The endocrine emergencies most commonly discussed by EMS providers typically deal with diabetes mel-litus, a condition associated with malfunction of the pancreas or its hormones and improper regulation of the blood glucose level. It is important to recognize that there are many other emergencies that may be related to
malfunctioning endocrine glands or hormones. These emergencies may produce acute life-threatening conditions that
exhibit a wide variety of clinical presentations based on the gland or hormones involved. Some patients may not readily
recognize, or may ignore, the slow and progressive clinical changes that are occurring and allow the disease to create an
acute life-threatening condition.
Since EMS providers may be called upon to manage the patient experiencing this acute and potentially life-threatening
condition, it is prudent for them to possess an awareness and understanding of other potential life-threatening endocrine
emergencies, such as those involving the thyroid gland and its related hormones.
By Joseph J. Mistovich, MEd, NREMT-P,
William S. Krost, BSAS, NREMT-P,
& Daniel D. Limmer, AS, EMT-P
Part 1: Hyperthyroidism and Thyroid Storm
This CE activity is approved
by EMS Magazine, an
organization accredited by
the Continuing Education
Coordinating Board
for Emergency Medical
Services (CECBEMS), for
1.5 CEUs.
OBJECTIVES
• Review anatomy of the
thyroid gland
• Discuss metabolic
disturbances
• Review emergency
management of
endocrine emergencies
Sponsored by
CONTINUING
EDUCATION FROM EMS
endocrine emergencies
This article is the first in a two-part series addressing endocrine emergencies involving thyroid hormone
disorders. The second part will follow in next month’s issue and cover conditions related to hypothyroid-
ism. The section below on anatomy and physiology of the thyroid gland pertains to both articles. It will be
important to review this section prior to reading the next article to completely understand the hypothyroid-
ism conditions covered in part two.
BEYOND THE BASICS:BEYOND THE BASICS:
Part 1: Hyperthyroidism and Thyroid Storm
This CE activity is approve
by EMS Magazine, an
organization accredited by
the Continuing Education
Coordinating Board
for Emergency Medical
Services (CECBEMS), for
1.5 CEUs.
OBJECTIVESJ
• Review anatomy of the
thyroid gland
• Discuss metabolic
disturbances
• Review emergencyThis article is the first in a two part series addressing endocrine emergencies involving thyroid hormoneThis article is the first in a two part series addressing endocrine emergencies involving thyroid hormone
ENDOCRINEENDOCRINE
EMERGENCIESEMERGENCIES
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an
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im
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r
www.emsresponder.com ■ EMS ■ OCTOBER 2007 123
123-127 ce article.indd 123123-127 ce article.indd 123 9/18/2007 3:38:33 PM9/18/2007 3:38:33 PM
ANATOMY AND
PHYSIOLOGY OF THE
THYROID GLAND
The thyroid is a butterfly-shaped
endocrine gland l.
The document discusses thyroid disease and its implications for dental care. It begins with background on the thyroid gland and thyroid diseases. It then reviews the literature on thyroid disease and dental care, finding few articles that specifically address the topic. The conclusions state that dental professionals should screen for undiagnosed thyroid disease and understand how thyroid conditions can impact dental treatment. Modifications to dental care may be needed for patients with thyroid disease.
The document discusses the pharmacology of the endocrine system. It begins by introducing hormones and how they regulate metabolic processes more slowly than the autonomic nervous system. It then discusses specific endocrine glands and hormones. A large portion focuses on the thyroid gland, its hormones, and drugs used to treat thyroid disorders like hypothyroidism and hyperthyroidism. These include thyroid hormone preparations, iodides, thionamides, radioactive iodine, and more. The document provides details on the mechanisms, pharmacokinetics, uses, and adverse effects of drugs related to the thyroid and endocrine system.
This document discusses thyrotoxicosis, which results from excess thyroid hormone production regardless of cause. It is one of the more common endocrine disorders seen by family physicians. The causes of thyrotoxicosis include Graves' disease, toxic multinodular goiter, solitary toxic nodule, and thyroiditis. Graves' disease is an autoimmune condition characterized by a diffuse goiter, ophthalmopathy, and dermopathy. Toxic multinodular goiter develops from autonomy in a pre-existing nodular goiter. A solitary toxic nodule refers to autonomy developing in an otherwise normal thyroid. Thyroiditis can cause a transient thyrotoxic phase followed by hypothyroidism. Treatment depends on
The thyroid gland secretes three hormones: T3, T4, and calcitonin. T3 and T4 regulate metabolism, while calcitonin regulates calcium levels. The thyroid is located in the neck below the Adam's apple. T3 and T4 are synthesized from tyrosine and stored bound to thyroglobulin. They are regulated by TSH from the pituitary and feedback to decrease TSH secretion. The main actions of thyroid hormones are to increase growth, metabolism, and heart rate. Hypothyroidism is treated with thyroxine replacement therapy.
1. The thyroid gland secretes thyroid hormones that regulate metabolism and growth. Thyroid hormones are synthesized within thyroid follicles by iodination of tyrosine residues on thyroglobulin.
2. Thyroid hormone synthesis and secretion is regulated by a negative feedback loop involving thyroid stimulating hormone (TSH) from the pituitary gland.
3. Disorders of the thyroid gland include hyperthyroidism (overproduction of hormones) and hypothyroidism (underproduction of hormones).
A complete presentation on hypothroidism endocrine disorder based on latest editon of harrison and reference books. this presentation will help to learn about this second most common endocrine disorder.
This document provides information about thyroid function tests. It begins with an introduction to the thyroid gland and its role in producing thyroid hormones that regulate metabolism. It then discusses disorders like hyperthyroidism and hypothyroidism. The bulk of the document describes various diagnostic tests used to evaluate thyroid function, including TSH, total and free T4 and T3, thyroid hormone uptake, and secretory capacity. Each test is explained in terms of its clinical significance and normal reference ranges. The document concludes with references.
The document summarizes the structure and function of the thyroid gland. It discusses that the thyroid gland is located in the front of the neck and is butterfly shaped with two lobes connected by an isthmus. It produces important hormones like thyroxine and triiodothyronine which regulate metabolism. The thyroid takes up iodine and uses it to produce the hormones through a series of steps in a negative feedback loop involving the hypothalamus and pituitary gland. The hormones have wide-ranging effects on growth, development, and metabolic processes in nearly all tissues of the body. Diseases like hypothyroidism and Graves' disease can disrupt the thyroid's normal functioning.
The document discusses thyroid disease and its implications for dental care. It begins with background on the thyroid gland and thyroid diseases. It then reviews the literature on thyroid disease and dental care, finding few articles that specifically address the topic. The conclusions state that dental professionals should screen for undiagnosed thyroid disease and understand how thyroid conditions can impact dental treatment. Modifications to dental care may be needed for patients with thyroid disease.
The document discusses the pharmacology of the endocrine system. It begins by introducing hormones and how they regulate metabolic processes more slowly than the autonomic nervous system. It then discusses specific endocrine glands and hormones. A large portion focuses on the thyroid gland, its hormones, and drugs used to treat thyroid disorders like hypothyroidism and hyperthyroidism. These include thyroid hormone preparations, iodides, thionamides, radioactive iodine, and more. The document provides details on the mechanisms, pharmacokinetics, uses, and adverse effects of drugs related to the thyroid and endocrine system.
This document discusses thyrotoxicosis, which results from excess thyroid hormone production regardless of cause. It is one of the more common endocrine disorders seen by family physicians. The causes of thyrotoxicosis include Graves' disease, toxic multinodular goiter, solitary toxic nodule, and thyroiditis. Graves' disease is an autoimmune condition characterized by a diffuse goiter, ophthalmopathy, and dermopathy. Toxic multinodular goiter develops from autonomy in a pre-existing nodular goiter. A solitary toxic nodule refers to autonomy developing in an otherwise normal thyroid. Thyroiditis can cause a transient thyrotoxic phase followed by hypothyroidism. Treatment depends on
The thyroid gland secretes three hormones: T3, T4, and calcitonin. T3 and T4 regulate metabolism, while calcitonin regulates calcium levels. The thyroid is located in the neck below the Adam's apple. T3 and T4 are synthesized from tyrosine and stored bound to thyroglobulin. They are regulated by TSH from the pituitary and feedback to decrease TSH secretion. The main actions of thyroid hormones are to increase growth, metabolism, and heart rate. Hypothyroidism is treated with thyroxine replacement therapy.
1. The thyroid gland secretes thyroid hormones that regulate metabolism and growth. Thyroid hormones are synthesized within thyroid follicles by iodination of tyrosine residues on thyroglobulin.
2. Thyroid hormone synthesis and secretion is regulated by a negative feedback loop involving thyroid stimulating hormone (TSH) from the pituitary gland.
3. Disorders of the thyroid gland include hyperthyroidism (overproduction of hormones) and hypothyroidism (underproduction of hormones).
A complete presentation on hypothroidism endocrine disorder based on latest editon of harrison and reference books. this presentation will help to learn about this second most common endocrine disorder.
This document provides information about thyroid function tests. It begins with an introduction to the thyroid gland and its role in producing thyroid hormones that regulate metabolism. It then discusses disorders like hyperthyroidism and hypothyroidism. The bulk of the document describes various diagnostic tests used to evaluate thyroid function, including TSH, total and free T4 and T3, thyroid hormone uptake, and secretory capacity. Each test is explained in terms of its clinical significance and normal reference ranges. The document concludes with references.
The document summarizes the structure and function of the thyroid gland. It discusses that the thyroid gland is located in the front of the neck and is butterfly shaped with two lobes connected by an isthmus. It produces important hormones like thyroxine and triiodothyronine which regulate metabolism. The thyroid takes up iodine and uses it to produce the hormones through a series of steps in a negative feedback loop involving the hypothalamus and pituitary gland. The hormones have wide-ranging effects on growth, development, and metabolic processes in nearly all tissues of the body. Diseases like hypothyroidism and Graves' disease can disrupt the thyroid's normal functioning.
The document summarizes thyroid physiology and the biosynthesis and metabolism of thyroid hormones. It discusses how iodide is transported into thyroid cells and incorporated into thyroglobulin to form T3 and T4. It also describes the regulation of thyroid hormones through feedback between the hypothalamus, pituitary gland and thyroid gland. Common tests used to evaluate thyroid function are also mentioned.
The thyroid gland is located in the anterior neck, spanning from the C5 to T1 vertebrae. It consists of two lobes connected by an isthmus, wrapping around the cricoid cartilage and trachea. The thyroid gland produces the hormones thyroxine (T4), triiodothyronine (T3), and calcitonin, which regulate metabolism, growth and development, body temperature, heart rate, and energy production. Thyroid hormone synthesis involves iodine being transported into follicular cells and binding to tyrosine residues on thyroglobulin, forming T3 and T4 which are then cleaved and released.
The thyroid gland secretes thyroxine (T4) and triiodothyronine (T3), which are regulated by thyroid stimulating hormone from the pituitary gland. T4 is converted to the active hormone T3 in tissues. Thyroid hormones increase metabolism by stimulating oxygen consumption in cells. Hypothyroidism causes a decrease in metabolic rate and symptoms like weight gain, dry skin, and slowed thinking.
The document discusses thyroid metabolic hormones and their functions. It covers:
- Synthesis and secretion of thyroid hormones thyroxine and triiodothyronine by the thyroid gland under control of TSH.
- Physiologic functions of thyroid hormones which increase metabolic rate by activating genes in cells.
- Regulation of thyroid hormone secretion by TSH and TRH from the hypothalamus and pituitary, and by negative feedback from thyroid hormones.
- Diseases of the thyroid including hyperthyroidism which causes excessive thyroid hormone secretion and hypothyroidism which causes inadequate secretion.
1. The document discusses thyroid hormones, the thyroid gland, and thyroid disease. It describes how the thyroid gland produces thyroid hormones like T3 and T4 which regulate metabolism.
2. Symptoms of thyroid disease include changes in heart rate, weight, and mood. Hypothyroidism is caused by insufficient hormone production while hyperthyroidism is caused by excessive hormones.
3. Thyroid disease is diagnosed through blood tests measuring TSH, T3, and T4 levels. Treatment for hypothyroidism involves thyroid hormone replacement medication while hyperthyroidism may be treated with anti-thyroid drugs, radioactive iodine, surgery, or beta blockers.
Thyroid hormones T3 and T4 are produced by the thyroid gland and regulate metabolism. T4 is converted to the more active T3 in tissues. Their production requires iodine and is regulated by TSH from the pituitary which is inhibited by thyroid hormone feedback. Thyroid hormones act through nuclear receptors to increase gene transcription and metabolism. Deficiency causes hypothyroidism while excess causes hyperthyroidism, and both can impact growth, development and multiple body systems.
The thyroid gland produces hormones that regulate metabolism. It is located in the neck and has a butterfly shape. The thyroid secretes thyroxine and triiodothyronine, which increase metabolic rate. Iodine is necessary for hormone production - it is absorbed into thyroid cells and combined with tyrosine to form the hormones. The hormones increase processes like carbohydrate metabolism, basal metabolic rate, respiration, and muscle function when secreted. Thyroid secretion is regulated by a negative feedback loop involving the hypothalamus and pituitary gland.
This document discusses thyrotoxicosis and hyperthyroidism. It begins by covering thyroid physiology including iodine metabolism and thyroid hormone synthesis. It then discusses the causes and clinical manifestations of Graves' disease (diffuse toxic goiter), toxic multinodular goiter, and toxic adenoma. Diagnostic tests and treatment options including antithyroid drugs, radioactive iodine therapy, and surgery are described for hyperthyroidism. Thyroid storm, a medical emergency, is also summarized.
Provide rest periods and schedule activities to allow for rest. Encourage light exercise like walking.
The patient complains of constipation:
recommend
The document discusses the physiology of the thyroid gland. It describes the anatomy of the thyroid, located below the larynx. The thyroid synthesizes and secretes the hormones thyroxine and triiodothyronine which regulate metabolism. When functioning properly, the thyroid regulates growth and development. However, diseases can cause the thyroid to be underactive (hypothyroidism) or overactive (hyperthyroidism), producing a range of symptoms that require treatment.
Diagnosis and treatment of hypothyroidism.pptxvivianOkoli1
Hypothyroidism is a common endocrine disorder where the thyroid gland does not produce enough hormones. It can be caused by iodine deficiency, autoimmune disease, or drugs/radiation affecting the thyroid. Symptoms are often subtle and vary in children, women, and elderly people. Laboratory tests show low thyroid hormones and high TSH. Treatment is with levothyroxine replacement to restore hormone levels, with dose adjustments over time based on symptoms and follow-up tests. In severe cases, myxoedema coma requires emergency treatment in hospital.
This document discusses thyroid function tests, which measure thyroid hormone levels to diagnose thyroid disorders like hypothyroidism and hyperthyroidism. It covers the types of tests, normal hormone rates, interpreting results, preparation, and risks. It also describes the thyroid gland's hormone functions, common thyroid diseases like hypothyroidism and hyperthyroidism, their symptoms and treatments. Dietary modifications for managing thyroid conditions are also outlined.
This document provides an overview of the endocrine system presentation by a group of 5 students. It discusses the pituitary gland, thyroid gland, and parathyroid gland. For the pituitary gland, it describes its anatomy and location, the hormones produced by the anterior and posterior pituitary, and disorders like gigantism, acromegaly, and dwarfism. For the thyroid gland, it explains hormone synthesis and secretion, thyroid function tests (T3, T4, TSH), conditions like goiter and hyper/hypothyroidism, and the role of thyroid hormones in metabolism. It also briefly discusses the parathyroid gland's organization and histology.
lecture class for 4th year MBBS students. this lecture is based on the book 'Robbins' Pathologic basis of disease'. This is delivered by Dr. Umme Kulsum Munmun, Assistant professor (pathology) to the 4th year MBBS students of Chandpur Meducal College, Bangladesh
This document summarizes information about hypothyroidism and hyperthyroidism (thyrotoxicosis). It discusses the epidemiology, causes, clinical manifestations, investigations, treatment, and prevention of hypothyroidism. For hyperthyroidism/thyrotoxicosis, it covers the epidemiology, causes, clinical signs and symptoms, investigations, treatment options including anti-thyroid drugs, surgery and radioactive iodine, and considerations for treatment in pregnancy. It also provides details on myxedema coma, a rare but serious complication of severe untreated hypothyroidism.
The document provides information about the thyroid gland, adrenal gland, and gonads. It discusses the thyroid gland's hormones including thyroxine, triiodothyronine, and calcitonin. It describes diseases of the thyroid such as hypothyroidism, myxedema, goiter, Hashimoto's thyroiditis, and exophthalmic goiter. It also briefly discusses the adrenal gland's hormones and parts as well as diseases of the adrenal gland and functions. Finally, it mentions the gonads including the testis and ovary along with their hormones.
The document discusses various endocrine glands and hormones, including the thyroid gland which produces hormones that regulate metabolism, and the adrenal glands which produce cortisol to help the body cope with stress and aldosterone to regulate sodium levels. It also covers conditions that can arise from too much or too little of these hormones, such as hypothyroidism, hyperthyroidism, Cushing's syndrome, and adrenal insufficiency.
The thyroid gland produces thyroid hormones that regulate metabolism. It is located in the neck below the thyroid cartilage. The main thyroid hormones are T3 and T4, which are synthesized from iodine and tyrosine. Hormone production is regulated by TSH from the pituitary and TRH from the hypothalamus. Common thyroid disorders include hypothyroidism, in which hormone production is deficient, and hyperthyroidism, in which hormones are in excess. Blood tests can measure thyroid hormones and TSH/TRH to evaluate thyroid function and diagnose disorders.
1. The document discusses thyroid hormones and anti-thyroid drugs. It covers the production and effects of thyroid hormones, diseases related to thyroid hormones like hypothyroidism and hyperthyroidism, and therapeutic uses of thyroid drugs including levothyroxine and anti-thyroid drugs.
2. Common anti-thyroid drugs discussed are thioamides like propylthiouracil and methimazole which inhibit hormone synthesis, iodides which block hormone release, and radioactive iodine-131 which destroys thyroid tissue.
3. Adrenergic drugs like propranolol are also used as an adjuvant therapy to relieve symptoms of hyperthyroidism like tremors and palpit
The thyroid hormones T4 and T3 are produced by the thyroid gland and regulate metabolism. TSH produced by the pituitary stimulates the thyroid gland. The thyroid secretes mostly T4 which is converted to the more active T3 in tissues. Thyroid hormones increase metabolism and are essential for growth and development. Abnormalities in thyroid hormone levels can cause hypothyroidism or hyperthyroidism with various symptoms. Diseases like Graves' disease and Hashimoto's thyroiditis can also affect thyroid function.
The employee life cycle is a foundational framework for robust and h.docxtodd701
The employee life cycle is a foundational framework for robust and healthy employee experience and is a major contributor to the success of the organization. It is also a powerful mechanism that can, when well-designed and properly used, make a company a workplace that employees want to be at every day of the week and creativity and innovation show up even when leaders are just hoping for it. Learners are asked to respond to the following question for this last discussion in the course: Which parts of the employment life cycle do you consider most important and why?
Resources
Employee Life Cycle Impact on Engagement
(2018, Feb 28).
Report details how moments that matter & employee value propositions impact worker engagement.
PR Newswire.
"Among the most critical components shaping (the organization's engagement) ecosystem is the employee value proposition, the tangible and intangible deal that organizations provide in exchange for employee effort, commitment and performance."
Bradison, P. (2019).
HR Matters: From recruiting to onboarding the importance of quality new hire work flows.
Alaska Business Monthly,
35
(4), 83.
This article describes how "employees from multiple generations are seeking employment with a consumer’s approach" when they consider more than the pay structure before applying for a position.
Working in HRM
Justin, T. C. (2018).
Addressing the top HR challenges in 2019.
HR Strategy and Planning Excellence Essentials.
This preview to the year in HRM in Canada considers these hot topics: "catering to a multi-generational workforce, employee engagement, increasing feedback, attracting and keeping the right employees, and now marijuana in the workplace."
Sato, Y., Kobayashi, N., & Shirasaka, S. (2020).
An analysis of human resource management for knowledge workers: Using the three axes of target employee, lifecycle stage, and human resource flow.
Review of Integrative Business and Economics Research, 9
(1), 140–156.
This study considers human resource flow management and how to foster that along with two other HRM initiatives with knowledge workers.
Tyler, K. (2019).
10 steps to unlocking innovation at your organization.
HRMagazine, 64
(1), 1.
Innovation is a key component for the longevity of an organization and "HR can't expect to foster an innovative company culture if it does not have an innovative culture within its own function." This resource is inspiring to help HR professionals find a purpose for their efforts to improve all steps in the employee life cycle and embrace the HR platforms and tools that will help them towards this goal.
Case Study
Saurombe, M., Barkhuizen, E. N., & Schutte, N. E. (2017).
Management perceptions of a higher educational brand for the attraction of talented academic staff.
SA Journal of Human Resource Management
, 15.
This study gives a great example of how managers think about branding in higher education and how a.
The economy is driven by data ~ Data sustains an organization’s .docxtodd701
The economy is driven by data ~ Data sustains an organization’s business processes and enables it to deliver products and services. Stop the flow of data, and for many companies, business comes quickly to a halt. Those who understand its value and have the ability to manage related risks will have a competitive advantage. If the loss of data lasts long enough, the viability of an organization to survive may come into question.
What is the significant difference between quality assurance & quality control? Explain
Why is there a relationship between QA/QC and risk management? Explain
Why are policies needed to govern data both in transit and at rest (not being used - accessed)? Explain
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The document summarizes thyroid physiology and the biosynthesis and metabolism of thyroid hormones. It discusses how iodide is transported into thyroid cells and incorporated into thyroglobulin to form T3 and T4. It also describes the regulation of thyroid hormones through feedback between the hypothalamus, pituitary gland and thyroid gland. Common tests used to evaluate thyroid function are also mentioned.
The thyroid gland is located in the anterior neck, spanning from the C5 to T1 vertebrae. It consists of two lobes connected by an isthmus, wrapping around the cricoid cartilage and trachea. The thyroid gland produces the hormones thyroxine (T4), triiodothyronine (T3), and calcitonin, which regulate metabolism, growth and development, body temperature, heart rate, and energy production. Thyroid hormone synthesis involves iodine being transported into follicular cells and binding to tyrosine residues on thyroglobulin, forming T3 and T4 which are then cleaved and released.
The thyroid gland secretes thyroxine (T4) and triiodothyronine (T3), which are regulated by thyroid stimulating hormone from the pituitary gland. T4 is converted to the active hormone T3 in tissues. Thyroid hormones increase metabolism by stimulating oxygen consumption in cells. Hypothyroidism causes a decrease in metabolic rate and symptoms like weight gain, dry skin, and slowed thinking.
The document discusses thyroid metabolic hormones and their functions. It covers:
- Synthesis and secretion of thyroid hormones thyroxine and triiodothyronine by the thyroid gland under control of TSH.
- Physiologic functions of thyroid hormones which increase metabolic rate by activating genes in cells.
- Regulation of thyroid hormone secretion by TSH and TRH from the hypothalamus and pituitary, and by negative feedback from thyroid hormones.
- Diseases of the thyroid including hyperthyroidism which causes excessive thyroid hormone secretion and hypothyroidism which causes inadequate secretion.
1. The document discusses thyroid hormones, the thyroid gland, and thyroid disease. It describes how the thyroid gland produces thyroid hormones like T3 and T4 which regulate metabolism.
2. Symptoms of thyroid disease include changes in heart rate, weight, and mood. Hypothyroidism is caused by insufficient hormone production while hyperthyroidism is caused by excessive hormones.
3. Thyroid disease is diagnosed through blood tests measuring TSH, T3, and T4 levels. Treatment for hypothyroidism involves thyroid hormone replacement medication while hyperthyroidism may be treated with anti-thyroid drugs, radioactive iodine, surgery, or beta blockers.
Thyroid hormones T3 and T4 are produced by the thyroid gland and regulate metabolism. T4 is converted to the more active T3 in tissues. Their production requires iodine and is regulated by TSH from the pituitary which is inhibited by thyroid hormone feedback. Thyroid hormones act through nuclear receptors to increase gene transcription and metabolism. Deficiency causes hypothyroidism while excess causes hyperthyroidism, and both can impact growth, development and multiple body systems.
The thyroid gland produces hormones that regulate metabolism. It is located in the neck and has a butterfly shape. The thyroid secretes thyroxine and triiodothyronine, which increase metabolic rate. Iodine is necessary for hormone production - it is absorbed into thyroid cells and combined with tyrosine to form the hormones. The hormones increase processes like carbohydrate metabolism, basal metabolic rate, respiration, and muscle function when secreted. Thyroid secretion is regulated by a negative feedback loop involving the hypothalamus and pituitary gland.
This document discusses thyrotoxicosis and hyperthyroidism. It begins by covering thyroid physiology including iodine metabolism and thyroid hormone synthesis. It then discusses the causes and clinical manifestations of Graves' disease (diffuse toxic goiter), toxic multinodular goiter, and toxic adenoma. Diagnostic tests and treatment options including antithyroid drugs, radioactive iodine therapy, and surgery are described for hyperthyroidism. Thyroid storm, a medical emergency, is also summarized.
Provide rest periods and schedule activities to allow for rest. Encourage light exercise like walking.
The patient complains of constipation:
recommend
The document discusses the physiology of the thyroid gland. It describes the anatomy of the thyroid, located below the larynx. The thyroid synthesizes and secretes the hormones thyroxine and triiodothyronine which regulate metabolism. When functioning properly, the thyroid regulates growth and development. However, diseases can cause the thyroid to be underactive (hypothyroidism) or overactive (hyperthyroidism), producing a range of symptoms that require treatment.
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Hypothyroidism is a common endocrine disorder where the thyroid gland does not produce enough hormones. It can be caused by iodine deficiency, autoimmune disease, or drugs/radiation affecting the thyroid. Symptoms are often subtle and vary in children, women, and elderly people. Laboratory tests show low thyroid hormones and high TSH. Treatment is with levothyroxine replacement to restore hormone levels, with dose adjustments over time based on symptoms and follow-up tests. In severe cases, myxoedema coma requires emergency treatment in hospital.
This document discusses thyroid function tests, which measure thyroid hormone levels to diagnose thyroid disorders like hypothyroidism and hyperthyroidism. It covers the types of tests, normal hormone rates, interpreting results, preparation, and risks. It also describes the thyroid gland's hormone functions, common thyroid diseases like hypothyroidism and hyperthyroidism, their symptoms and treatments. Dietary modifications for managing thyroid conditions are also outlined.
This document provides an overview of the endocrine system presentation by a group of 5 students. It discusses the pituitary gland, thyroid gland, and parathyroid gland. For the pituitary gland, it describes its anatomy and location, the hormones produced by the anterior and posterior pituitary, and disorders like gigantism, acromegaly, and dwarfism. For the thyroid gland, it explains hormone synthesis and secretion, thyroid function tests (T3, T4, TSH), conditions like goiter and hyper/hypothyroidism, and the role of thyroid hormones in metabolism. It also briefly discusses the parathyroid gland's organization and histology.
lecture class for 4th year MBBS students. this lecture is based on the book 'Robbins' Pathologic basis of disease'. This is delivered by Dr. Umme Kulsum Munmun, Assistant professor (pathology) to the 4th year MBBS students of Chandpur Meducal College, Bangladesh
This document summarizes information about hypothyroidism and hyperthyroidism (thyrotoxicosis). It discusses the epidemiology, causes, clinical manifestations, investigations, treatment, and prevention of hypothyroidism. For hyperthyroidism/thyrotoxicosis, it covers the epidemiology, causes, clinical signs and symptoms, investigations, treatment options including anti-thyroid drugs, surgery and radioactive iodine, and considerations for treatment in pregnancy. It also provides details on myxedema coma, a rare but serious complication of severe untreated hypothyroidism.
The document provides information about the thyroid gland, adrenal gland, and gonads. It discusses the thyroid gland's hormones including thyroxine, triiodothyronine, and calcitonin. It describes diseases of the thyroid such as hypothyroidism, myxedema, goiter, Hashimoto's thyroiditis, and exophthalmic goiter. It also briefly discusses the adrenal gland's hormones and parts as well as diseases of the adrenal gland and functions. Finally, it mentions the gonads including the testis and ovary along with their hormones.
The document discusses various endocrine glands and hormones, including the thyroid gland which produces hormones that regulate metabolism, and the adrenal glands which produce cortisol to help the body cope with stress and aldosterone to regulate sodium levels. It also covers conditions that can arise from too much or too little of these hormones, such as hypothyroidism, hyperthyroidism, Cushing's syndrome, and adrenal insufficiency.
The thyroid gland produces thyroid hormones that regulate metabolism. It is located in the neck below the thyroid cartilage. The main thyroid hormones are T3 and T4, which are synthesized from iodine and tyrosine. Hormone production is regulated by TSH from the pituitary and TRH from the hypothalamus. Common thyroid disorders include hypothyroidism, in which hormone production is deficient, and hyperthyroidism, in which hormones are in excess. Blood tests can measure thyroid hormones and TSH/TRH to evaluate thyroid function and diagnose disorders.
1. The document discusses thyroid hormones and anti-thyroid drugs. It covers the production and effects of thyroid hormones, diseases related to thyroid hormones like hypothyroidism and hyperthyroidism, and therapeutic uses of thyroid drugs including levothyroxine and anti-thyroid drugs.
2. Common anti-thyroid drugs discussed are thioamides like propylthiouracil and methimazole which inhibit hormone synthesis, iodides which block hormone release, and radioactive iodine-131 which destroys thyroid tissue.
3. Adrenergic drugs like propranolol are also used as an adjuvant therapy to relieve symptoms of hyperthyroidism like tremors and palpit
The thyroid hormones T4 and T3 are produced by the thyroid gland and regulate metabolism. TSH produced by the pituitary stimulates the thyroid gland. The thyroid secretes mostly T4 which is converted to the more active T3 in tissues. Thyroid hormones increase metabolism and are essential for growth and development. Abnormalities in thyroid hormone levels can cause hypothyroidism or hyperthyroidism with various symptoms. Diseases like Graves' disease and Hashimoto's thyroiditis can also affect thyroid function.
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The employee life cycle is a foundational framework for robust and healthy employee experience and is a major contributor to the success of the organization. It is also a powerful mechanism that can, when well-designed and properly used, make a company a workplace that employees want to be at every day of the week and creativity and innovation show up even when leaders are just hoping for it. Learners are asked to respond to the following question for this last discussion in the course: Which parts of the employment life cycle do you consider most important and why?
Resources
Employee Life Cycle Impact on Engagement
(2018, Feb 28).
Report details how moments that matter & employee value propositions impact worker engagement.
PR Newswire.
"Among the most critical components shaping (the organization's engagement) ecosystem is the employee value proposition, the tangible and intangible deal that organizations provide in exchange for employee effort, commitment and performance."
Bradison, P. (2019).
HR Matters: From recruiting to onboarding the importance of quality new hire work flows.
Alaska Business Monthly,
35
(4), 83.
This article describes how "employees from multiple generations are seeking employment with a consumer’s approach" when they consider more than the pay structure before applying for a position.
Working in HRM
Justin, T. C. (2018).
Addressing the top HR challenges in 2019.
HR Strategy and Planning Excellence Essentials.
This preview to the year in HRM in Canada considers these hot topics: "catering to a multi-generational workforce, employee engagement, increasing feedback, attracting and keeping the right employees, and now marijuana in the workplace."
Sato, Y., Kobayashi, N., & Shirasaka, S. (2020).
An analysis of human resource management for knowledge workers: Using the three axes of target employee, lifecycle stage, and human resource flow.
Review of Integrative Business and Economics Research, 9
(1), 140–156.
This study considers human resource flow management and how to foster that along with two other HRM initiatives with knowledge workers.
Tyler, K. (2019).
10 steps to unlocking innovation at your organization.
HRMagazine, 64
(1), 1.
Innovation is a key component for the longevity of an organization and "HR can't expect to foster an innovative company culture if it does not have an innovative culture within its own function." This resource is inspiring to help HR professionals find a purpose for their efforts to improve all steps in the employee life cycle and embrace the HR platforms and tools that will help them towards this goal.
Case Study
Saurombe, M., Barkhuizen, E. N., & Schutte, N. E. (2017).
Management perceptions of a higher educational brand for the attraction of talented academic staff.
SA Journal of Human Resource Management
, 15.
This study gives a great example of how managers think about branding in higher education and how a.
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What is the significant difference between quality assurance & quality control? Explain
Why is there a relationship between QA/QC and risk management? Explain
Why are policies needed to govern data both in transit and at rest (not being used - accessed)? Explain
.
THE EMERGENCY DEPARTMENT AND VICTIMS OF SEXUAL VIOLENCE AN .docxtodd701
THE EMERGENCY DEPARTMENT AND
VICTIMS OF SEXUAL VIOLENCE: AN
ASSESSMENT OF PREPAREDNESS TO HELP
STACEY BETH PLICHTA, SC.D.
TANCY VANDECAR-BURDIN, M.A.
Old Dominion University, Norfolk, VA
REBECCA K ODOR, M.S.W.
Virginia Department of Health, Richmond, VA
SHANI REAMS, A.A.S.
Virginia Sexual and Domestic Violence Action Alliance,
Richmond, VA
YAN ZHANG, M.S.
Old Dominion University, Norfolk, VA
ABSTRACT
The Emergency Department (ED) is a key source of care for
victims of sexual violence but there is little information available about
the extent to which EDs are prepared to provide this care. This study
examines the structural and process factors that the ED has in place to
assist victims. A survey of all 82 publicly accessible EDs in the
Commonwealth of Virginia was conducted (RR 76%). In general, the
EDs provide the recommended medical care to victims. However, at
least half do not have the needed resources in place to effectively assist
victims and most (80%) do not provide regular training to their medical
staff about sexual violence. Further, almost one-quarter do not have a
relationship with a local rape crisis center. It is recommended that each
ED partner with local rape crisis centers to provide training to their
staff and to ensure continuity of support for victims. It is also
suggested that the state government explore ways in which a forensic
(SANE) nurse be made available to every victim of sexual violence that
presents to the ED for medical assistance. Ideally, each ED would
become part of a community-wide Sexual Assault Response Team
286 JHHSA WINTER 2006
(SART) in order to provide comprehensive care to victims and
thorough evidence collection and information to law enforcement.
INTRODUCTION
This study seeks to examine the extent to which
Emergency Departments (EDs) in the Commonwealth of
Virginia are prepared to provide care for victims of sexual
violence through an examination of both structural and
process factors that are currently in place. Many studies
indicate that sexual violence victimization has both long-
term and short-term health consequences (Plichta and Falik,
2001; see also Rentoul and Applebloom 1997; Cloutier,
Martin and Poole, 2002; Bohn and Holz, 1996). The ED is
a key source of care for victims of sexual assault. It is one
of the first points of entry to care. Competent care by
professionals trained in treating sexual assault victims is
critical to the timely recovery of physical and mental
health. The ED also plays a critical role in the collection of
evidence that may lead to the conviction of the perpetrator
and a recent study found that specially trained (forensic)
nurses perform this function significantly better than do
other staff (Sievers, Murphy and Miller, 2003). Forensic
nurses are registered nurses (R.N.’s) who have advanced
training in the examination of sexual assault victims; this
includes training on legal aspe.
The emergence of HRM in the UK in the 1980s represented a new fo.docxtodd701
The emergence of HRM in the UK in the 1980s represented a new form of managerialism and was instrumental in increases in work intensification’. Discuss.
Word count: 2,000 words (excluding references) and the 10% convention applies
· Minimum use of 15 academic journal articles/ research reports.
· It must be single-sided with size 12 font, 1.5 spacing with the pages numbered and stapled.
Structure – a clear logical format with linked points and arguments.
Broadly, your essay should be structured in the following manner (subheadings are not necessary)
1. Introduction – summary of your ideas and the structure
2. Review of the literature – critical discussion
3. Conclusions
4. References
Background material – evidence of the background research drawing from literature sources. This should include enough descriptive content and factual information from which to derive arguments and assessment of key themes, issues and problems addressed.
Accuracy – in the presentation and description of theories used in the argument
Argumentation – the main argument of the report should relate to the objectives you have initially stated. They should be supported by evidence, both from a variety of sources in the literature.
Presentation – the answers should be well planned – clear, coherent and well constructed. Remember- never write in the first person.
Relevant references and sources must be cited using the Harvard style of referencing. Marks will be removed for wrong or poor referencing.
Useful tips on essay writing
http://www.reading.ac.uk/internal/studyadvice/studyresources/essays/stadevelopessay.aspx
.
The elimination patterns of our patients are very important to know .docxtodd701
The elimination patterns of our patients are very important to know as we continue to assess and do our care plans. How can impaired elimination affect the integumentary system?
Remember that your posts must exhibit appropriate writing mechanics including using proper language, cordiality, and proper grammar and punctuation. If you refer to any outside sources or reference materials be sure to provide proper attribution and/or citation.
.
The Elements and Principles of Design A Guide to Design Term.docxtodd701
The Elements and Principles of Design
A Guide to Design Terminology
The elements of design are some of the basic building blocks that make up the design or artwork.
Understanding and using this terminology can help the designer articulate what works and what doesn’t
work in a design, and to think critically about a design on a more conscious level. Combined, the elements
and principles of design can make for a strong, complete and well-established composition. The principles
of Gestalt, which arise from the elements of design, are included at the end of this document. Learning to
use these elements and principles will be the focus of Beginning Design.
The elements of design are: Point, Line, Form, Value, Texture, Shape, Space, Color
(Color is covered in Art 110; we will be focusing on black, white, and gray scale values.)
DEFINITIONS:
A Point is a position in space.
A Line is the path of a moving point. Two points connected make a line. Lines often imply motion, and can
be rendered in a variety of ways. Contour lines or outlines, define the boundary between shapes. Lines can
create texture or value when used in crosshatching. In addition to these types of actual lines, our eyes can
invent implied lines, such as in dotted lines, or where area boundaries describe lines that may not be there.
Shape is a two dimensional form. The variety of possible shapes is endless. Several common ones are as
follows:
• Simple Geometric: circles, squares, triangles are some of the examples.
• Complex Geometric: straight and curved shapes that have more sides and angles.
• Curvilinear: French curves, ellipses, circles and ovals used in combination.
• Accidental: an example of this might be a coffee ring or paint splatters.
Form is a shape with dimension, an object existing in three dimensional space physically or implied.
Value is the tone created by black, white and shades of gray. The value or tone of an element can create
mass, dimension, emphasis or volume.
Texture can be actual or visual.
• Actual texture is tactile: you can feel it by touching it.
• Visual texture are the markings of a two dimensional artwork that imply actual texture.
Space is an illusion or feeling of 3-dimensionality, which can be created in a two-dimensional design in
several ways, for example:
• Overlapping one object in front of another;
• Using differences in value, amount of detail, etc. between elements;
• Using techniques related to linear perspective, such as differences in size or height on page between
elements
The principles of design are: Unity, Variety, Movement, Balance, Emphasis, Contrast, Proportion,
and Pattern.
DEFINITIONS:
Unity or harmony is the quality of wholeness or oneness that is achieved through the effective use of the
elements and principles of design. The most basic quality of a design or artwork, unity gives a piece the
feeling of being an integrated human expression. The princi.
The emergence of HRM in the UK in the 1980s represented a new form o.docxtodd701
The document provides instructions for a 2,000 word essay discussing how the emergence of human resource management in the UK during the 1980s represented a new form of managerialism and was instrumental in increasing work intensification. The essay should include a minimum of 15 academic sources, follow a clear structure with an introduction, literature review, conclusions, and references section, and demonstrate accurate presentation of evidence and a well-supported argument.
The eligibility requirements to become a family nurse practition.docxtodd701
The eligibility requirements to become a family nurse practitioner include completion of “APRN core (advance physical assessment, advanced pharmacology, and advanced pathophysiology), supervised clinical hours, completion of an accredited graduate program with evidence of an academic transcript, and an active nurse license” (American Academy of Nurse Practitioners, 2021).
The value associated with certification as an FNP is very personal to me. Along with providing higher quality care to clientele, I will have a more fulfilled inner sense of purpose and also be able to provide for my family in a higher capacity than I was previously able to, with an estimated average nurse practitioner salary being over $100,000 annually in the state of Wisconsin. Achieving both my master's and nurse practitioner certification would allow my employer, fellow professional comrades, and most of all; my clients, to have a higher sense of security knowing I’ve worked and studied hard to bring them the highest quality care available. Staying up to date on my continuing education and state-of-the-art processes and pathology will also instill confidence in my clientele to not only continue coming to me with their individual and family healthcare needs but likely will ensure referrals into my practice.
Any time a nurse genuinely takes on a holistic approach towards the practical application of nursing theory, a client is in a better position for patient-centered care, maintaining anonymity, and ensuring positive effective communication during the care process. In the nursing profession, nurses need to not only advocate for their clients, but themselves by participating in associations that work towards advancing the field through by working towards lower nurse-to-client ratios to decrease burnout, leadership education, and opportunity, and also grants to advance continuing education.
.
The Electoral College was created to protect US citizens against.docxtodd701
The Electoral College was created to protect US citizens against mob rule. Mob rule is the control of a lawful government system by a mass of people through violence and intimidation. However, some Americans question the legitimacy of this process. Pick one election where the outcome of the popular vote and the electoral college vote differed to create an argument in favor of or opposed to the use of the electoral college. List at least three valid points to support your argument. Present you argument in a PowerPoint presentation.
As you complete your presentation, be sure to:
Use speaker's notes to expand upon the bullet point main ideas on your slides, making references to research and theory with citation.
Proof your work
Use visuals (pictures, video, narration, graphs, etc.) to compliment the text in your presentation and to reinforce your content.
Do not just write a paper and copy chunks of it into each slide. Treat this as if you were going to give this presentation live.
Presentation Requirements (APA format)
Length: 8-10 substantive slides (excluding cover and references slides)
Font should not be smaller than size 16-point
Parenthetical in-text citations included and formatted in APA style
References slide ( 3 scholarly sources)
.
The Emerging Role of Data Scientists on Software Developmen.docxtodd701
The Emerging Role of Data Scientists
on Software Development Teams
Miryung Kim
UCLA
Los Angeles, CA, USA
[email protected]
Thomas Zimmermann Robert DeLine Andrew Begel
Microsoft Research
Redmond, WA, USA
{tzimmer, rdeline, andrew.begel}@microsoft.com
ABSTRACT
Creating and running software produces large amounts of raw data
about the development process and the customer usage, which can
be turned into actionable insight with the help of skilled data scien-
tists. Unfortunately, data scientists with the analytical and software
engineering skills to analyze these large data sets have been hard to
come by; only recently have software companies started to develop
competencies in software-oriented data analytics. To understand
this emerging role, we interviewed data scientists across several
product groups at Microsoft. In this paper, we describe their educa-
tion and training background, their missions in software engineer-
ing contexts, and the type of problems on which they work. We
identify five distinct working styles of data scientists: (1) Insight
Providers, who work with engineers to collect the data needed to
inform decisions that managers make; (2) Modeling Specialists,
who use their machine learning expertise to build predictive mod-
els; (3) Platform Builders, who create data platforms, balancing
both engineering and data analysis concerns; (4) Polymaths, who
do all data science activities themselves; and (5) Team Leaders,
who run teams of data scientists and spread best practices. We fur-
ther describe a set of strategies that they employ to increase the im-
pact and actionability of their work.
Categories and Subject Descriptors:
D.2.9 [Management]
General Terms:
Management, Measurement, Human Factors.
1. INTRODUCTION
Software teams are increasingly using data analysis to inform their
engineering and business decisions [1] and to build data solutions
that utilize data in software products [2]. The people who do col-
lection and analysis are called data scientists, a term coined by DJ
Patil and Jeff Hammerbacher in 2008 to define their jobs at
LinkedIn and Facebook [3]. The mission of a data scientist is to
transform data into insight, providing guidance for leaders to take
action [4]. One example is the use of user telemetry data to redesign
Windows Explorer (a tool for file management) for Windows 8.
Data scientists on the Windows team discovered that the top ten
most frequent commands accounted for 81.2% of all of invoked
commands, but only two of these were easily accessible from the
command bar in the user interface 8 [5]. Based on this insight, the
team redesigned the user experience to make these hidden com-
mands more prominent.
Until recently, data scientists were found mostly on software teams
whose products were data-intensive, like internet search and adver-
tising. Today, we have reached an inflection point where many.
The Earths largest phylum is Arthropoda, including centipedes, mill.docxtodd701
The Earth's largest phylum is Arthropoda, including centipedes, millipedes, crustaceans, and insects. The insects have shown to be a particularly successful class within the phylum. What biological characteristics have contributed to the success of insects? I'm many science fiction scenarios, post-apocalyptic Earth is mainly populated with giant insects. Why don't we see giant insects today?
250-500 words done by 12:40pm today which is about two hours from now. Cite work.
.
The economic and financial crisis from 2008 to 2009, also known .docxtodd701
The economic and financial crisis from 2008 to 2009, also known as the global financial crisis, was considered to be the worst financial crisis since the Great Depression. The general situation of financial markets has been additionally complicated by the introduction of new financial products as well as other modes of operations including globalization. The global financial market seems to be playing a different function in our economy and it has been working because of new regulations. The introduction of new trade platforms, online access to information, integration and globalization of the market have caused some revisions of finance theories.
What are reliable predictors of economic and financial crises (list at least 3 of them)?
Describe some achievements and some pending issues in context of a global crisis.
Are we still in danger of economic and financial crises today (please refer to current Covid-19 situation)?
Instructions:
Conduct research from viable and credible sources such as and not limited to economic journals, periodicals, books, data base, and websites. This assignment should be submitted/uploaded via D2L on the date the assignment is due. Any late assignments will be subject to a letter grade reduction unless an extension has been negotiated with the professor prior to the due date.
In this written assignment, the quality of your writing and the application of APA format will be evaluated in addition to your content. Evaluation based on these criteria is designed to help prepare you for completing your college projects, which must be well written and follow APA guidelines. Each written assignment should contain a minimum of 800 words, but no more than 900 words. Make sure that you use correct spelling, grammar, and punctuation.
.
The Economic Development Case Study is a two-part assign.docxtodd701
The document provides instructions for a two-part economic development case study assignment. For the first part, students must write a paper analyzing a local economic development project or plan in San Bernardino or Riverside counties. The paper should be 750-1000 words and discuss the project introduction, the government's role, public involvement, economic impacts, analysis, and current status. For the second part, students must create a 10-minute presentation with graphics about their case and record a video of the presentation. The presentation and video are due by April 19th for approval and grading.
The Eighties, Part OneFrom the following list, choose five.docxtodd701
The Eighties,
P
art
One
From the following list, choose five
events
during the 1980s.
I
dentify
the basic facts, dates, and purpose of the event in 2 to 3 sentences in the Identify column. Include why the event is significant in the Significance column, and add a reference for your material in the Reference column.
·
The Sunbelt
·
Suburban Conservatism
·
The Tax Revolt
·
Corporate Elites
·
Neoconservatives
·
Populist Conservatives
·
Deregulation
·
The Federal Reserve Board
·
The Energy Glut
·
The 1981 Tax Cuts
·
Spending Cuts
·
Military Spending
·
Technology
Event
Identify
Significance
Reference
The Eighties,
P
art
Two
From the following list, choose five
events
during the 1980s.
I
dentify
the basic facts, dates, and purpose of the event in 2 to 3 sentences in the Identify column. Include why the event is significant in the Significance column, and add a reference for your material in the Reference column.
·
Feminism
·
Homelessness
·
Republicans and the environment
·
Malls
·
Alternative rock
·
Madonna
·
Michael Jackson
·
AIDS
·
The Cosby Show
·
Sandra Day O’Connor
·
We Are the World
·
Global Warming
·
Geraldine Ferraro
Event
Identify
Significance
Reference
.
The Election of 1860Democrats split· Northern Democrats run .docxtodd701
The Election of 1860
Democrats split
· Northern Democrats run Stephen Douglas
· Southern Democrats run John C. Breckinridge
Republicans decide for moderate
· Republicans nominate Lincoln
· Lincoln opposes slavery in territories
· Republican platform comprehensive
Fourth party enters race
· Constitutional Unionists
· Run John Bell
Republican Victory
· Lincoln gains 40% popular vote
· Lincoln wins in electoral college
· Most Americans want settlement
South Carolina fire-eaters demand secession
· South Carolina secedes December 20, 1680
· Deep South follows
· Buchanan unable to shape compromise
Crittenden Compromise
· Proposed extension of 36º 30’
· John Tyler proposed constitutional amendment
· Lincoln cannot accept slavery in territories
· Compromises fail
Confederate States of America
· Seven states of deep South
· Montgomery original capital
· Constitution similar to that of U.S.
· Constitution protects slavery
President Jefferson of CSA
· Model slave owner; not fire-eater
· Cold personality, irritable, inflexible
· Lacks self-confidence
· Surrounds himself with yes-men
President Abraham Lincoln of United States
· Knows value of unity, competency
· Appoints rivals to cabinet
· Brunt of jokes, criticism
· Sharp native intelligence, humble
Border states
· Virginia, North Carolina, Tennessee, Arkansas join CSA
· Maryland, Kentucky, Missouri stay with Union
· West Virginia secedes from Virginia
A war of nerves
· Two Southern forts in U.S. hands
· Davis willing to let status quo stand for moment
· Lincoln decides to re-supply forts without force
· Confederates fire, beginning April 12, 1861
Art of War influences commanders
· Focus on occupying high ground
· Focus on taking enemy cities
· Retreat when necessary
· Jomini’s 12 models of war
The Armies
· Calvary: for reconnaissance
· Artillery: weakens enemy
· Infantry: backbone of army
· Also support units
Infantry
· Brigades of 2,000–3,000
· Form double lines of 1,000 yards
· Advance into enemy fire
· Then fight hand-to-hand
· Most battles in dense woods
Yanks and Rebs
· Most between 17 and 25
· From all states, social classes
· Draft exempts upper class
· Anti-draft riots in New York City
· Draft dodgers in South
· Some bounty hunters
· High desertion rates
· Shirking duty not common
First Battle of Manassas (Bull Run)
· Both sides thought war would be short
· First battle 20 miles from Washington
· South wins, Union forces flee in panic
First Battle of Manassas (Bull Run)
· South fails to attack Washington
· South celebrates victory
· Stonewall Jackson hero for South
· South disorganized even in victory
Consequences of Manassas (Bull Run)
· South becomes overconfident
· North prepares for long fight
· George McClellan given command of Army of Potomac
Northern strategy
· Defend Washington; take Richmond
· Split Confederacy by taking Mississippi River
· Blockade southern coastline
Mismatch
· North had population advantage of 22 to 9 million
· Industry in north
· Railroads mainl.
The early civilizations of the Indus Valley known as Harappa and Moh.docxtodd701
The early civilizations of the Indus Valley known as Harappa and Mohenjo-Daro had many of the markings of a sophisticated culture. In a
2-3 page
paper discuss the noted advancements of these cultures including significant archaeological finds that suggest these civilizations were far more advanced than originally believed. For this paper, you will need to find
at least (2) outside
resources that support your writing.
.
The Early Theories of Human DevelopmentSeveral theories atte.docxtodd701
The Early Theories of Human Development
Several theories attempt to describe human development.
Briefly describe the Freud, Erickson, and Piaget theories regarding development. Provide the major similarities and differences between each.
Explain how these early theories were developed, and why there is concern related to race, gender, socioeconomic status, and other areas of diversity in how these theories were developed.
.
The Electoral College was created to protect US citizens against mob.docxtodd701
The Electoral College was created to protect US citizens against mob rule. Mob rule is the control of a lawful government system by a mass of people through violence and intimidation. However, some Americans question the legitimacy of this process. Pick one election where the outcome of the popular vote and the electoral college vote differed to create an argument in favor of or opposed to the use of the electoral college. List at least three valid points to support your argument.
Present you argument in a PowerPoint presentation.
Use speaker's notes to expand upon the bullet point main ideas on your slides, making references to research and theory with citation.
Use visuals (pictures, video, narration, graphs, etc.) to compliment the text in your presentation and to reinforce your content.
Treat this as if you were going to give this presentation live.
8-10 slides
.
The early modern age was a period of great discovery and exploration.docxtodd701
The early modern age was a period of great discovery and exploration. The frontiers of knowledge were being pushed out in many directions through the work of scientists and the colonizing of the New World by the European nations. Discuss how our world today is also a world of discovery and exploration. Reflect on this in a short paragraph (250–300) that specifically links the kinds of changes five hundred years ago with the kinds of changes our culture is experiencing today.
.
How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
Walmart Business+ and Spark Good for Nonprofits.pdfTechSoup
"Learn about all the ways Walmart supports nonprofit organizations.
You will hear from Liz Willett, the Head of Nonprofits, and hear about what Walmart is doing to help nonprofits, including Walmart Business and Spark Good. Walmart Business+ is a new offer for nonprofits that offers discounts and also streamlines nonprofits order and expense tracking, saving time and money.
The webinar may also give some examples on how nonprofits can best leverage Walmart Business+.
The event will cover the following::
Walmart Business + (https://business.walmart.com/plus) is a new shopping experience for nonprofits, schools, and local business customers that connects an exclusive online shopping experience to stores. Benefits include free delivery and shipping, a 'Spend Analytics” feature, special discounts, deals and tax-exempt shopping.
Special TechSoup offer for a free 180 days membership, and up to $150 in discounts on eligible orders.
Spark Good (walmart.com/sparkgood) is a charitable platform that enables nonprofits to receive donations directly from customers and associates.
Answers about how you can do more with Walmart!"
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
-------------------------------------------------------------------------------
Find out more about ISO training and certification services
Training: ISO/IEC 27001 Information Security Management System - EN | PECB
ISO/IEC 42001 Artificial Intelligence Management System - EN | PECB
General Data Protection Regulation (GDPR) - Training Courses - EN | PECB
Webinars: https://pecb.com/webinars
Article: https://pecb.com/article
-------------------------------------------------------------------------------
For more information about PECB:
Website: https://pecb.com/
LinkedIn: https://www.linkedin.com/company/pecb/
Facebook: https://www.facebook.com/PECBInternational/
Slideshare: http://www.slideshare.net/PECBCERTIFICATION
Strategies for Effective Upskilling is a presentation by Chinwendu Peace in a Your Skill Boost Masterclass organisation by the Excellence Foundation for South Sudan on 08th and 09th June 2024 from 1 PM to 3 PM on each day.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
हिंदी वर्णमाला पीपीटी, hindi alphabet PPT presentation, hindi varnamala PPT, Hindi Varnamala pdf, हिंदी स्वर, हिंदी व्यंजन, sikhiye hindi varnmala, dr. mulla adam ali, hindi language and literature, hindi alphabet with drawing, hindi alphabet pdf, hindi varnamala for childrens, hindi language, hindi varnamala practice for kids, https://www.drmullaadamali.com
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
The endocrine emergencies most commonly discussed by EMS provi.docx
1. The endocrine emergencies most commonly discussed by EMS
providers typically deal with diabetes mel-litus, a condition
associated with malfunction of the pancreas or its hormones and
improper regulation of the blood glucose level. It is important
to recognize that there are many other emergencies that may be
related to
malfunctioning endocrine glands or hormones. These
emergencies may produce acute life-threatening conditions that
exhibit a wide variety of clinical presentations based on the
gland or hormones involved. Some patients may not readily
recognize, or may ignore, the slow and progressive clinical
changes that are occurring and allow the disease to create an
acute life-threatening condition.
Since EMS providers may be called upon to manage the patient
experiencing this acute and potentially life-threatening
condition, it is prudent for them to possess an awareness and
understanding of other potential life-threatening endocrine
emergencies, such as those involving the thyroid gland and its
related hormones.
By Joseph J. Mistovich, MEd, NREMT-P,
William S. Krost, BSAS, NREMT-P,
& Daniel D. Limmer, AS, EMT-P
Part 1: Hyperthyroidism and Thyroid Storm
This CE activity is approved
by EMS Magazine, an
2. organization accredited by
the Continuing Education
Coordinating Board
for Emergency Medical
Services (CECBEMS), for
1.5 CEUs.
OBJECTIVES
• Review anatomy of the
thyroid gland
• Discuss metabolic
disturbances
• Review emergency
management of
endocrine emergencies
Sponsored by
CONTINUING
EDUCATION FROM EMS
endocrine emergencies
This article is the first in a two-part series addressing endocrine
emergencies involving thyroid hormone
disorders. The second part will follow in next month’s issue and
cover conditions related to hypothyroid-
ism. The section below on anatomy and physiology of the
3. thyroid gland pertains to both articles. It will be
important to review this section prior to reading the next article
to completely understand the hypothyroid-
ism conditions covered in part two.
BEYOND THE BASICS:BEYOND THE BASICS:
Part 1: Hyperthyroidism and Thyroid Storm
This CE activity is approve
by EMS Magazine, an
organization accredited by
the Continuing Education
Coordinating Board
for Emergency Medical
Services (CECBEMS), for
1.5 CEUs.
OBJECTIVESJ
• Review anatomy of the
thyroid gland
• Discuss metabolic
disturbances
• Review emergencyThis article is the first in a two part series
addressing endocrine emergencies involving thyroid
hormoneThis article is the first in a two part series addressing
4. endocrine emergencies involving thyroid hormone
ENDOCRINEENDOCRINE
EMERGENCIESEMERGENCIES
P
h
o
to
s
b
y
D
an
L
im
m
e
r
www.emsresponder.com ■ EMS ■ OCTOBER 2007 123
123-127 ce article.indd 123123-127 ce article.indd 123
9/18/2007 3:38:33 PM9/18/2007 3:38:33 PM
ANATOMY AND
PHYSIOLOGY OF THE
THYROID GLAND
5. The thyroid is a butterfly-shaped
endocrine gland located in the ante-
rior neck just inferior to the thyroid
cartilage (Adam’s apple). It consists of
two lateral lobes that are connected
anteriorly by a mass of tissue referred
to as the isthmus. It can be easily pal-
pated just below the cricoid cartilage.
The size of the gland varies in indi-
viduals depending on many factors.
The thyroid gland is the largest pure
endocrine gland in the body and has
a very rich blood supply. Thus, when
performing a needle cricothyrotomy,
it is extremely important to ensure
that the proper landmarks have been
identified to avoid inadvertent lac-
eration of the vascular lateral lobes or
isthmus of the thyroid gland. If these
are lacerated, an excessive amount
of bleeding may occur, complicating
an already dire airway situation. The
gland may also be lacerated and
bleed heavily from blunt or penetrat-
ing trauma to the anterior neck.
The thyroid gland produces and
secretes two distinct hormones: thy-
roid hormone (TH) and calcitonin.
Calcitonin is produced by a differ-
ent group of cells within the thyroid
gland, and is responsible for lowering
the blood levels of calcium and stim-
ulation of bone growth and develop-
ment in childhood. It may also play a
6. role in reducing bone loss associated
with starvation and in late stages of
pregnancy when the fetus is compet-
ing for calcium being absorbed in the
digestive tract. Otherwise, the role of
calcitonin in the healthy adult is not
well understood; it may serve merely
as a weak hypocalcemic agent.
The thyroid hormone is comprised
of two different iodide-attached mol-
ecules. Thyroxine, also known as tet-
raiodothyronine or T4, makes up the
majority of hormone secreted by the
thyroid cells. It consists of four iodide
ions attached to its molecular struc-
ture. Triiodothyronine, also known as
T3, is the other hormone secreted by
the thyroid gland. It has only three
iodide ions attached to it. Although
only a small amount of T3 is secreted
by the thyroid gland, approximately
10% of the TH secretion, a large
amount is formed from the conver-
sion of T4 through the removal of
one iodine group by enzymes from
the liver, kidneys and other tissues.
Interestingly, though, T3 is primar-
ily responsible for the thyroid hor-
mone effect, which is primarily a very
strong, immediate and short-acting
increase in cellular metabolism.
It is important to review the trans-
port, binding and concentration of
T3 and T4 in the blood in order to
7. understand a potential trigger for the
disease process involving the thyroid
hormone. Approximately 75% of T4
and 70% of T3 hormones attach
to thyroid-binding globulins, also
known as thyroxine-binding globu-
lins (TBGs), upon entering the blood.
A majority of the remaining T3 and
T4 are attached to the plasma pro-
tein albumin or a thyroid-binding
prealbumin. Very small amounts of
the thyroid hormone, approximately
0.3% of T3 and 0.03% of T4, are left
unbound to diffuse into the periph-
eral tissue. Thus, the only useable
form of thyroid hormone is in an
unbound form.
Both T3 and T4 bind to target
tissue receptors; however, T3 binds
much more readily and is about 10
times more active than T4. Equilibrium
must be maintained in the blood
between the amount of thyroid hor-
mones bound to protein carriers and
the amount being released into the
peripheral tissue. Levels of T4 and
the thyroid-stimulating hormone
(TSH) play a major role in maintain-
ing this blood level equilibrium. It is
interesting to note that more than a
week’s supply of thyroid hormone is
found in the bloodstream.
Thyroid hormones affect many of
8. the major organ systems and tissues
within the body, with the exception
of only the adult brain, spleen, testes,
uterus and thyroid gland itself. Effects
of the thyroid hormones are to:
• Maintain normal sensitivity of
respiratory centers to changes in oxy-
gen and carbon dioxide concentra-
tions
• Maintain normal cell oxygen use
• Maintain a normal basal meta-
bolic rate (BMR)
• Promote calorigenesis (heat pro-
duction) by increasing the metabolic
rate of cells
• Enhance the effects of the sym-
pathetic nervous system
• Promote glucose metabolism,
fat mobilization and protein synthesis
• Maintain normal adult nervous
system function
• Promote normal cardiac func-
tion to include rate and force of
contraction
• Promote normal muscle devel-
opment and function, and skeletal
growth and maturation
9. endocrine emergencies
Patients with hyperthyroidism may experience tachycardia and
an
elevated systolic pressure. Pulse pressure may also be widened.
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• Promote normal gastrointestinal
(GI) motility and tone, and increase
digestive enzyme secretion
• Maintain hydration and secre-
tory function of the skin.
Hypothyroidism, an insufficient
number of thyroid hormones, or
hyperthyroidism, an excessive num-
ber of thyroid hormones, will cause
metabolic disturbances that disrupt
normal body function and have
an impact on most or all of the
aforementioned hormone effects.
Hypothyroidism results in a decrease
in hormonal effects on the body
systems; hyperthyroidism increases
or accentuates the thyroid hormone
effects on body systems. Both condi-
10. tions can lead to acute and poten-
tially lethal emergencies.
PATHOPHYSIOLOGY
Hyperthyroidism describes a con-
dition of excessive secretion of thy-
roid hormone resulting from elevated
and inappropriate thyroid function.
Thyrotoxicosis, also associated with
an excessive amount of circulating
thyroid hormone, results from the
patient taking too much thyroid hor-
mone (an exogenous source), or from
an inflamed thyroid gland releasing
too much stored thyroid hormone.
Although these terms are often used
interchangeably to describe an elevat-
ed thyroid hormone level, they have
different etiologies that affect long-
term treatment. Hyperthyroidism and
thyrotoxicosis typically describe the
milder form of the disease process.
Graves’ disease, also known as
diffuse toxic goiter, is the most com-
mon form of hyperthyroidism. It is
typically more common in women
and usually occurs between the ages
of 20 and 40. Graves’ results from an
autoimmune condition that affects
the function of the thyroid-stimulat-
ing hormone, causing the thyroid
gland to increase its production and
12. Graves’ is typically diffuse and
nontender to palpation. This
woman also shows signs of exop-
thalmos, which occurs when the
tissue behind the eyes becomes
edematous and fibrous and the
extraocular muscles degenerate.
For More Information Circle 105 on Reader Service Card For
More Information Circle 106 on Reader Service Card
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secretion of thyroid hormone and
leading to hyperthyroidism.
Thyroid storm, also referred to as
thyrotoxic crisis, represents a severe
and potentially life-threatening con-
dition. Although it is a relatively rare
condition, occurring in only 1% to
2% of patients with hyperthyroid-
ism, if left untreated, thyroid storm
can be fatal, sometimes within days.
It carries an adult mortality rate of
10%–20%. The pathophysiology
of thyroid storm is not completely
understood; however, it is thought
that the excessive levels of thyroid
hormone are not necessarily from the
thyroid gland but from the conver-
13. sion of bound-thyroid hormone in
the blood to an unbound form. The
unbound form becomes active and
can easily enter peripheral tissue,
producing a dangerous and possibly
life-threatening hypermetabolic state
and increased sympathetic nervous
system activity. The patient may pres-
ent with an excessively high fever
(106°F), tachycardia, nausea, vomit-
ing, diarrhea and hypotension.
Graves’ disease is the most com-
mon underlying cause of thyroid
storm. Other causes include taking
an excessive amount of thyroid hor-
mone (factitious hyperthyroidism)
and administration of amiodarone,
a rich iodine-containing antidysrhyth-
mic agent that can have complex
effects on the thyroid gland and hor-
mone function. Other conditions that
may precipitate thyroid storm in the
patient with hyperthyroidism include:
infection, surgery, burns, trauma,
cardiovascular events, preeclampsia
or eclampsia, diabetic ketoacidosis,
hyperglycemic hyperosmolar non-
ketotic syndrome, insulin-induced
hypoglycemia, pulmonary embolism,
ingestion of thyroid hormone and
drug reactions (Mellaril, Itrumil).
ASSESSMENT
It is important to understand the
14. history and physical exam findings
in a patient with hyperthyroidism.
A patient who presents with life-
threatening thyroid storm may have
an undiagnosed history of hyper-
thyroidism. Although hyperthyroid-
ism and thyroid storm may present
with a wide clinical array of signs
and symptoms, clinical features of a
hypermetabolic state and increased
sympathetic activity are the most
common. Key findings include agita-
tion, weight loss, nervousness and
palpitations. History findings include:
• Weight loss of approximately
15% of prior weight (often greater
than 40 pounds)
• Cardiac palpitations
• Nervousness
• Anxiety, agitation, restlessness
• Wide mood swings
• Tremors
• Chest pain in the absence of
cardiovascular disease
• Dyspnea
• Edema
• Disorientation
• Psychosis
• Weakness
• Diarrhea and increased bowel
movements
15. • Increased perspiration
• Fatigue
• Intolerance to heat from the
hypermetabolic state
• Abdominal pain.
Physical exam findings include:
• Fever (excessively high in thy-
roid storm)
• Tachycardia (often 100–170 bpm)
that is out of proportion to the fever
• Wide pulse pressure (40–100
mmHg) due to the increase in cardiac
contractility (inotrope) with an eleva-
tion in systolic blood pressure
• Warm skin
• Diaphoresis
• Dehydration (may be secondary
to diaphoresis and diarrhea)
• Congestive heart failure
• Thyromegaly (enlarged thyroid
gland)
• Exopthalmos (protruded eye-
balls)
• Stare with eyelid retraction
• Atrial fibrillation, atrial flutter, or
premature atrial contractions
• Tremors
16. • Tender liver
• Shock
• Jaundice
• Coma or obtunded mental
state.
The enlarged thyroid gland in
Graves’ is typically diffuse and non-
tender to palpation. If there is infec-
tion or inflammation, the gland will
present with diffuse enlargement and
pain on palpation.
Exopthalmos occurs when the tis-
sue behind the eyes becomes edem-
atous and fibrous and the extraocular
muscles degenerate. This is thought
to result from the autoimmune dis-
order associated with hyperthyroid-
ism. In some cases, the protrusion
is so severe that the optic nerve
is stretched and vision is impaired.
Severe eyeball protrusion may cause
the eyelids to stretch and not close
completely when the patient blinks
or sleeps. This may lead to drying
and irritation of the outer eye tissue,
causing corneal ulcerations.
It is important for EMS providers
to recognize not only the patient
experiencing a thyroid storm, but
also one who is exhibiting an array
of signs and symptoms that are char-
acteristic of hyperthyroidism. The
17. hyperthyroid condition may progress
rapidly to thyroid storm or conges-
tive heart failure if not treated.
MANAGEMENT
Thyroid storm is a life-threaten-
ing condition that requires immedi-
ate emergency care and transport.
Severe hyperthyroidism may also
require supportive emergency care.
Consider the following when man-
endocrine emergencies
Photo courtesy Bechara Y. Ghorayeb, MD
Surgery to remove an enlarged
thyroid gland. The thyroid is
normally a butterfly-shaped gland
that lies in the anterior neck
inferior to the thyroid cartilage.
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aging a patient with an acute and
severe hyperthyroid condition:
• Establish and maintain a pat-
18. ent airway. If the patient presents
with an altered mental status or is
comatose, it may be necessary to
establish an airway by a manual
maneuver, and potentially with a
mechanical device, including endo-
tracheal intubation, in severely
altered mental states.
• Establish and maintain an
adequate ventilation status. If the
patient’s respiratory rate or tidal vol-
ume is inadequate, it is necessary to
provide positive pressure ventilation.
• Establish and maintain ade-
quate oxygenation. Assess the
patient for evidence of hypoxia.
Apply a pulse oximeter and deter-
mine the SpO
2
reading. If there is
either clinical evidence of hypoxia
or a SpO
2
reading of less than
95% on room air, administer a high
concentration of oxygen via a non-
rebreather mask. If the patient is
exhibiting no signs of hypoxia or
the SpO
19. 2
reading is greater than
95%, supplemental oxygen may
be applied via a nasal cannula at
2–4 lpm, especially if any dyspnea,
chest pain or congestive heart fail-
ure is exhibited during the history
or physical exam.
• Provide continuous ECG moni-
toring. Patients experiencing hyper-
thyroidism or thyroid storm may
present with cardiac dysrhythmias.
Atrial fibrillation is common, espe-
cially in the elderly. Patients may also
experience atrial flutter and prema-
ture atrial contractions. Traditional
management of the ventricular rate
control in atrial fibrillation or conver-
sion to a sinus rhythm may not be
effective until the thyroid levels have
been managed.
• Initiate an intravenous line of
normal saline. Patients may lose
significant amounts of fluid from
excessive sweating and diarrhea.
Aggressive fluid resuscitation may be
necessary in severe cases.
• Initiate cooling measures if high
fever is present. Remove the patient’s
clothing, mist the body with water
20. and fan aggressively. If antipyretic
therapy is considered, avoid the use
of aspirin. Aspirin may decrease pro-
tein binding of thyroid hormones
and increase the levels of unbound
T3 and T4, thereby increasing the
tissue uptake of thyroid hormone.
Acetaminophen would be preferred
over aspirin since it does not have
this effect.
• Expeditious transport. If the
patient is experiencing a thyroid
storm or a severe hyperthyroid con-
dition, consider rapid transport to an
appropriate medical facility that can
initiate definitive therapy to decrease
the thyroid hormone levels.
• Consider medications.
Blockading the peripheral adrener-
gic hyperactivity with beta blockers
could be a critical factor in man-
aging the thyroid storm patient.
Propranolol (Inderal), the current beta
blocker agent of choice, can reduce
tachydysrhythmias, high body core
temperature, tremors, restlessness,
anxiety and palpitations. Another
major indication for the specific use
of propranolol is its ability to inhibit
the conversion of T4 to T3 in the
peripheral tissue. Keep in mind that
T3 is responsible for the majority
of thyroid hormone activity in the
21. peripheral tissue. Contraindications
to propranolol’s use include reac-
tive airway disease, atrioventricular
blocks, bradydysrhythmias, cardio-
genic shock, hypersensitivity to the
drug and congestive heart failure. It
is important to note that heart failure
in hyperthyroidism and thyroid storm
is typically a high-output CHF, or
heart failure due to tachydysrhyth-
mias that may respond well to the
beta blocker therapy. However, use
beta blockers with extreme caution
if heart failure is suspected. The
dose of propranolol is 1–2 mg intra-
venously, repeated every 10 to 15
minutes until the symptoms are con-
trolled. Be sure to follow your local
protocol in managing the thyroid
storm patient.
Another medication to consider
is dexamethasone (Decadron), which
also blocks the conversion of T4 to T3
in the peripheral tissue. Administer 2
mg intravenously. Again, it is impor-
tant to follow local protocol when
managing the patient.
CONCLUSION
Even though the chance of
responding to a patient experiencing
a thyroid storm or thyrotoxic crisis is
rare, be prepared to quickly identify
22. the severity of the condition and initi-
ate rapid supportive emergency care
and transport. Possessing a funda-
mental understanding of the disease
process will better prepare the EMS
provider to rapidly recognize and
manage this potentially acute life-
threatening condition.
Bibliography
Bledsoe BE, Porter RS, Cherry RA. Paramedic Care:
Principles and Practice, Medical Emergencies, 2nd ed.
Upper Saddle River, NJ: Prentice Hall Health, 2006.
Guyton AC, Hall JE. Textbook of Medical Physiology,
10th ed. Philadelphia: W.B. Saunders, 2001.
Marieb EN. Anatomy and Physiology, 2nd ed. San
Francisco: Pearson Education, 2005.
Martini FH. Anatomy and Physiology. San Francisco:
Pearson Education, 2005.
Marx JA, Hockberger RS, Walls RM. Rosen’s Emergency
Medicine: Concepts and Clinical Practice, 5th ed. St.
Louis: Mosby, Inc., 2002.
Schraga ED. Hyperthyroidism, Thyroid Storm, and
Graves Disease. www.emedicine.com/emerg/
topic269.htm.
Joseph J. Mistovich, MEd, NREMT-P, is a
professor and chair of the Department of Health
Professions at Youngstown (OH) State University,
author of several EMS textbooks and a nationally
recognized lecturer.
William S. Krost, BSAS, NREMT-P, is an
operations manager and flight paramedic
with the St. Vincent/Medical University of
Ohio/St. Rita’s Critical Care Transport Network
23. (Life Flight) in Toledo, OH, and a nationally
recognized lecturer.
Daniel D. Limmer, AS, EMT-P, is a paramedic
with Kennebunk Fire-Rescue in Kennebunk, ME.
He is the author of several EMS textbooks and a
nationally recognized lecturer.
Th yroid storm is a life-threatening
condition that requires immediate
emergency care and transport.
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ENDOCRINE EMERGENCIES
1. The “Adam’s apple” is a commonly
used name for the _____.
A. Thyroid gland
B. Thyroid cartilage
C. Cricoid cartilage
D. Isthmus
2. The hormone secreted by the
thyroid cells is made up mostly of
_____.
24. A. Calcitonin
B. Triiodothyronine
C. Thyroxine
D. Albumin
3. More than _____ supply of thyroid
hormone can be found in the
bloodstream.
A. One week’s
B. Two weeks
C. One day’s
D. One month’s
4. Thyroid hormones affect many of
the body’s major organ systems and
tissues, with the exception of the
_____.
A. Adult brain
B. Spleen
C. Uterus
D. All of the above
5. The effects of thyroid hormone on
body systems are accentuated by
_____.
A. Calorigenesis
B. Thyrotoxicosis
C. Hypothyroidism
D. Hyperthyroidism
6. According to the article, _____ is
the most common underlying cause
of thyroid storm—a potentially
25. life-threatening condition.
A. Thyrotoxicosis
B. Graves’ disease
C. Hypothyroidism
D. Excessive levels of T3
7. A patient who is suspected of
having thyroid storm may exhibit
all of the following signs, with the
exception of _____.
A. Low-grade fever
B. Congestive heart failure
C. Tremors
D. Atrial fi brillation
8. When examining the patient with
suspected hyperthyroidism, the
EMS provider would not fi nd _____
in the patient’s history.
A. Wide mood swings
B. Edema
C. Signifi cant weight gain
D. Chest pain in the absence of
cardiovascular disease
9. _____ is a condition that occurs
when tissue behind the patient’s
eyes becomes edamatous and the
extraocular muscles degenerate.
A. Thyromegaly
B. Inotrope
26. C. Exopthalmos
D. Graves’ disease
10. Blockading the peripheral
adrenergic hyperactivity with beta
blockers can be a critical factor in
managing the thyroid storm patient.
According to the article, _____ is
the current beta blocker of choice
for treating hyperthyroidism.
A. Atenolol
B. Propranolol
C. Labetalol
D. Betaxolol
11.The thyroid gland consists of two
lateral lobes that are connected
anteriorly by a mass of tissue, which
is called the ____.
A. Thyroid cartilage
B. Cricoid cartilage
C. Fibrous tissue
D. Isthmus
12. Concerning management of the
patient with thyroid storm, which
one of the following statements is
not correct?
A. It is important to provide
continuous ECG monitoring to
assess for cardiac dysrhythmias.
B. If the patient’s respiratory rate is
27. inadequate, provide positive
pressure ventilation.
C. If fever is excessive, initiate cooling
measures and administer aspirin to
the patient until the fever subsides.
D. Assess the patient for hypoxia and
administer oxygen as needed.
Sponsored by
The following questions are based on Beyond the Basics:
Endocrine Emergencies, beginning on page 123.
EMS Magazine’s CE Review offers affordable continuing
education credits. Simply read the CE article beginning on page
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then answer the test questions below, marking your answers in
the answer strip on the opposite page. The test is worth 1.5
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Board for EMS (CECBEMS). Upon receiving a grade of 80% or
better,
participants will be issued a CE certificate that attests to a
passing score. The cost per test is $5, or $4 each when you
purchase
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Check the correct answers and mail this entire page, along with
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28. for test
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9/18/2007 3:41:20 PM9/18/2007 3:41:20 PM
RESEARCH AND REPORTS
Salivary Cortisol Levels in Students Challenged with
a Testing Stressor
KATHLEEN KENWRIGHT, PATTY W LIDDELL, LEONARD
BLOOM, AUDREY ZUCKER-LEVIN,
ANN H NOLEN, LAWRENCE W FAULKNER, ROSEMARY E
BATORSKI
OBJECTIVE: The objective was twofold. The focus of
the study was primarily to determine if the stress of a
particularly difficult exam could cause students to lose
the normal diurnal variation seen in human cortisol
levels and secondarily, to validate the use of a
competitive enzyme immunoassay for salivary cortisol.
29. i nDESIGN: Physical therapy students enrolled
Research Design were asked to participate in the study
by collecting baseline evening and morning salivary
Cortisols during what was regarded as a relatively stress
free time in the Fall of 2009. The following spring, the
same students were asked for samples the evening before
and morning of their first Kinesiology test, traditionally
a stressful time. Method validation was accomplished
using instrumentation owned by the Medical
Laboratory Science (MLS) Program and analysis was
performed by MLS faculty and a second year MLS
student.
SETTING: Participants were enrolled in the College of
Health Sciences at the University of Tennessee in
Memphis. Sample collection and testing was performed
in the student laboratory of the Medical Laboratory
Science Program.
PARTICIPANTS: Physical therapy students in their
first year of a three-year entry level doctorate program,
DPT.
RESULTS: This group of students did not lose their
diurnal variation of cortisol. However, an unexpected
finding was noted: the students' salivary cortisol
specimen collected in the morning of the fall semester
was significantly higher than the salivary cortisol
specimen collected the morning of the test in the spring
semester (p = .019). Method validation was successful
demonstrating a strong correlation ( r = 0.915) when
compared to the reference laboratory.
C O N C L U S I O N S : Cortisol diurnal variation was not
lost in the study participants, but further studies should
30. be performed due to the low percentage of students
completing the study and the lack of demographic
diversity. Even though the method validation in the
student laboratory setting demonstrates that it is indeed
possible to obtain the same excellent correlation as is
seen in a clinical setting, the student laboratory is not
CLIA certified, so assays can be performed for research
use only.
ABBREVLTIONS: ACTH-adrenocorticotropic hor-
mone, CRH-corticotrophin-releasing hormone, D P T -
Doctorate in Physical Therapy, BS-Baccalaureate of
Science, BA-Baccalaureate of Arts, IRB-Internal Review
Board, GPA-Grade Point Average, EIA-Enzyme
Immunoassay, BMI-Basic Metabolic Index, CLIA-
Clinical Laboratory Improvement Amendments, N D -
none detected
INDEX TERMS: stress, cortisol, exams, students
Clin Lab Sei 2011;24(4):221
Kathleen Kenwright, MS, MT,(ASCP)SL,MB"^,
University of Tennessee Health Science Center, Memphis,
TN38163.
Patty W. LiddellMS, MT(ASCP)SH, Baptist College of
Health Sciences, Memphis, TN 38163
Leonard Bloom MPH, CT(ASCP), The University of
Tennessee Health Science Center, College of Allied Health
Sciences, Memphis, TN.
Audrey Zucker-Levin PT, PhD, MBA, GCS, The
University of Tennessee Health Science Center, College of
31. Allied Health Sciences, Memphis, TN.
VOL 24. NO 4 FALL 2011 CLINICAL LABORATORY
SCIENCE 221
RESEARCH A N D REPORTS
Ann H. Nolen, Psy.D., OTR, FAOTA, The University of
Tennessee Health Science Center, College o/^Allied Health
Sciences, Memphis, T N .
Lawrence W. Faulkner, Ph.D. OTIL, The University of
Tennessee Health Science Center, College of Allied Health
Sciences, Memphis, TN.
Rosemary E. Batorski, MEd, MOT, OTR, The
University of Tennessee Health Science Center, College of
Allied Health Sciences, Memphis, TN
Address for Correspondence: Kathleen Kenwright, MS,
MT,(ASCP)SI,MB^^, University of Tennessee Health
Science Center, 930 Madison Avenue, Suite 672,
Memphis, TN 38163, 901-448-6338, [email protected]
edu
I N T R O D U C T I O N
Cortisol is a steroid hormone produced by the adrenal
glands in response to adrenocorticotropic hormone
(ACTH) secreted by the pituitary.' The typical ditirnal
32. variation of cortisoi secretion has been well established.
Cortisol shows an increase in the early morning hours,
peaking at or slightly before the time of waking, and
decreases in the evening.' This hormone plays an
important role in maintaining homeostasis by affecting
multiple organ systems and processes. Under stressful
situations, the body responds by increasing the
production of cortisoi by initiating a series of events
involving the hypothalamus, pituitary and adrenal
cortex called the H PA axis. Specifically, corticotrophin-
releasing hormone (CRH) released by the hypothalamus
triggers release of adrenocorticotropic hormone
(ACTH) from the pituitary which in turn causes the
secretion of glucocorticoids from the adrenal cortex.'
The strength of the stimulus causes some variation in
circadian peak levels and the normal variation has been
shown to be disrupted during times of stress.^
Effect on memory
Though elevated cortisoi in response to stress is a
natural response, it is sometimes detrimental for
students in that some forms of memory are impaired.
There is abundant evidence that the secretion of
glticocorticoid stress hormones may modulate memory
functioning.'* The frontal lobe and hippocampus in
humans contain a high density of glucocorticoid
receptors and are areas for cognition and emotion.
During times of stress there may be a pronounced
deficit in working memory but at the same time,
enhancements may be seen associated with other forms
of memory.'
MATERIAL AND M E T H O D S
Multidisciplinary Project
33. Four departments within the College of Allied Health at
the University of Tennessee Health Science Center
participated in various aspects of this project. The
following outlines some goals anticipated by the faculty
of the departments involved in the study.
The purposes of this multidisciplinary project were to:
r- Validate salivary cortisoi in our Clinical
Laboratory Science (MLS) student laboratory.
" Determine if the stress of an exam would cause
students to lose their normal diurnal variation
of cortisoi.
'- Determine if there is a correlation between
cortisoi concentration and a test grade.
Determine if there is a correlation between
students' perceived stress and the biological
marker of stress-cortisol.
To serve as a working example of research
design to physical therapy students starting a
research course.
-- Provide opportunities for multi-disciplinary
scholarly activity to tenured and non-tenured
faculty.
This paper will focus on only two aspects of the study:
the method validation and whether or not the students
lose their diurnal variation when challenged with a
Stressor.
Participants
After IRB approval was obtained, the entire student
body, of the first year physical therapy class, was
34. approached at the beginning of a structured lecture to
ask for their participation in the project. These students
were in their fourth month (4''') of a thirty three (33)
month entry-level Doctor of Physical Therapy (DPT)
program. All students had a BA or BS degree prior to
admission to the program. The study was explained in
detail and informed consent was obtained from 50
students. Of these 50 students, 23 completed the
research protocol. The students who completed the
study were on average 23 (± 1.21) years old; 18 female.
222 VOL 24, NO 4 FALL 2011 CLINICAL LABORATORY
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5 male; 22 Caucasian, 1 Asian, 1 Hispanic with an
average undergraduate GPA of 3.54 (±.27) and an
average GRE score of 1025 (±92.7).
Design
Salivary rather than serum or plasma samples were
obtained because levels measured in saliva agree very
well with the amount of free cortisol in blood.** Studies
have shown that the rate of saliva production does not
affect the level of cortisol present.^ Using saliva also
eliminated the possibility of falsely increased cortisol
due to anxiety associated with venipunctures.
Baseline salivary cortisol samples were obtained during
the beginning of the first semester at a time that was
deemed less academically stressful. Test samples were
collected the second semester, one in which they take
35. 36 credits. This heavy course load makes this semester
particularly difficult for the students and an ideal time
to test how stress influences performance.
Students were given specific instructions to follow
(Table 1) for all collections and asked to refrigerate the
specimens collected in the evening and bring them to
campus the following day. For the baseline samples
collected in November 2009, participants were asked to
collect 1 mL of saliva at home between 7:30 and 8:30
pm. The subjects collected their saliva samples by
drooling, through a straw, into a 2 mL polypropylene
screwcap tube. The specimens were refrigerated
overnight and brought to campus the next morning.
Participants collected a morning sample the day after
their evening collection between 7:30 and 8:00 am.
Table 1. Instructions for students
Sample collection instructions:
Do not collect a sample if you have a fever.
Avoid alcohol for 12 hours before sample collection.
Do not eat a major meal within 60 minutes of sample
collection.
Avoid dairy products for 20 minutes before sample collection.
Avoid foods with high sugar or acidity or high caffeine content
immediately before sample collection.
Rinse mouth with water to remove food residue before sample
collection.
Please refrigerate samples overnight.
In February of 2010, the second semester, the same
participants were again asked to collect an evening saliva
sample at home between 7:30 and 8:30 pm the evening
before their 8:00 am kinesiology exam. Many students
36. also collected their morning sample at home and
brought it in with them. Specimens were collected
Sunday night and Monday morning before the test.
Exclusion criteria
Students previously diagnosed with a condition related
to variation in cortisol such as Cushing s syndrome or
Addison's disease' were excluded from the study. In
addition, students taking steroid medication either oral,
nasal or topical were not enrolled. Students were asked
to avoid the following situations that have been shown
to affect cortisol levels: excessive exercise, smoking, and
food or alcohol intake immediately prior to obtaining a
sample.'*
Salivary cortisol determination
An enzyme immunoassay method purchased from
Salimetrics* was used to determine the salivary cortisol
levels. This method was chosen because it used a matrix
which accommodated the use of saliva." Other methods
available are designed for serum/plasma but are not
validated for saliva. After samples were brought to
campus, they were stored at -20°C until assayed. Saliva
was thawed, vortexed, and centrifuged at 1500 x g for
15 minutes to spin down any mucus in the sample. The
assay was performed by following the package insert
from Salimetrics" (State College, PA).« A BIO-TEK,
Inc. ELx800 Absorbance Microplate Reader, set at 450
nm wavelength, was used to perform the cortisol assays
in the MLS student chemistry laboratory. Raw data
(absorbance values) was sent to Salimetrics for
interpretation using Gen5™ data analysis software, a
program that was not installed on our instrument at the
time.
37. Method Verification
Ninety-one salivary cortisol samples from participants
were assayed in-house as previously described. Aliquots
of these samples were also sent, on dry-ice, to
Salimetrics for correlation.
Statistical analysis was performed using SPSS 18.0
PASW Statistics. A paired sample t-test and Pearson
correlation was performed (n=91) on the split samples
performed in the student lab and sent to Salimetrics.
The paired sample correlation r =.915 and p < .001
VOL 24, NO 4 FALL 2011 CLINICAL LABORATORY
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RESEARCH A N D REPORTS
showed a very strong correlation between the two
methods (Figure 1).
An intra-assay coefficient of variation was 5.5%.
Cortisol Test Comparison
u
T
H
S
C
L
A
B
38. 1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Salimetrics
Figure 1. Method Verification - Ninety-one salivary eortisol
samples were assayed at U T H S C and at Salimetrics.
A laboratory offering the salivary eortisol testing for
clinical purposes would be required to perform a more
in-depth verification protocol. Sensitivity, specificity
and lower limit of detection assays were not performed.
RESULTS
Interpretation of the students' eortisol values (n=23)
showed a mean fall evening value of .075 ug/dL, a mean
fall morning value of 0.63 ug/dL, a mean test evening
value of 0.08 ug/dL, and a mean test morning value of
0.41 Ug/dL (Table 2). Ranges are shown on Table 3.
The normal diurnal variation between evening and
morning samples did occur with evening samples
reading lower than morning samples.
A paired samples t-test comparing the difference
between the evening and morning values collected in
the fall (baseline), compared with the difference
39. between the evening and morning values collected in
February (test) showed a statistically significant
difference (p =.028). There was a greater difference in
the evening and morning values during the non-stressful
Table 2. Salivary eortisol values*
Baseline
Fall eveninj;
Ba.seline
Fall morning
Test
Spring evening
Test
Spring morning
N
23
23
23
23
•"All vaiues are reporrcd in iig/dL.
Table 3. Salivary eortisol ranges*
Range
Minimum
Maximum
Fall evening
.19
42. semester (mean = .5557), than the difference in the
evening and morning values during the test semester
(mean = .3291). Cohen's d effect size = .4. Interestingly,
this difference was due to lower eortisol values on the
morning of the test than on the morning they were
collected in the fall. A paired samples t-test comparing
the difference in the baseline morning eortisol value
(mean = 0.6300) and test morning eortisol (mean =
0.4117) showed a statistically significant difference p =
.019. Results for the paired samples t-tests are shown in
Table 4.
Power analysis was not performed with this pilot study
because estimates of effect size and sample variance
must be known before conducting a power analysis.''"'
When larger studies are performed, researchers can
224 VOL 24, NO 4 FALL 2011 CLINICAL LABORATORY
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RESEARCH A N D REPORTS
utilize effect size estimates from pilot data such as the
current study. Cohen's d effect size was calculated by
subtracting baseline diurnal differences from test
diurnal differences and dividing by the pooled estimate
of variance.
Table 4. Paired samples t-test
her fall evening value was abnormally high and
inconsistent with the rest of her results. This may have
been due to a collection error, medication, or a personal
43. issue.
Pair 1
Pair 2
Pair 3
fall difference- test difference
fall evening-test evening
fall morning-test morning
df
22
22
22
S ig. (2-tailed)
.028*
.826
.019*
'denotes statistical significance, p < ,05
DISCUSSION
People are able to maintain relative homeostasis because
the human body naturally responds to stressful
situations in ways that allow us to react appropriately.
Dealing with stress for prolonged periods of time will
eventually affect us adversely." Students deal with the
stress of school individually with some thriving but
others struggling to cope. Helping students learn how
to cope with academic pressures benefits all involved.
In this group of students, the cortisol level prior to the
stressful event did not increase as expected. This may be
due to the fact that the students had an additional day
44. to study due to weather related closing of the campus.
Another explanation might be that these students have
been coping with this type of Stressor for the last four or
five years resulting in desensitization. Repeated exposure
to the same Stressor can result in desensitization or
failure to respond. This is called adaptation or
habituation." Another explanation could be that these
students as a group have developed skills that allow
them to manage test related stress. The students are
selected through a competitive process using criteria
that would exclude students who succumb easily to the
stress of an exam.
This initial small sample study made the researchers
aware of problems that should be addressed before a
larger study is designed. When participants bring in
specimens collected at home, investigators need to make
sure the specimen is properly labeled before the
participant leaves. Several participants were dropped
from the study because the collection tubes were not
labeled. One sample was lost because the cap was not
tightened properly and the specimen leaked. One
participant's data was deleted from the study because
Cortisol diurnal variation was not lost in the study
participants, but further studies should be performed
due to the low percentage of students completing the
study and the lack of demographic diversity. The
weekend immediately before the test, the students had
an unexpected 3-day weekend due to a weather- related
closure of the university. It is possible that this extra day
to study decreased the stress the students would have
otherwise felt. Also, these physical therapy students tend
to be more physically active, compared to a more
generalized adult population, which could affect the
results.
45. C O N C L U S I O N S
Diurnal variation of cortisol was not lost in the study
participants but further studies need to be performed
due to the low number of participants completing the
study and the lack of demographic diversity. Other
variables that should be controlled, in future studies,
include: physical activity level, grade point average, and
body mass index (BMI).
Even though the method validation performed in the
student laboratory setting demonstrates that it is indeed
possible to obtain the same excellent correlation as is
seen in a clinical setting, the student laboratory is not
CLIA certified so assays can be performed for research
use only.
The fact that the students' cortisol levels were
significantly higher in the fall semester than the spring
semester has raised some interesting questions that will
be investigated in the future. One such question is,
"Does the stress of life events, including moving to a
new location, affect students more than academic
Stressors"?
A C K N O W L E D G E M E N T S The authors would like to
thank Thomas A. Hughes M.D. at the University of
Tennessee Health Science Center for his advice on this
project. Kametricia N. Derricks is gratefully
acknowledged for her contributions. This project was
supported with a seed grant from the College of Allied
VOL 24, NO 4 FALL 2011 CLINICAL LABORATORY
SCIENCE 225
46. RESEARCH A N D REPORTS
Health Sciences at the University of Tennessee Health
Science Center.
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