spices, and many others like chocolate or coffee.

Malted barley is a naturally processed form of barley, which is a grain similar to wheat in appearance. A “maltster” will steep the barley in water until it begins to sprout under certain conditions. The germinated barley is then dried and once the drying is complete the barley is officially malted. During this procedure, sugars, soluble starches and characteristics in the barley desirable for brewing beer are developed. The malt is mostly converted to sugars through a process called mashing where the malt is submerged in water at precise temperatures that allow enzymes in the barley to convert starches to sugars. These sugars are converted to alcohol, carbon dioxide and the flavor of beer through fermentation as stated before. The liquid extracted from the mashing process is known as wort. Some brewers choose to substitute corn, rice, wheat, rye, or other grains for a portion of the malt because although the fermentable sugars created from the starches of these grains will ferment through the same process as the malt sugars do, they will add their individual fermented character to the beer. This is used mostly to lighten the taste of the beer (Briggs, 1971).

For home brewers there are malt extracts available so that they do not have to go through the process of malting the barley or even mashing the grains. The malt extract is malted barley that has been processed into a sweet malt soup. Then, depending on if the brewer wants moist or dry malt, 70-80 percent of the water is evaporated to give a concentrated syrup or all of the water is evaporated to give a dry powder. There are also many malt extracts and home-brew kits that have different hop flavors so that the home brewer can add that floral taste unique to hops just as breweries do to their beer. All that would need to be done by the home brewer is to add water and yeast, which is sometimes also provided in the kits (Papazian, 2003).

As hops are considered primarily as a flavour ingredient for beer, with the added benefit of having anti-microbial effects, hop research is focused on hops as a bittering agent, as an aroma contributor and as a preservative (Schönberger & Kostelecky, 2011). Hops have been used in making beer for approximately 200 years (Filmer, 1982). It is important to remember that hops are conelike flowers of the hop vine and because of this add a floral aroma along with their bitterness. Unfortunately, because of this same reason they are perishable (Lewis & Young, 1995). The sweetness of malts is balanced by the hop’s bitterness. Hops can also extend the life of the beer and can improve head retention, which is why brewers consider hops extremely important. It is important to understand the biochemistry of hops and how it can interact with the beer making process. Hop's produce Lupulin glands, which are tiny capsules containing resins and oils that become the major contributing factors through the brewing process. The hop oils provide the floral flavor and smell while the resins add to the bitterness of the beer. Hop oils should be used scarcely and can be added at many stages of the brewing process either at the end of boiling, during or after fermentation or even just before packaging (Lewis & Young, 1995).

Even though it may seem unimportant, the water you use for making beer is also very important especially for home brewers because it will add its character to the beer as well. It is important to make sure that the water tastes good and that it does not contain any excess chemicals or minerals because they will change the taste of the beer. It is also important to use potable water in breweries so that the microbial growth can be minimal.

In my opinion the most important ingredient in the brewing process is the yeast. Yeast is responsible for converting the bittersweet “tea” made from the fermentable sugars and the hops to the alcoholic beverage known as beer. Yeasts are living microorganisms that use sugar as food for their life cycle. Yeast can grow aerobically (respiration) or anaerobically (fermentation) but only the anaerobic process is used in beer production. Unfortunately, even though there are thousands of unique yeasts in the world, most of them are wild yeasts, which will result in the production of some very unique brews that aren’t always very delightful to taste. Wild yeasts not only cause odd savors but also overflowing, over carbonation, haze development and all kinds of indescribable fermentation features. In general there are two types of yeast used in brewing. These are lager yeast and ale yeast. Lager yeasts ferment at cooler temperatures and generally yield a much cleaner tasting beer with fewer esters while ale yeasts tend to yield a beer with fruitier esters. There is much more diversity among ale yeasts than lager yeasts. Ale yeasts (Saccharomyces cerevisiae) are said to be “top-fermenters” because during the beginning of fermentation period they tend to flocculate on the surface of the beer while lager yeasts (Saccharomyces carlsbergensis) are said to be “bottom-fermenters” because they flocculate and sediment at the bottom of the tank. Both of the yeasts are broken down again into groups of strains (Papazian, 2003).

The cooled wort obtained from mashing of the malted barley is fermented by yeast to make an immature beer also known as green beer. The main fermentation, in which this green beer along with the yeast is produced, is followed by a slower process at a lower temperature and with less yeast also known as secondary fermentation or maturation. Secondary fermentation is the process of keeping green beer in contact with yeast after the primary fermentation has ended. For the yeast to live and grow successfully the wort must contain sufficient amount of nutrients. Yeasts need very specific conditions and nutrients to be able to flourish as needed to for the brewing process. For example, they need fermentable carbohydrates, assimilable nitrogen, molecular oxygen, biotin, sources of phosphorus and sulfur, calcium and magnesium ions and trace elements such as copper and zinc ions. Some worts can be enhanced by adding certain trace elements or other nutrients needed for the yeast to grow successfully. Another important parameter for the wort is the dissolved oxygen content because the molecular oxygen requirement is different for certain yeasts. Enough molecular oxygen has to be supplied at the beginning of fermentation but once this is done then no more is needed and anaerobic conditions are established and essential to prevent detrimental oxidation reactions that can spoil the beer. The quantity of oxygen is inversely proportional to the specific gravity as well as the temperature. Too much oxygen results in too vigorous fermentation and excessive yeast growth and too little cause accelerated loss in yeast vitality and viability. Even on wort, yeast must be induced to produce the maximum amount of alcohol and have the minimum amount of growth. This is done by restricting the availability of oxygen and using lower fermentation temperature than those preferred by the organism.

As stated earlier secondary fermentation involves keeping the green beer in contact with the yeast after primary fermentation in ended. An advantage of doing this is that any oxygen which gains access will be absorbed instantaneously by the microbe. Once the yeast is removed then the brewer must be careful and make sure that oxygen does not enter and touch the product. Maturation most often involves the gradual lowering of the temperature and giving enough time so that the yeast can settle out or flocculate and chill haze particles can form. This waiting period is called lagering or aging as mentioned earlier. This process can be expansive and many brewers rather accelerate this process. Brewers can accelerate the formation, prevent the formation, or accelerate the removal of the chill haze that usually forms during maturation. The formation of these particles is catalyzed by molecular oxygen and controlling it can help accelerate its formation or simply stop its production.

Once pitched into wort, yeast uses the nutrients in the wort to provide energy (ATP) and in the process produces alcohol and carbon dioxide. This process also produces reducing power (NADPH) for the synthesis of new yeast substance. The nutrients can also be directly assimilated into new cell components or used to generate intermediates for this process. In addition, these energies lead to the synthesis and secretion into the work of a large number of minor metabolic products, which can add special features savors and scents (Lewis & Young, 1995).

The production of beer includes not only fermentation but glycolysis as well. It is extremely important to understand all biochemical pathways involved in brewing so that the complexity of the beer making process can be appreciated. First of all a biochemical pathway is recognized as a serious of reactions, each mediated by an enzyme in which the product of one reaction becomes the substrate of the next. Pathways whose purpose is to make energy chemically oxidize their substrates normally achieved by transferring a hydride ion to an enzyme cofactor. This oxidized cofactor NAD⁺is converted to NADH (reduced form). Dehydrogenase enzymes conduct the oxidation-reduction reactions. Because energy is released through oxidation, the reaction is controlled so that some of the energy released is held by the cell in the form of ATP (adenosine triphosphate).

ADP + inorganic phosphate (P_i) à ATP

The reaction above consumes energy and is driven by high-energy compounds formed during metabolism and the inverse reaction (hydrolysis of ATP) releases energy which can be used to synthesize new products. The source of the heat rising during fermentation of the wort comes from the fact that energy transfer reactions are never 100% effective and waste energy is always dispersed. Usually sufficient waste heat is formed to increase the temperature of a lagged vessel about 17°C and this heat must be removed by cooling. Glycolysis (figure 1), which is an important pathway in the brewing process, is said to be amphibolic. This means that it can have both catabolic and anabolic functions.

Figure 1. Simplified Process of Glycolysis

The fermentable sugars in brewer’s wort are maltose, maltotriose and smaller amounts of sucrose glucose and fructose. The trisaccharides are transported into the cell and hydrolyzed to glucose while sucrose is hydrolyzed outside the cell to glucose and fructose then transported into the cell. The enzyme invertase is located in the outer layers of the cell wall however some leaks into the beer but fortunately is quickly deactivated by heat. The glucose located inside the cell is phosphorylated using ATP by the enzyme hexokinase to yield glucose 6-phosphate while fructose is phosphorylated to yield fructose 6-phosphate because subsequent enzymes recognize only phosphorylated compounds. The metabolism of glucose proceeds by the glycolytic pathway that contains 10 enzymes that oxidize the six-carbon sugar to two molecules of pyruvate and through this process two molecules of ATP and two of NADH are gained (Lewis & Young, 1995).

The job of a brewer is to combine all of the ingredients discussed and pursue fermentation, which lasts 10 days to several months depending of the beer style. During this time the yeast will reproduce and disperse throughout the fermenting beer while converting sugars to carbon dioxide, alcohols, a variety of flavors. The yeast will have run through its supply of sugar and will began to settle at the bottom of tank, or other fermentation vessel, after the initial 5 to 14 days. Most brewers will transfer the clear beer top layer to a different tank and once the fermentation process is over the beer is packaged in the designated bottle, can, or keg. Some breweries choose to filter the beer for preservation purposes as well as some economic reasons but some breweries prefer to not do so because it may take some of its special character away along with the things being filtered out.

The fermentation temperature and quality of the yeast will determine how long the beer should be aged or if it should be done at all. Beer made with Ale yeast and with a fermentation temperature above 65 degrees Fahrenheit will be ready for bottling in about 2 weeks more or less. If the beer is made with very high quality lager yeast and a fermentation temperature below 45 degrees Fahrenheit, then aging can be advantages (Papazian, 2003).

One of the most important things to avoid during the brewing process is the growth of unwanted organisms. The science of microbiology involves the study of organisms less than 1 mm in size. Prokaryotes, which have no nucleus, as well as eukaryotes, which do have a nucleus, are both important in the brewing process but for very different reasons. Prokaryotes are the main concern when beer spoilage occurs. On the other hand eukaryotes are divided into lower and higher eukaryotes and the lower group includes the brewing yeast, wild yeast, and other fungi or molds. Unfortunately microorganisms are found anywhere if the right nutrients and other conditions are present even in air. For example, acid-tolerant bacteria are capable of surviving in beer because they can grow in the absence of oxygen and given the right nutrients will grow perfectly in an acidic anaerobic environment. It is very important to make sure that the brewer does not provide the right environment for these organisms to grow because they may be detrimental to the beer and the person who drinks it. The brewer’s job is to monitor their equipment and product for the appearance of any unwelcome microbes. This can be very difficult because microbes survive best in places where water is abundant and water, malt and cereals, sugars and hops all provide a good environment for microbes to flourish.

Microbes found in brewing are usually gram positive, gram negative, or simply wild yeast. The most important members of the gram-positive group are lactic acid bacteria, Leuconostoc, streptococcus, micrococcus, and Bacillus. The ones that have become the greatest concern to brewers are the lactic acid bacteria specifically Lactobacillus and Pediococcus because they are found most often and can spoil the beer by making it more sour, turbid and producing diacetyl which gives an unwanted smell and flavor. Pediococcus is encountered more often than Lactobacillus but fortunately they can both be isolated using the same type of media.

The gram-negative bacteria include Enterobacteriaceae, acetic acid bacteria, Zymomonas, Pectinatus, and Megasphaera. Enterobacteriaceae for example, which is a bacteria encountered if poor cleaning methods are used, can spoil the beer by affecting the wort and growing quickly producing dimethyl sulfide and diacetyl. If they affect the beer during the beginning stages of fermentation they can produce an unwanted taste in the beer or even decrease the growth of the yeast (Lewis & Young, 1995).

Like stated earlier, wild yeasts can give an undesirable taste and aroma to the beer. Any yeast that is not considered a brewing strain is said to be a wild yeast. Unfortunately wild yeasts can become a huge problem specifically cause they are extremely hard to detect and are not as easily removed. They can really change the taste of the beer if they affect the beer in early stages as well as make it cloudier in appearance.

During the brewing process it is important to take certain readings and make specific observation such as temperature, specific gravity, pH, cell count, etc. A hydrometer is an instrument used to measure the density of a liquid relative to the density of water. This is also known as the specific gravity. Because the density of water was determined to be 1.000, it is known that the density of the beer will be higher because of all of the components added to the water. In result the specific gravity will also rise to about 1.035 to 1.042. Once the yeast begins to ferment the dissolved sugars into alcohol and carbon dioxide, the density will begin to decrease because of the reduction in sugar content and also because alcohol is less dense than water. A digital gravity meter can also be used to measure the specific gravity of samples taken from tanks in the laboratory setting.

The common media used to determine what organisms are growing in the beer are Mac Conkey agar used to detect coliforms, Plate count agar/PCA used to detect all forms of bacteria, Walerstein nutrient medium/WLN used to detect all forms of bacteria, Schwarz differential medium used to detect only wild yeast, Lysine medium used to detect only wild yeast, and Raka Ray medium which is an anaerobic medium (LinkedIn, 2014). Other media used include LWYM (Lin's Wild Yeast Medium) used to detect saccharomyces wild yeast, LCSM (Lin's Cupric Sulfate Medium) used to detect non-saccharomyces wild yeast, HLP (Hsu's Lactobacillus/Pediococcus Medium) used to detect the growth of Lactobacillus and Pediococcus and WLD media used to detect all bacteria and wild yeast while impeding the growth of brewer’s yeast. To plate the beer samples on each of the media the membrane filtration method or the spread plate method can be used and then they are either incubated aerobically or anaerobically. Finding Saccharomyces species is very important because 3 of 11 killer yeasts are displayed within the Saccharomyces genus. These killer yeasts produce toxins that are lethal to other yeast strains and they are immune to toxins themselves (Hammond & Eckersley, 1984).

Some of the tests and measurements commonly used in the laboratory setting for quality assurance are the international bitterness unit (IBU) test, pH test, gravity test measured in degrees Plato (density of beer wort in terms of percentage of extract by weight), cell counts/viability, and standard reference method (SRM) test. The IBU test simply measures the bitterness of the beer, which is usually caused by the hops added. The pH of the beer usually starts to increase when the beer is almost ready because of this it is important to measure the pH everyday until it is constant or begins to increase. The original gravity is the gravity of the sample before yeast is added and the final gravity is that which is measured when the beer has finished fermenting. The original gravity of wort is important because it has been shown that as it increases the ethanol concentration of the beer coming out increases as well (Dragone, Mussatto, & Almeida e Silva, 2007). This can produce unbalanced flavor in the beer, which can be undesirable. The gravity will decrease as the beer finishes off because the yeast will have fermented most if not all of the fermentable sugar to alcohol, which is less dense than water. The SRM test is used specify beer color by measuring the attenuation of light at a particular wavelength (430 nm) when passing through 1 cm of the beer and is done by using a spectrophotometer. The purpose of taking cell counts is to determine the concentration of cells per mL of beer and the viability simply shows how effective or viable the yeast in that sample is. The cell count should decrease towards the end of the brewing process and the viability should always be close to or at exactly 100% although it might be slightly lower when the yeast is first pitched in. If the viability is low than there is definitely something wrong and this should be checked immediately. Checking for all of these measurements is extremely important so that the beer is at its best quality possible and no money is lost by having to dispose of an entire tank of beer simply because quality control was not adequate.

All in all it is extremely important to follow all quality assurance protocol so that large quantities of beer are not lost by contamination or any other reasons. Microbes are everywhere and avoiding their contact with the beer is vital. Knowing ways to detect or prevent contamination is one of the most significant attributes of any brewery or homebrewer. Understanding the importance of all the ingredients included in the brewing process from the malt to the hops and even the type of yeast and water used is very pertinent in beer making because only through this comprehension will you understand why they are added at a certain stage of the process and not others. Each and every ingredient provides some character to the beer and all of them together in the right amounts will make the perfect beer. Whether someone is brewing at home or for a large Brewery this paper can help understand the basics of the beer making process

Bibliography

Briggs, H. S. (1971). Malting and Brewing Science . New York : Chapman and Hall.

Chemists, A. S. (2014). Methods of Analysis. Retrieved July 2014, from http://www.asbcnet.org/MOA/toc.aspx

Dragone, G., Mussatto, S. I., & Almeida e Silva, J. B. (2007). High Gravity Brewing by Continuous Process Using Immobilised Yeast: Effect of Wort Original Gravity on Fermentation Performance. The Institute Of Brewing , 113 (4), 391-398.

Fix , G. (1989). Principles of Brewing Science . Boulder , Colorado: Brewers Publications.

Filmer, R. (1982). Hops and Hop Picking . Aylesbury : Shire Publication.

Hammond, J. M., & Eckersley, K. W. (1984). Fermentation Properties of Brewing Yeast With Killer Character. The Institute of Brewing , 90, 167-177.

Lewis, M. J., & Young, T. W. (1995). Brewing . London : Chapman & Hall.

LinkedIn. (2014). Microbiological & Analytical Techniques in Quality control of Beer. Retrieved July 2014, from SlideShare: http://www.slideshare.net/sini_jince/microbiological-analytical-techniques-in-quality-control-of-beer

Murray, D. W. (2009). Home Brewing And Serious Leisure: An Empirical Evaluation. Publication Manual of the American Psychological Association, 5th Edition , 1-117.

Papazian, C. (2003). The Complete Joy Of Homebrewing, Third Edition. New York, New York : HarperCollins .

Schönberger, C., & Kostelecky, T. (2011). 125th Anniversary Review: The Role of Hops in Brewing . The Institute of Brewing & Distilling , 117 (3), 259-267.

Rabin, D., & Forget, C. (1998). The Dictionary of Beer and Brewing, 2nd edition. Boulder, Colorado: Brewers Publications.

THE QUESTIONING LEADER

2014-02-06T07:58:00.001-08:00

The ability to listen and question are two invaluable skills to the effective leadership. How many managers do you know who are good of then? Fortunately is possible to strengthen listening and questioning.

We going to explore these skills through different prospect

Ø Strategies for questioning

Ø Effective question

Ø Leadership through listening

Good listening and questioning techniques can improve collaboration among employees. We can get employees to work together by asking question that encourage them to collaborate with each other.

Effective questioning and listening skills provide data that is essential to business strategies. Many employees know more than they’re able to verbalize. A good leader can elicit information that helps everyone see the most important facts and the impact they have on a situation.

Leader who listen and question encourage employees to experiment and be creative. When leaders are willing to ask questions they don’t know the answer to, they encourage to employees’ experimentation and creativity.

Knowing how question and listen can educate both yourself and other. The smartest people are those who know how to listen and ask the right question, by using these skills, they can find out anything.

The different between manager and leadership is the ability to give people direction when are telling what to do, these is accomplish of listen and question.

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COMMUNICATION AND LEADERSHIP

2014-01-28T09:53:00.000-08:00

Essential elements on leadership communication

Ø Achieving clarity in communications

Ø Maximizing the use of questions

Ø Transforming conflict into progress

Ø Maintaining high performance

Good Communication Strategies

Ø Understanding the concerns of the other person increases your effectiveness.

The most effective way to communicate with others is to understand their perspectives on the issues you’re discussing.

Ø Avoiding repetition of your message eliminates boredom and keeps your massage fresh.

Repeating your message in different forms can ensure the clarity of your position.

Ø Leader who know how to listen and question are better able to tell employees what to do.

Listening and questioning allow leaders discover the details about how their organization works, thus improving their ability to give direction.

Ø Maintaining quality standards can help leaders determine when there are performance problems.

Without quality standards, there is no way to measure the consistency of your product or the effort of your employees.

Ø Employees should feel free to vent their frustration in group meeting.

It’s important that employees feel OK about expressing their concerns and venting frustrations in group setting; otherwise, resentments build up.

Ø Leaders should listen more than they talk when meeting with subordinates.

Leaders who listen to their subordinates more than they talk will learn more about what is going on than they would if they dominated the conversations.

Ø Following up on message you’ve sent can be viewed as intrusive by their receiver.

Because message sometimes get lost or are misunderstood, it’s important to follow up and make sure they were properly received.

Ø Using the grapevine can be a destructive way of communication with group.

The grapevine, or informal person-to-person means of obtaining information, can be positive or negative, depending on how it’s used. And, since it’s not about to go way you should use it to clear up misunderstanding.

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COACHING FOR SUCCESS

2014-01-23T10:56:00.001-08:00

In this brief review we will learn a few simple tools that will we able to conduct and participate in effective coaching situation, in addiction we’ll learn a few easy coaching tips and review a number of different coaching scenarios.

§ What is coaching?

§ What is feedback?

§ Why is this important?

§ Effective tips

§ Listening skill

§ Coaching scenarios

To beginning let’s thinking about a definition of coaching, in a simple term coaching is defined (2014 Merriam-Webster, Incorporated, 2014) as:

Coach (Kōch) is defined as:

1. To instruct, direct, or prompt as a coach.

2. To train intensively (as by instruction and demonstration).

3. To act as a coach.

Effective coaching also depended on the ability to give and receive proper feedback, it is an essential component of coaching.

Feedback (‘fēd-bak) is defines (2014 Merriam-Webster, Incorporated, 2014)as:

1. The transmission of evaluative or corrective information about an action, event or process to the original or controlling source.

In order for us to learn how to be an effective coaching we must also master the tools of effective feedback.

Why is this important?

So why are coaching and feedback essential tools for leaders?

Coaching and feedback are essential because across the globe a lot of employees in your organization depend on you for leadership, each and every day; you are the connection between our employees and our future (organization’s future).

Before we can be an effective coach, we must understand the purposes of coaching and feedback, the four main purposes of coaching and feedback are:

§ To reinforce desired behaviors and results

§ To redirect undesired behaviors and results

§ To develop our employees skills and competencies

§ To motivate our employees to continue positive performance

Well, we now know the importance of coaching and feedback, it is also important to know when to provide effective coaching. We should of try to find teachable moment with our employees and use coaching on a number of different scenarios such as:

· Informal, day-to-day situations

· At the start of a project

· During a project

· During a performance review

· Each and every day

We have all benefited for effective coaching through our personal and professional live, take a moment and thinking a time when you were the recipient of effective coaching: What characteristic did this person display?

As you thought about an effective coach he/she probably…

· Base their coaching on trust

· Remain positive about other people

· Give people the opportunity to take risk and learn

· Listen more than they talk

· Be patient

· Speak candidly, but effectively

· Be personally accountable

· Know their strengths and limitations

· Be continuous learners

The Keys to Effective Coaching include:

· Provide positive recognition in a timely manner

· Confront poor performance immediately

· Help other learn from mistakes

· Focus feedback on behavior

· Recognize efforts and results

· Serve as a role model

· Encourage continuous improvement

All these attributes will make you a better coach to the employees you lead.

Let’s turn on attention to feedback, we all probably know that are two main type of feedback: Positive Feedback and Constructive Feedback.

Ø Positive Feedback: it is the praise and recognition for a job well done

Ø Constructive Feedback: it is the feedback focuses on helping correct a problem or situation.

Both type of feedback are crucial component of an effective coaching section. We all have strength and development opportunities, as we known coaching section are focuses on those thing are doing well and indentifying those thing that we need to correct.

To aid you in given feedback there is a very simple 4 step model, that you can try on your next feedback and coaching section, when you practice it will come it naturally.

4-Step Feedback Model

1. Describe what happened

2. Describe the positive impact

3. Check for understanding and get the other’s views

4. Describe what you want to happen

Too often we as a leader made some common errors on coaching and feedback situation, these errors include:

· Spending too much time with poor performers

· Spending equal time with everyone

· Ignoring top performers

· Coaching only when there is a problem

· Training used as a substitute for coaching

Make sure that you try to avoid these common coaching errors, practice make perfect, and you will quickly come to realize that your coaching need to be base on the individuals need of each of your employees.

Through all this training session we had learned some very good tip and technique for coaching and feedback. To summarize what we learned so far great coaching and feedback should:

· Provide both positive and constructive feedback

· Focus on behavior not personality

· Make it timely

· Give a little at a time

· Be creative, but sensitive

· Document and maintain notable performance examples and feedback

One of the skills you will master quickly in any coaching and feedback session is that of effective listening.

Remember:

· A coaching session is a two way dialogue

· A coaching session involves active listening skill

· Some important listening skills include:

Attending: Eye –contact

A non-distractive environment

Following: Minimal encouragers

Infrequent questions

Reflective: Emphasizing with feelings

Para-phrasing

Summary:

ü Coaching is a critical part of your job

ü There are some simple tools and techniques that you can use with our employees

ü Our employees want to know how they are doing

ü Our employees want to do a good job for our company

ü You are a role model for the people working around you

ü Look for opportunities to provide coaching each and every day

ü Be sensitive, but candid

ü Practice attentive listening

ü Provide both positive and constructive feedback

ü Effective coaching takes practice

retrived from: http://berryplastics.skillport.com/skillportfe/main.action?content=home

MULTIPLE MYELOMA

2013-11-19T11:30:00.001-08:00

Clinical

Average age is 60-70
Men much more common than women
Most have an elevated serum protein with 80-90% in the globulin fraction, especially IgG
Bence-Jones protein in 40-60% of patients (light chains)

X-ray findings

Osteoporosis is most common skeletal abnormality in this disease
Lesions are usually multiple and found in vertebrae, ribs, skull, pelvis, and femur
Over 50% of solitary lesions are found in vertebrae
Mandible involved in 1/3 of patients with diffuse involvement
Widespread lucencies in bone
- Discrete, “punched-out” lesions
- Uniform in size
Distinctive to MM are the lucent, elliptical, subcortical shadows, especially in long bones=endosteal scalloping
- Due to buttressing since MM is usually a slower process than mets
In spine, MM destroys body and spares pedicle

DDX: mets and disuse osteoporosis

MM is more widespread
More discrete holes in MM
Large foci of coalescence more often due to mets
Severe disuse osteoporosis may simulate bone changes of MM

Sclerosis is usually seen only with treatment or fracture

Bone scans may typically be negative and many hot areas on scan may be healing fractures

Most believe that almost all patients with a solitary plasmacytoma will develop multiple myeloma

Solitary plasmacytoma produces “soap-bubbly” expansile, septated lesion, when characteristic

Multiple myeloma . The pelvis contains numerous lytic lesions without reactive sclerosis which
have an almost "soap-bubbly" appearance in the ischia. There are also lytic lesions in
both proximal femora.

Other examples of Multiple Myeloma (Click on each to enlarge)

retrieved from: http://www.learningradiology.com/archives06/COW%20223-Multiple%20myeloma/mmccorrect.html

ERGONOMIC IN THE WORKPLACE

2013-11-14T12:16:00.001-08:00

Each year, employees miss work and potential wages due to work-related musculoskeletal disorders (MSDs). According to the Bureau of Labor Statistic (BLS), 335,390 American workers experienced MSDs serious enough to require time off work in 2007.

In fact, injuries to the muscles and skeleton are among the most common lost time illnesses and injuries in virtually every industry.

Musculoskeletal disorders occur when there is a mismatch between what your job requires you to do and what your body is capable of doing. MSDs can affect worker in job activities across many diverse workplaces and tasks.

The Institute of Medicine estimates that the economic burden of MSDs in the workplace, as measured by compensation costs, lost wages, and lost productivity, are between $45 and $54 billion annually. Historically, overexertion, one form of MSDs, is the number one cause of workplace injury.

In 2007, there were 1,2 million MSD cases requiring days away from work in private industry out of 4 million total recordable cases. Of these, 335, 390 cases required an average of nine days away from work, two more days than the average for all days away from work cases.

Because of statistics like these, ergonomics has become an important and serious issue for industry.

The term “ergonomic” is derived from two Greek words: “erg” meaning work and “nomas” meaning natural laws.

Basically, ergonomics is the science of adjusting job conditions, equipment, and tasks to match the body’s natural ways of functioning.

The goal of ergonomics is to prevent illness and injury, assure high productivity, and promote satisfaction in the workplace.

In the absence of a federal ergonomics standard, the Occupational Safety and Health Administration (OSHA) has addressed ergonomics in the workplace under the authority of section 5 (a)(1) of the Occupational Safety and Health Act.

This section is referred to as the General Duty Clause and requires employers to provide work and a work environment free from recognized hazards.

Many employers have realized that the implementation of an ergonomics program is in their best interest for the reduction of injuries and illnesses.

An ergonomics program addresses some basic elements such as employers and employee responsibilities, hazards identification and information, job hazard analysis and control, training, medical management, records, and programs evaluation.

Your company’s ergonomics programs is designed to help keep you healthy, productive and motivated while making your working life as enjoyable as possible.

Your company can express its commitment in a variety of ways. These include holding employee meeting to discuss ergonomics operational goals and priorities that are firm, achievable, and in line with cost reduction, productivity, and quality initiatives.

In addition, your employer may commit resources to training, administrative needs, expertise, and ergonomics improvements or issue policy statements that define support and cooperation from management, supervision, and employees.

Musculoskeletal Disorders (MSDs) definitions: Are disorders of the muscles, ligaments, tendons, cartilage, joints, nerves, or spinal discs that have been diagnosed by physical exam, medical history, or specific medical test.

They typically result from gradual or chronic development, as opposed to an acute event or injury caused by, for example, a slip or fall. MSDs like carpal tunnel syndrome have very distinct signs and symptoms. Other disorders, such as lower back pain, are simply defined by the location of the pain.

To better understand ergonomics, you should be familiar with the major parts of the musculoskeletal system:

Ø Bones: Provide structural support and are connected to one another at joints, which allow movement between body segments.

Ø Muscles: Contract and shorten, causing movement, just contract to provide stability. The respiratory and circulatory systems supply nutrients and oxygen necessary for movement of muscles.

Ø Ligaments and tendons: ligaments connect bone to bone and provide stability at the joints, while tendons attach muscle to the bone.

Ø Cartilage: Provides the joints with low friction surface that help with movement.

Ergonomics Awareness

Recognizing the early signs and symptoms of injuries to the muscles and skeleton and reporting them as soon as possible is very important. A health care provider (HCP) can observe the signs. Symptoms, however, are subjective and a patient needs to report them to HCP.

Signs of injury to the muscles and skeleton include redness or loss of color, swelling, loss of function, deformity such as a lump, decreased range of motion, and decreased grip strength.

Symptoms are your body’s way of warning you that you may be developing an injury. Symptoms of injury to the muscles and skeleton can vary in severity, depending on the amount of your exposure.

Eventually the symptoms become more severe as exposure continues and will appear even after rest. The pain may increase to a point where it becomes difficult to perform your work or even to a point where you are unable to perform any physical work activities.

Examples of symptoms of injury to the muscles and skeleton include numbness, burning, tingling, aching, pain or soreness, stiffness, and cramping.

Early reporting is vital in preventing or minimizing injury to the muscles and skeleton. As an employee, you must feel free to report any signs or symptoms of physical discomfort as soon as possible to your supervisor or other personnel, such as a plant nurse or HCP.

Employers can also gather information by conducting symptoms surveys and interviews.

Risk Factors

The OSHA has identified a high rate of injury among workers in various industries. It is impossible to determine the exact weight lifted or the number of repetition that will either cause or prevent injury.

However, establishing a systematic approach to address such issues as repetition, excessive force, awkward posture, and heavy lifting reduces the chance that you may ne injured.

Identifying risk factors in the workplace, before injuries to the muscle and skeleton are discovered, is an important step in keeping you healthy.

Your employer can use several methods to detect risk factors, such as interviews with workers and supervisors, and walk-through observations of the workplace.

A more formal approach would be to use a standardized checklist to evaluate job tasks against risk factors.

There are many different types of risk factors for injuries to the muscle and skeleton, some of which are not entirely work-related.

Risk factors for work-related musculoskeletal disorders are cumulative and can include off-work activities as well. Physical limitations, previous injuries, or existing health problems can contribute to increased risk.

It is often difficult to determine the impact that work activities versus non-work activities (sport or medical conditions such as rheumatoid arthritis, diabetes, and thyroid conditions) have on the disorder.

For example, in the general population, non-work causes of lower back pain are probably more common than workplace causes.

When jobs have risk factors in combinations and high levels, the risk of developing a musculoskeletal disorder will increase. The level of risk also depends on the intensity, frequency, and duration of exposure. Examples of risk factors include repetitive, forceful, or prolonged exertion and pushing, pulling, or carrying heavy objects.

Risk factors (Actions)

· Repetitive, forceful, or prolonged exertion

· Frequent or heavy lifting

· Pushing, pulling, or carrying of heavy objects

· Prolonged awkward postures

· Work in the cold

· Insufficient pauses and rest breaks for recovery

Risk factors (Conditions)

· Contact stresses

· Machine-paced work

· Stress

· Unfamiliar or unaccustomed work

· Vibration

Gathering data is a vital step toward the identification of a problem. Checklists can be used to provide the initial identification of a job or task which may put a worker at risk for developing an injury to the muscles or skeleton.

It is important to understand that the checklist findings must be viewed as a whole to determine if the individual problems suggest the same underlying root cause.

Control Methods

Many employers provide engineering controls, such as lift-assist equipment, that go unused or under-used as the employees hurry to complete their tasks.

Engineering controls reduce or eliminate the condition by modifying or redesigning workstations, environmental conditions, tools and equipment, processes, or materials.

For instance, a situation was reviewed in the electrical industry, where tasks included hammering, crimping, wrapping, winding, soldering, painting, and various electric motor assemble operations.

Problem: risk factor involved in these types of tasks included repetitive and forceful exertions, awkward postures, and contact stress. Workers were found to suffer from upper limb and neck illnesses and injuries.

Solutions: included raised standing surfaces, a modified mallet handle, and low force clamps. Job rotation, training programs, and early reporting were also needed.

Workstation should be adjustable to fit your body. Furniture and equipment should be positioned to prevent excessive twisting, reaching, and leaning.

Eyes: Computer monitors should be placed so that the top of the screen is just below eye level.

Arms and back: Chair should have adjustable armrests to take the load off your neck and shoulders. Chair should have back rests that fit your back.

Knees and feet: Chair should ne adjustable to allow your knees to be bent at a right angle. Chair should be adjustable to allow your feet to rest flat on the floor. Footrest may be used.

When your finger are on the keyboard, your wrist should be straight in a neutral position with the upper arm vertical and the forearm at a 90 degree angle to the upper arm.

Your shoulders should be relaxed and your elbows close to your sides. Reclining and reaching should also be avoided.

When using the mouse, you should be able to maintain the correct arm and wrist position. The mouse should be at the same levels as the keyboard and the same distance from your body as the keyboard.

Administrative controls are changes in the workplace that adjust work practices, procedures, and management policies.

Specific examples include rest breaks, alternative tasks, slower work pace, redesign of work methods, and employee rotation.

Consider his example of an office work setting. Management reviewed an office environment that involved primarily data entry and tasks involving video display units.

Problems: risk factors identified from these tasks included repetitive exertions, awkward postures, glare, and poor illumination. Personnel experienced problems with upper limbs, neck, back, and eyestrain.

Solutions: included reduction glare and improving workstation design. A vision test program and a rest break schedule where also suggested.

You would use personal protective equipment (PPE), such as gloves, to reduce vibration and prevent injury.

Always use engineering control s first if possible, followed by administrative controls. Use PPE only as a last resort.

Studies show that wearing a back belt does not reduce injury rates or the number of lost work days. However, wearing a back belt and having training on lifting techniques may reduce lost work days for people who have had lower back pain in the past.

Because musculoskeletal disorders involving the back are among the most costly occupational injuries, it is important to review back safety and some basic techniques for prevention of back injuries.

These techniques include good posture, proper lifting, and the practice of basic exercises, such as stretching.

To evaluate your posture, stand with your back against a doorframe and slip your hand between the doorframe and the small of your back. Your hand should slide in easily and slightly touch your back and the doorframe.

When possible, plan jobs to avoid unnecessary lifting. Improper lifting, especially when combined with twisting, is the most common way to injure your back.

Correct posture: Place feet firmly apart with one foot forward for stability. Bend at the knees (not at the waist) and keep your back as close to vertical as possible.

Incorrect posture: two of the most common mistake made when lifting are bending at the waist instead of the knees and holding the load too far out in front of you.

When lifting, tighten your stomach muscle as soon as you lift to support your spine, breathing out as you lift. Do not hold your breath.

Remember t use your leg muscles instead of your back muscle to lift the load. Do not twist your body while lifting and keep the load close to your body as you lift.

The best path to a healthy back is to control your weight, exercise, and reduce back stress caused by lifting or poor posture.

Excessive upper body weight such as potbelly contributes to poor back posture and back pain because of the added stress placed on the components of the back.

A regular exercise program that includes flexibility and strengthening exercises can help prevent injury or re-injury to your back. Consult your healthcare provider before beginning an exercise program.

Remember to report signs, symptoms, and hazards of MSDs and make recommendations on appropriate ways to control them. Ways to make these recommendations include e-mail, letters, and notes to your supervisor.

Recommendations can also be made verbally through an employee representative or by serving on health and safety committees. Always follow applicable workplace procedures and safety and health rule.

Summary:

Employers are not the only ones with specific responsibilities. You, as an employee, have an important role also.

Your responsibilities include:

v Recognizing the signs and symptoms of MSDs and the value of reporting them early

v Identifying MSD hazards in your job

v Knowing how to use and evaluate the control measures your employers implements, and

v Working in ways that will reduce the risks in your job

Retrieved from: http://berryplastics.skillport.com/skillportfe/main.action?content=myprogressNew

JOB SAFETY ANALYSIS AND HAZARD CONTROL METHODS

2013-10-17T09:13:00.002-07:00

Summary: The Job Safety Analysis is one of the tools available for identifying safety hazards in the workplace, as well as the safety control methods that can be used to minimize hazards. It can take the form of a group discussion or direct observation.

The first step in the JSA is to identify every step of a job sequence. The second step is to identify the potential hazards in each step. The final step is to find controls methods that could eliminate or minimize employee exposure to each hazard. Control measures include design, safety interlock, warning devices, and procedural controls.

Safe work practice can prevent injury. They form the foundation of a company’s safety program which is developing based on the belief that all accidents are preventable.

Job Safety Analysis and Workplace Inspections are two methods used to identify workplace hazards and the hazards control measures that will be put in place to prevent accidents the hazards may cause.

Safety can only be ensured when there is a clear understanding of a potential hazard in the work environment, and appropriate safe work practices are put in place to prevent accident. The hazard control measures will then become the safe work practices for the job.

One method used to identify hazards associated with a specific job is the Job Safety Analysis (JSA).

The JSA is an analytical tool that is used to:

Ø Record each step of a job in sequence

Ø Identify and explain the hazards encountered at each step

Ø Identify hazard control method

There are two basic methods for performing a JSA: group discussion and direct observation.

During group discussion, the supervisor and employees meet away from the work area or location to discuss the JSA. This method is used to analyze jobs not often performed or those that are difficult to observe, such as those performed in confined spaces, the discussion group may include other experienced persons.

In the other hand, on direct observation, the supervisor observes the employee performing a task to identify hazards within each step. The advantage of this method is that the supervisor does not have to recall how the task is actually done.

The first step in conducting the JSA is to identify each step of the task in sequence of how the job is performed, describe what is done, not how it is done. Avoid making the breakdown so general those important steps are left out.

The second step is to identify how each step in a task is performed so that the associated hazards can be identified. Identify every possible hazard, even if it seems improbable.

One of the most common errors is to only identify the most obvious hazards, some hazard may be overlooked. Past accident history can also be reviewed to identify possible hazards.

The final step is to think of methods to eliminate or minimize employee exposure to the hazards previously identified. It is important to list more than one control method, and they should be listed in order of preference. The supervisor or person in charge should choose the best control method considering benefits, costs, and all hazard control method.

There are a variety of ways hazards identified through a job safety analysis that can be controlled.

Hazard Control Method can be listed from the most effective to the least effective:

Ø Design

Ø Safety interlocks

Ø Warning devices

Ø Procedure control

The most effective hazards control method is to design the work environment to eliminate hazards; this method is also commonly referred to as engineering controls. An example is a filter ventilation system for cool dust removal.

If the hazard cannot be eliminated by design controls, consider controlling the hazard with a safety interlock, these devices operate automatically and do not require an employee to do anything, an example is an electrical interlock system.

The next chose for controlling hazard is the use of a warning device, it automatically detects the condition and gives a warning signal, audio or visual indicator are the most commonly used; however, unlike safety devices, warning devices require an employee to react to the warning. The warning device should be designed to minimize the probability of incorrect employee reaction.

Procedure Control attempt to control a certain hazard by use of a procedure, this is the least effective control measure because it relies on person fully following the steps of the procedure. Lock-out and tag-out boundaries should be identified and written on the JSA.

Other method used to minimize employee exposure to hazard is the Personal Protective Equipment, commonly known as PPE. It requires for the job or task will be identified as part of the JSA. This step ensures and documents that the PPE hazard assessment has been conducted.

As noted, the PPEs can be a highly effective method for minimize exposure to a hazards. However, you must be aware that the equipment does not eliminate the hazard when used properly; it protects workers from the hazard that still exist.

A completed JSA is not effective until it is incorporated into the task through employee training and management direction.

JSAs are very helpful in planning jobs and should be reviewed with employees before performing the task. One of the best uses of JSAs is for on-the-job training of new employee.

Change in personnel, processes, equipment, or materials can introduce new hazards that may require JSAs to be revised.

Regardless of the methods used, the supervisor or person in charge should encourage everyone’s participation in the JSA process. Employee’s involvement helps ensure a more thorough analysis by identifying and eliminating hazards that may otherwise be overlooked. Employee involvement allows employees to establish their own safe work practices.

Retrieved:http://berryplastics.skillport.com/skillportfe/SbJaSummaryPage.action?id=ESH_SAH_A52_SH_ENUS_sbESH_SAH_A52_SH_ENUS009011&time=34&displayDevPlanEditDeleteIcon=1&lpName=

SUPPORT YOUR HEART

2013-09-24T09:40:00.005-07:00

“If you exercise regularly, eat right and don’t smoke, you are on your way to healthier heart”, says Dr. Willet.

Taking a few healthy lifestyle steps can help you feel better and reduce your risk of heart attack and stroke. Here, what you need to know to eat right, get active and quit smoking.

To put the pieces of an ideal heart-healthy eating plan together, “think of diet and nutrition like an orchestra- all components should be balanced for optimal heart health”, says Walter Willett, MD chair of the nutrition department at the Harvard School of Public Health.

EAT FOR YOUR HEART:

To get started, try these six simple steps:

Ø Control your portion size

Fill half a normal dinner plate with green leafy, bright or deeply colored vegetables such as spinach and beets. These veggies are packed with heart-healthy nutrients. Leave a quarter each for lean protein and complex carbohydrates, such as potatoes (no fried), brown rice and whole wheat pasta.

Ø Eat less red meat

It’s high in saturated fat, which boosts cholesterol levels. Instead, choose proteins such as broiled or grilled fish, skinless poultry and beans. Consider eating one meat-free meal a day.

Ø Choose nonfat and low-fat dairy

Opt for skim or soy milk, fat-free yogurt and low fat cheese. Dairy is rich in potassium, which reduce stroke risk, according to recent research.

Ø Fill up on fruits and vegetables

The American Heart Association (AHA) recommends you get at least four to five cups of fruit and the same amount of vegetable daily. One cup is about of woman’s fist.

Ø Favor fiber-filled foods

Fiber-rich foods such as produce and whole grains are satiating- so you may feel fuller longer. Soluble fiber, found in beans, peas, oats, apples, citrus, barley and psyllium, can help lower cholesterol.

Ø Toss the salt shaker

Salt causes fluid retention, which raises blood pressure and can worsen angina. Follow the AHA recommendation of less than 1500 mg a day, unless your doctor suggest otherwise. To reduce salt in your diet, eat more fresh food and fewer processed products, which tend to be loaded with sodium. If you’re out at a restaurant, ask if the chef can prepare low salt versions of menu items for you.

GET MOVING:

Exercise will help make you stronger and increase what’s known as exercise tolerance, how much you can physically exert yourself before becoming exhausted. The better your exercise tolerance becomes, the harder you can work out without experiencing angina pain. Exercise also helps lower blood pressure, cholesterol and blood glucose levels.

Ø Enlist a buddy

Plan to exercise with your spouse, a family member or friends to help you stay committed.

Ø Start slow and build up

“You don’t have to work out like an Olympic athlete”, says Robert Eckel, MD, head of preventive cardiology at the University of Colorado Anschutz Medical Campus in Aurora.

How much exercise is enough to help your heart?

Thirty minutes a day, at least five days a week, of brisk walking is fairly standard. However, if you heart’s sake, your doctor may want you to strive for an hour of physical activity daily. You can break it up into 15 minute chunks.

Ø Log it

Keep track of the time, speed and duration of you walks.

KICK BUTTS

Quitting is essential for anyone who smokes, but it’s especially important for people with angina.

Smoking causes your arteries to constrict, which can make angina worse. Talk to your doctor about tools for quitting. Research shows that combining support and medical therapy is most effective.

Get helpful tips and information….at www.SpeakFromTheHeart.com

FISH OIL MAY PROTECT AGAINST ALCOHOL-RELATED DEMENTIA

2013-09-19T08:06:00.000-07:00

Exposure to a compound found in fish oil may protect against the development of dementia in heavy drinkers, new research suggests.
A study presented at the recent Congress of the European Society for Biomedical Research on Alcohol in Warsaw, Poland, examined rat brain cells exposed to alcohol levels equivalent to 4 times the legal driving limit.
Results showed that the cell cultures that were also exposed to omega-3 docosahexanenoic acid (DHA) showed approximately 90% less neuroinflammation and 90% less neuronal brain cell death compared with the cells that were not exposed to the fish oil compound.
"We hypothesized that omega-3 fatty acids, specifically DHA (which has been shown to neuroprotect from other acquired brain insults in the laboratory and to some degree in human studies) would suppress or prevent the neuronal degeneration due to binge alcohol exposure," principal investigator Michael A. Collins, PhD, professor in the Department of Molecular Pharmacology and Therapeutics at the Stritch School of Medicine at Loyola University, Chicago, Illinois, told Medscape Medical News.
"And basically, that is what we found," he added.
Relevant to Humans
Dr. Collins noted that although this was an animal study designed to measure neurodegeneration and related phenomena, and not a study specifically of dementia, "since brain degeneration underlies persistent or permanent dementia, the results were extrapolated to what might happen in humans."
And although he noted in a release that further studies are now needed, "fish oil has the potential of helping preserve brain integrity in abusers. At the very least, it wouldn't hurt them."
In 2011, Dr. Collins and colleagues published a meta-analysis of 143 studies showing that consuming up to 2 alcoholic drinks a day for men and 1 drink a day for women appeared to reduce the risk for dementia and cognitive impairment.
However, "too much alcohol overwhelms the cells," they noted in a release.
"Our previous work and that of others had linked neurodegeneration to 'neuroinflammatory'-like mechanisms that include oxidative stress (oxygen and nitrogen free radicals). The oxidative stress, we suspected, resulted in part from alcohol-induced excessive release of unsaturated fatty acids from brain membranes," explained Dr. Collins.
In the current study, the researchers exposed brain cell cultures from adult rats to heavy amounts of alcohol and then compared half the cells, which were further exposed to omega-3 DHA, with the other nonexposed half.
"Our results indicate excessive arachidonic acid (AA) mobilization due to increased phospholipase A2 (PLA2) levels/activity, and this appears related to elevations in astroglial aquaporin-4 (AQP4) and brain edema," write the investigators.
In other words, excessive drinking can cause higher levels of PLA2 activity, leading to excessive production of AA (a polyunsaturated omega-6 fatty acid), which in turn leads to increased AQP4/neuroinflammation and swelling of the brain.
However, inhibiting AQP4 was found to be neuroprotective to the cells.

Best Protection

LA FDA REFUERZA LA ADVERTENCIA DE NEUROPATÍAS POR FLUOROQUINOLONAS

2013-08-18T12:24:00.001-07:00

La Administración de Drogas y Alimentos de los EE.UU. (FDA) ha anunciado que los antibióticos de Fluoroquinolonas por vía oral o por inyección plantean el riesgo de neuropatía periférica permanente, un riesgo que aparecerá en las etiquetas actualizadas de los medicamentos.

Hay 6 medicamentos de Fluoroquinolonas aprobados por la FDA en el mercado: ciprofloxacina, gemifloxacina, levofloxacina, moxifloxacina, norfloxacino y ofloxacino. En 2011, 23 millones de pacientes recibieron una receta para medicamentos de Fluoroquinolonas orales en farmacias minoristas ambulatorias; alrededor de 3,8 millones de pacientes hospitalizados se facturan para las versiones inyectables de estos fármacos.

Las Fluoroquinolonas tópicas, aplicados a los ojos o los oídos, no se sabe que tienen el riesgo de neuropatía periférica, según la FDA.

La FDA agregó la posibilidad de neuropatía periférica en las etiquetas de las Fluoroquinolonas orales e inyectables en 2004. La agencia dijo que ha seguido recibiendo informes de este evento adverso desde entonces. Una revisión reciente de los casos con el resultado de la discapacidad en el Adverse Event Reporting System FDA a partir del 1 de enero de 2003 al 1 de agosto de 2012, mostró que la aparición de la neuropatía periférica después del inicio de la terapia con Fluoroquinolonas fue rápida, a menudo dentro de los primeros días, declaro la FDA. Algunos pacientes que habían dejado de tomar el medicamento continuaron experimentando síntomas de daño del nervio durante más de un año.

La agencia aconseja a los médicos a poner a los pacientes que reciben un medicamento de Fluoroquinolonas, en otra clase de antibióticos si se desarrollan síntomas de la neuropatía periférica, a menos que el médico considera que los beneficios del tratamiento con Fluoroquinolonas son mayores que los riesgos.

Más información sobre este anuncio está disponible en el sitio web de la FDA.

Para reportar problemas con Fluoroquinolonas, contacto MedWatch, información de seguridad de la FDA y el programa de eventos adversos, por teléfono al 1-800-FDA-1088, por fax al 1-800-FDA-0178; en línea en https://www.accessdata .fda.gov / scripts / MedWatch / medwatch-online.htm, con franqueo pagado formulario FDA 3500, disponible en http://www.fda.gov/MedWatch/getforms.htm, o por correo a MedWatch, 5600 Fishers Lane , Rockville, Maryland 20852-9787.

COMO AMAR A LOS ADULTOS MAYORES

2013-08-08T06:54:00.002-07:00

DOMINIO DEL ESCENARIO

2013-07-17T05:55:00.000-07:00

Cómo lograr meterse en el bolsillo a cualquier audiencia

lucía dorronsoro@ABC_es / madrid

Día 17/07/2013 - 08.34h

Una de las habilidades directivas más codiciadas es saber enfrentarse a la audiencia en las presentaciones. Del miedo a la superación. Primer paso, ganar confianza en uno mismo

Se puede hablar en público en diferentes supuestos —homenajes, concursos empresariales, presentaciones de proyectos, charlas y debates, bodas, funerales—, y se puede aprender a hacerlo en cada uno de ellos. Algunas culturas y profesiones utilizan de forma habitual esta herramienta de persuasión de la que a menudo depende la toma de importantes decisiones, pero para la mayoría de la población —incluida la de Estados Unidos— supone quedarse «solo ante un peligro» que nace de uno mismo. Es el miedo a la exposición pública el que paraliza a un conferenciante que, en petit comité, se comporta como un conversador ameno, ingenioso, interesante. ¿Cómo se puede transmitir a una audiencia de desconocidos la misma sensación de confianza que ante un grupo de amigos en una reunión informal?

José María Acosta, consultor y experto en oratoria y comunicación, destaca en su último libro, «Hablar en Público» (ESIC, 2012) la importancia de utilizar «el cerebro emocional. Hay que saber comunicarse con todo el cuerpo». Tener muy claro lo que se quiere decir y saber quién va a escucharlo son dos de las claves que ayudan a superar el miedo. El humor puede dar un gran resultado, pero también causar una mala imagen si no se emplea con naturalidad. Y la improvisación, sin excesos, como la sal.

José Luis Losa es un experimentado periodista y director de teatro que ha creado en Sevilla una empresa de cursos de comunicación personal para profesionales (www.comunicayconvence.com) que intenta dar respuesta a esa gran demanda existente. Se trata de cursos intensivos para sólo diez alumnos que ofrece en el Palacio de Congresos de Sevilla basados en tres disciplinas: «coaching», para vencer los miedos; periodismo, para controlar el mensaje; y teatro, para dominar las formas. A su juicio, «de nada sirven los cursos de declamación o de retórica si el problema previo que hay que resolver es conseguir que el orador pierda el miedo y se sienta a gusto. Para ello hay que enseñarles a apoyarse en sus puntos fuertes y minimizar los débiles». Sin embargo, concluye, la clave para generar esa confianza con la audiencia es «potenciar la capacidad de empatía con ella, de mirar al público a la cara y contarle nuestra verdad».

INFARTO AL MIOCARDIO, FACTORES DE RIESGO Y PREVENCION

2013-07-16T17:26:00.000-07:00

¿Que es un Infarto al miocardio?

Un infarto al miocardio consiste en la muerte del tejido muscular del corazón. Cuando el tejido muere este no puede contraerse y puede traer consecuencias siendo las principales insuficiencia cardiaca (bombeo insuficiente de sangre para las necesidades de tu cuerpo) y arritmia (alteraciones del ritmo cardiaco)....

Causas

La causa más común de un infarto al miocardio es la obstrucción a las arterias coronarias, estas llevan los nutrientes necesarios para que el corazón pueda contraerse eficazmente. Casi siempre la obstrucción de la arteria se debe a la arterioesclerosis la cual produce el endurecimiento de la capa interna de las arterias, la cual se endurece por una proliferación de ateromas los cuales son acúmulos de grasa de baja densidad (LDL), la acumulación puede llevar al cierre parcial o total de la arteria afectada, también el infarto se puede deber a una trombosis, se produce cuando los coágulos de sangre (trombos) obstruyen las venas o las arterias, dificultando o impidiendo el normal fluir de la sangre.

Sintomas

Saber reconocer los síntomas que anuncian un infarto es muy importante ya que la atención médica inmediata, puede evitar resultados fatales.

Dolor en el pecho (dolor también en el brazo izquierdo), Perdida de conocimiento, Frio y piel Húmeda, Dificultad para respirar. Entre otros síntomas se puede encontrar dolor en la mandíbula, sensación de mareos y vómitos.

Factores de Riesgos

Los factores son las condiciones que favorecen obstrucción arterial.

Podemos clasificarlos en tres grupos:

No modificables como por ejemplo:Tener antecedentes familiares de primer grado (padres,hermanos) con enfermedad cardiovascular prematura, la edad (cuanto más edad más riesgo) y el sexo (más frecuente en el sexo masculino).

Modificables: tabaquismo (fumador activo o pasivo), sedentarismo, Nutrición inadecuada (alta ingesta de grasas, hidratos de carbono y sal).

Los controlables: Hipertensión arterial, alteraciones de la glucemia (diabetes), Alteraciones de los lípidos ( Colesterol total y LDL elevado, Colesterol HDL disminuido, Triglicéridos elevados), Sobrepeso u obesidad abdominal, Síndrome metabólico.

Al Tener los factores de riesgo estos se pueden controlar para prevenir un futuro infarto al miocardio, acá se entregan los siguientes TIPS para llevar una vida más sana.

La dieta sana, la actividad física regular y el abandono del consumo de tabaco son fundamentales.
Consuma una dieta sana y equilibrada, abundantes frutas y verduras, cereales integrales, carnes magras, pescado y legumbres. Poca sal y azúcar.
Haga ejercicio regularmente: al menos 30 minutos diarios de actividad física ayudan a mantener el sistema cardiovascular en forma. Al menos 60 minutos casi todos los días ayudan a mantener un peso normal.
Evitar el consumo de tabaco, daña gravemente la salud, independientemente de cómo se consuma (cigarrillos, pipa o tabaco para mascar) La exposición pasiva al humo de tabaco también es peligrosa.
Controle su glucemia, su exceso en sangre (diabetes) aumenta el riesgo de infarto de miocardio y accidentes cerebrovasculares.
Controle sus lípidos en sangre, el aumento de colesterol en la sangre incrementa el riesgo de infarto de miocardio y accidentes cerebrovasculares.

retrived from: DR.AL SADI NASSER

El mensaje oculto de Rain Man

2013-07-05T05:38:00.001-07:00

El mensaje oculto de Rain Man

2013-06-27T09:06:00.000-07:00

PALABRAS SABIAS PARA DAR FUERZA A LO QUE EXPRESAMOS: (en ingles)

2013-06-18T14:21:00.000-07:00

Los gerentes en las entrevistas están cansados de escuchar y oír siempre las mismas frases y términos descriptivos, aquí algunas sugerencias para incluir en tu resume y tener en cuenta a la hora de la entrevista.

Tip para tu resume y entrevista en ingles.

COMMUNCATION/PEOPLE SKILLS

Instead of:	Try this:
I write…	I compose…
I answer…	I address…
I give…	I supply…
I watch…	I observe…
I explain…	I convey..
I plan…	I strategize…
I talk….	I express…

CREATIVE SKILLS

Instead of:	Try this:
I create…	I design…
I set up...	I display…
I draw…	I illustrate…
I think up…	I conceptualize…
I change…	I adapt…
I reduce…	I condense…
I copy…	I model…

DATA/FINANCIAL SKILLS

Instead of:	Try this:
I coordinate…	I manage…
I estimate…	I forecast…
I determine…	I assess…
I evaluate…	I appraise…
I fix…	I correct…
I look over…	I audit…
I save…	I conserve…

HELPING SKILLS

Instead of:	Try this:
I speak up for…	I advocate…
I encourage…	I coach…
I work with…	I collaborate…
I help…	I support…
I get used to…	I familiaraze…
I give…	I provide…
I show…	I demostrate…

LEADERSHIP SKILLS

Instead of:	Try this:
I pick…	I appoint…
I improve…	I enhance…
I begin…	I institute…
I make…	I generate…
I study…	I analyze…
I put together…	I merge…
I watch…	I monitor…

Retrieved from: Carrer Connections 2013 Florida Trend’s

dralmanza.memoria

Sickle Cell Anemia

Miscellaneous Echo finding (brief notes)

Bibliography

PREDICTION OF INTRACARDIAC PRESSURES (Reynolds, 2013)

Bibliography

PERICARDIAL DISEASE (my class notes)

FARMACOTERAPIA EN LA INSUFICIENCIA CARDIACA (I):

INFECTIVE ENDOCARDITIS: (my class notes)

PULMONARY REGURGITATION (my class notes)

MITRAL VALVE STENOSIS (my class notes)

MANEJO DEL SINDROME DE DIFICULTAD RESPIRATORIA AGUDA

Introduction to the Brewing Process

THE QUESTIONING LEADER

COMMUNICATION AND LEADERSHIP

COACHING FOR SUCCESS

MULTIPLE MYELOMA

ERGONOMIC IN THE WORKPLACE

JOB SAFETY ANALYSIS AND HAZARD CONTROL METHODS

SUPPORT YOUR HEART

FISH OIL MAY PROTECT AGAINST ALCOHOL-RELATED DEMENTIA

LA FDA REFUERZA LA ADVERTENCIA DE NEUROPATÍAS POR FLUOROQUINOLONAS

COMO AMAR A LOS ADULTOS MAYORES

DOMINIO DEL ESCENARIO

Temas relacionados

Una de las habilidades directivas más codiciadas es saber enfrentarse a la audiencia en las presentaciones. Del miedo a la superación. Primer paso, ganar confianza en uno mismo

INFARTO AL MIOCARDIO, FACTORES DE RIESGO Y PREVENCION

El mensaje oculto de Rain Man

PALABRAS SABIAS PARA DAR FUERZA A LO QUE EXPRESAMOS: (en ingles)