In contrast, a "true missing" would be present if the individual item was not answered even though the screening question was answered "yes". Similarly, if this type of behavior change was not relevant for the respondent, then the item is "not applicable" and the observation would probably be excluded as well ("probably", because the appropriate treatment depends upon the purpose of the analysis and intended interpretation). A t-test assumes a Gaussian For example, what if a person responds to the question on race by circling 3 responses, Black, Hispanic, and White. There is a study protocol to classify such an individual; however, this protocol may differ from other similar studies or the U. Ideally the latter should have been specified in the research proposal or well before the analysis process has begun. Often new questions (or all questions) are formulated during the analysis process. In either case, it is highly desirable to articulate specific questions as a guide to how to proceed in the data analysis. Besides their relevance to the questions at hand, analyses generally need to reflect the study design. For example, cross-sectional designs do not provide direct estimates of incidence, matched designs may warrant matched analyses. Ensuring data quality in medical research through an integrated data management system. Epidemiology and public health Clinical versus the public health approaches In their report of a major study conducted by the U. Although it has been criticized for devoting insufficient attention to prevention, clinical medicine is not inherently tied to curative, rather than preventive approaches. In fact, in recent decades the time and resources devoted to preventing disease have greatly increased, especially in the realm of secondary prevention (e. What is more intrinsic to the clinical approach is the focus on the individual, or sometimes the family, in terms of diagnosis and intervention. The scope of inquiry is primarily the prevention and treatment of medically recognized diseases, trauma, and psychiatric disorders. Preparation of clinicians emphasizes core knowledge in biomedical sciences oriented towards understanding physiological and pathological processes, the effects of pharmacologic and surgical interventions, and techniques for investigation and intervention with the individual. In addition to allopathic medicine, numerous other approaches are offered in a clinical-type setting, including acupuncture, chiropractic, massage therapy, and many others. The public health mission is to serve the community, even when particular individuals may well be disadvantaged in some way. There is some ambiguity in this statement, though, since any given population may be regarded as consisting of various "communities", whose interests are often perceived to differ. The public health approach emphasizes prevention, though prevention in this context generally means preventing the occurrence of disease in individuals. At the level of the community, the distinction between prevention and cure may not be as clear. The scope of public health is much broader than that of the clinical approach, because there is no framework of a clinical encounter to confine the time for diagnosis or intervention, and the variety of people and their situations in a community multiply the range of factors that can affect health. Therefore, in addition to specific and general causes of medically-recognized diseases, trauma, and psychiatric disorders, public health is concerned with the organization of society and the protection of the environment, and properly focuses on the future. Public health providers have a small core of common training, due to the many fields of knowledge that become relevant when one deals with factors outside the individual. Channels for intervention are similarly broad, as they can deal with individuals, families, government organizations, the media, and the physical environment. Here are some examples of these contrasting perspectives, taken from a commentary by Stephenson and Wagner (1993): Prevention! Copenhagen - options and recommendations for integration of preventive health services into an overall plan for the management of infertility in the community Geneva - no discussion of the prevention of infertility Health services planning! Copenhagen - a technology or procedure should have proven effectiveness, safety, and benefit as evaluated by clinical trials and other epidemiology methods, before acceptance as standard treatment.
Care for Heat Stroke Call 9-1-1 or the designated emergency number immediately for heat stroke as it is a life-threatening emergency. While waiting for help to arrive, you will need to immediately cool the person by following these steps: Remove the person from the hot environment. Rapidly cool the body by immersing the person up to the neck in cold water (preferred); douse the person with ice-water-soaked towels over the entire body, frequently rotating the cold, wet towels, spraying with cold water, fanning the person, or covering the person with ice towels or bags of ice placed over the body. Cold-Related Emergencies Frostbite and hypothermia are two types of cold-related emergencies. Hypothermia develops when the body can no longer generate sufficient heat to maintain normal temperature. Frostbite Frostbite is the freezing of body tissues, usually the nose, ears, fingers or toes. It usually occurs in exposed areas of the body, depending on the air temperature, length of exposure and the wind. In deep frostbite, Responding to Emergencies 344 Heat-Related Illnesses and Cold-Related Emergencies both the skin and underlying tissues are frozen. Signs and Symptoms of Frostbite the signs and symptoms of frostbite include: Lack of feeling in the affected area. Skin that appears waxy, is cold to the touch and is discolored (flushed, white, yellow or blue) (Figure 19-6). In more serious cases, blisters may form and the affected part may turn black and show signs and symptoms of deep tissue damage. Care for Frostbite When giving care for frostbite, the priority is to get the person out of the cold. Once the person is removed from the cold, follow these steps: Handle the area gently. If there is a chance that the body part may refreeze or if you are close to a medical facility, do not attempt to rewarm the frostbitten area. In serious cases of frostbite, the affected part may turn black and show deep tissue damage. Keep the frostbitten part in the water until normal color returns and it feels warm (about 20 to 30 minutes). Check the water temperature frequently to ensure it does not cool to less than normal body temperature. B, If the fingers or toes are frostbitten, place dry, sterile gauze between them to keep them separated before bandaging. Responding to Emergencies 345 Heat-Related Illnesses and Cold-Related Emergencies Do not use chemical heat packs, such as commercial hand warmers, to rewarm the frostbitten area as they can reach temperatures that will cause further (heat) injury to the damaged tissue. If the fingers or toes are frostbitten, place dry, sterile gauze between them to keep them separated (Figure 19-7, B). Call 9-1-1 or the designated emergency number or seek emergency medical care as soon as possible. Hypothermia Hypothermia is the state of the body being colder than the usual core temperature. Shivering occurs initially as a physiological response to maintain body temperature. As cooling continues, shivering ceases and the person becomes clumsy, slow to respond or unresponsive. If this happens, the heart will eventually stop and the person will die if not given care. The air temperature does not have to be below freezing for people to develop hypothermia. Contributing Factors As with heat-related emergencies, anyone can develop hypothermia, but predisposing factors place some people at a higher risk. Even if the ambient temperature is not extremely low, hypothermia can occur if a person is not adequately protected from the cold.
Since the management of a discovered systemic disease and its potential complications will rest within the domain of the internist or other specialist, the role of the primary eye care provider is to discover undiagnosed cases and monitor ocular health for the ocular complications. When these cells invade the episclera and sclera scaffolding upon branches of trigeminal nerve they can produce, patchy areas of bluish subconjunctival discoloration. This may be of importance as these patients may have increased risk for glaucoma or exhibit artificially low intraocular pressure measurements. Surgical repair of bilateral full thickness macular holes in a patient with blue sclera secondary to osteogenesis imperfecta. Severe conjunctivochalasis in association with classic type Ehlers-Danlos syndrome. Bevacizumab treatment for subfoveal choroidal neovascularization from causes other than age-related macular degeneration. Presenting signs and clinical diagnosis in individuals referred to rule out Marfan syndrome. Central corneal thickness is lower in osteogenesis imperfecta and negatively correlates with the presence of blue sclera. A new alternative to riboflavin/ultraviolet-a: collagen cross-linking with rose bengal/green light. Dendritic ulcerations with classic terminal end bulbs staining brightly with sodium fluorescein and rose bengal dyes have been reported as part of the syndrome. The mother in such cases should be examined for concurrent gynecological infection. In cases involving serotype-2, concurrent systemic infection or issues where immunosuppression is suspected, consider concurrent use of oral antiviral therapy with dosage based on age and body weight. The medication requires less frequent initial dosing (approximately every three hours while awake) and can be tapered as resolution is seen over seven to 10 days. Additionally, ganciclovir demonstrates greatly reduced corneal toxicity, primarily because it is only taken up by virus-infected cells. The disease is generally self-limiting and can be managed with palliative therapies such as artificial tear drops and ointments along with oral overthe-counter analgesics for any additional discomfort. If a papillomacular rash is present, topical prophylactic antibiotic ointments can be prescribed to prevent secondary cellulitis. Epithelial keratitis concurrently present, with or without subepithelial marginal infiltrates, may be cautiously 11. Delayed type hypersensitivity in the pathogenesis of recurrent herpes stromal keratitis. The impact of the herpetic eye disease studies on the management of herpes simplex virus ocular infections. However, if iritis is present, topical steroid use in the absence of topical antiviral coverage is not advised. In the setting of corneal involvement, topical steroids should not be used without topical antiviral coverage. Factors such as severity, recurrence, other topical medications used, atopic disease or a history of immunosuppression can significantly alter the presentation and risk of corneal involvement. Topical prophylactic antibiotic ointment can be dispensed to prevent secondary eyelid infections in cases where a rash is apparent, and drops can be used in cases where keratopathy is significant. Etiology of acute conjunctivitis due to coxsackievirus A24 variant, human adenovirus, herpes simplex virus, and Chlamydia in Beijing, China. Pediatric herpes simplex of the anterior segment: characteristics, treatment, and outcomes. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. Numerous etiologies, including infection, toxicity, allergy and autoimmune disease, may be implicated; nonetheless, signs and symptoms are often the same. Patients typically present with variable edema and hyperemia of the affected tissues of the bulbar and/or tarsal conjunctiva, sometimes with associated pathological manifestations such as follicles or papillae.
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May use large fractions: 30Gy/6F/1 wk Excision margins are involved or very close Palliative intent (brain mets, fungation or profuse bleeding, bone pain, etc) 2. In young children and those with immunodeficiency it presents as wide spread lymphadenopathy with or without skin lesions. Treatment: Chemotherapy: Adults: S: Adriamycin 40mg/sq m i/v D1 Plus S: Vincristine 1. Note: Sequential hemibody irradiation is sometimes necessary for aggressive disease. They may interfere with vital functions such as: Respiratory, swallowing, sight, speech and mastication. Important aetiological factors include excessive intake of tobacco either by smoking or chewing and alcohol intake (particularly spirits). Other features include: Non-healing ulcers, lymphadenopathy, hoarseness, pain and difficult in swallowing. Direct/indirect laryngoscopy/panendoscopy/bronchoscopy plus biopsy Histologies: Squamous cell carcinoma is the most common histology, though the frequency of other histological types and the degree of differentiation varies markedly with site. Decisions of treatment for head and neck tumours are best discussed at Tumour board. Radiotherapy: - Is standard treatment for nasopharyngeal carcinoma and other inoperable tumours of head and neck. Chemoradiation is a superior treatment of choice for all stages though mainly an early stage because this mode of treatment preserves anatomical functions including voice. Surgery: Partial or total laryngectomy is for advanced stages only where voice is compromised. Verrucous carcinoma is best treated surgically Leukoplakia should be excised totally 3. Tumour present as "goiter" and can remain silent for decades without any discomfort. Clinical features: Presence of a thyroid mass or scar, laryngeal nerve palsy, hoarseness, dyspnoea, dysphagia. Treatment Radioactive iodine ablation Further thyroxine replacement therapy (for life). Symptoms: Difficult in swallowing (dysphagia) is the commonest symptom which is associated with weight loss and poor performance status. Dilatation with or without intubation should always be considered to ensure continued ability to swallow. Look for pallor, weight loss, supraclavicular foss nodes, abdominal and rectal examination, epigastric mass, hepatomegally, periumbilical nodes. Surgery: Total or partial gastrectomy, bypass with or without tumour removal eg gastrojejunostomy. There is a strong association of this cancer and hepatitis B infection and/or alcohol consumption. Right upper abdominal swelling and pain often associated with weight loss, fever, jaundice. Anatomic extent of involvement: A: One lobe only; B: Two lobes; C: Metastatic disease; D: Cirrhosis. Surgery: Lobectomy where feasible Chemotherapy is not effective; However single agent Doxorubicin is used. Early stages may be superior to surgery in the sense that sphincter function is preserved. Detection/Prevention Any woman particularly at the age of 50 years should undergo mammography annually Anyone with familial risk ought to start earlier Self breast examination on monthly basis 7. This may be visible to the naked eye gross hematuria or detectable only by microscope.
Of the estimated 7000 to 8000 people reported bitten annually, fewer than five die. Most deaths occur because the person has an allergic reaction, is in poor health or because too much time passes before the person receives medical care. Figure 17-7, A-D shows the four kinds of venomous snakes found in the United States. Four kinds of venomous snakes are found in the United States: A, rattlesnake; B, cottonmouth; C, copperhead; D, coral snake. Severe pain and burning at the wound site immediately after or within 4 hours of the incident. Swelling and discoloration at the wound site immediately after or within 4 hours of the incident. Care for Venomous Snakebites If the bite is from a venomous snake such as a rattlesnake, copperhead, cottonmouth or coral snake, call 9-1-1 or the designated emergency number immediately. Myth: Actions such as applying a tourniquet, cutting the wound, applying suction, applying ice or applying electricity can help to slow the spread of venom throughout the body. Marine-Life Stings the stings of some forms of marine life are not only painful but can also make you sick and, in some parts of the world, can kill you (Table 17-1). The side effects include allergic reactions that can cause breathing and heart problems, as well as paralysis and death. The lifeguards in your area should know the types of marine life that may be present. Signs and Symptoms of Marine-Life Stings Signs and symptoms of marine-life stings include: Rash, which may be red, raised or purplish in the shape of tentacles. Additional steps to take if you encounter someone who has sustained a marine-life sting include: Get a lifeguard to remove the person from the water as soon as possible. If a lifeguard is not available, use a reaching assist, if possible (see Chapter 20). Avoid touching the person with your bare hands, which could expose you to the stinging tentacles. A credit card edge or shell can be used to gently scrape away remaining tentacles. If you know the sting is from a jellyfish, irrigate the injured part with large amounts of seawater as soon as possible for at least 30 seconds. Do not rub the wound or apply a pressure immobilization bandage, aluminum sulfate, meat tenderizer or other remedies because these may increase pain. Once the stinging action is stopped and tentacles removed, care for pain by hot-water immersion. If pain persists, consider applying a topical over-the-counter lidocaine gel or cream. If you know the sting is from a stingray, sea urchin or spiny fish, flush the wound with tap water. Keep the injured part still and soak the affected area in non-scalding hot water (as hot as the person can stand) for at least 20 minutes or until the pain goes away. If hot water is not available, packing the area in hot sand may have a similar effect if the sand is hot enough. Watch for signs and symptoms of infection and check with a healthcare provider to determine if a tetanus shot or additional care is needed. The use of urine to offset the toxin and reduce the pain of a jellyfish sting is not recommended; in fact, urine can actually cause the stingers to release more venom. To inactivate the venom and prevent further envenomation, follow the care steps in this chapter by rinsing with seawater, followed, once tentacles are removed, by a hot-water shower or immersion for at least 20 minutes or for as long as pain persists. Domestic and Wild Animal Bites the bite of a domestic or wild animal carries the risk for infection, as well as soft tissue injury. Rabies is an infectious disease that affects the nervous system and is caused by a virus transmitted commonly through the saliva of diseased mammals, such as skunks, bats, raccoons, cats, dogs, cattle and foxes.
Gloves need not be worn when feeding students, or when wiping saliva from skin, unless blood is present or the caregiver has cuts or wounds on their hands. Unanticipated skin contact with body fluids may occur in situations where gloves may not be immediately available (when wiping a runny nose, applying pressure to a bleeding injury outside of the classroom, helping a student in the bathroom). In these instances, hands and other affected skin areas of all exposed persons should be thoroughly washed with soap and water as soon as possible. As much as possible, have the injured student provide direct care for the wound (applying pressure, washing). Staff and students should be reminded to take care to prevent injuries when using needles and other sharps. Broken glassware, discarded needles, and other sharps must not be picked up directly with the hands. Cleanup must be accomplished using mechanical means such as a brush and dustpan, tongs, or forceps, by staff wearing appropriate protective gloves. Broken glass should be disposed of in a container which keeps others from being cut. Contaminated, reusable sharps must not be stored or processed in a manner which requires employees to reach by hand into the containers where these sharps have been placed. Contaminated sharps must be discarded immediately in containers which are closable, puncture resistant, leak proof on sides and bottom, and labeled or color-coded. Containers for contaminated sharps must be easily accessible to personnel and located as close as possible to the immediate area where sharps are used (health rooms, science classrooms). Sharps containers must be maintained upright throughout use, replaced routinely, and not be allowed to overfill. When moving containers of contaminated sharps from the area of use, they must be closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. The secondary container must be closable, constructed to contain all contents, and prevent leakage during handling, storage, transport, or shipping. Containers for contaminated reusable sharps must meet all of the qualifications for disposable containers, except they do not need to be closeable, since devices will be removed from these containers. Puncture resistant sharps containers should be provided if contaminated sharps (needles) are in the workplace. Check with the environmental health office of your local health jurisdiction for any additional local infectious waste disposal requirements and for information in the absence of a local infectious waste management program. Cleaning schedules must be as frequent as necessary, depending on the area of the school, the type of surface to be cleaned, and the amount and type of contamination present. Cleaning with soap and water with wiping, particularly with microfiber cloths, will remove dirt and organic matter and the majority of microorganisms. In cases of contamination with body fluids, bathrooms, and high-touch surfaces, registered disinfectants or appropriate bleach solutions will kill most of the organisms which are left. Sterilizers destroy or eliminate all forms of microbial life including fungi, viruses, and all forms of bacteria and their spores. Sanitizers reduce the level of microorganisms to levels considered safe for general purposes. There are several classes of disinfectants which are registered by their effectiveness against specific microorganisms as well as their effectiveness on types of hard surfaces. Many of the active ingredients in disinfectant products are skin, eye, and respiratory irritants. Manufacturer label instructions must be followed, including those for personal protective equipment. The area to be disinfected must stay wet for the length of time indicated on the label to kill the microorganisms. When choosing a disinfectant, determine what microorganisms you want to protect against and the area it is to be used in. For general disinfection, choose a product that is effective against most bacteria and viruses and lists schools as a recommended site. Nonenveloped viruses such as noroviruses are more difficult to kill than vegetative (growing) bacteria and enveloped viruses such as influenzas.
The New Zealand soft tissue sarcoma case-control study: Interview findings concerning phenoxyacetic acid exposure. The aryl hydrocarbon receptor directs hematopoietic progenitor cell expansion and differentiation. Phenoxy herbicides and chlorophenols: A case-control study on soft tissue sarcoma and malignant lymphoma. Ah receptor activation potentiates neutrophil chemoattractant (C-X-C motif) ligand 5 expression in keratinocytes and skin. Post-traumatic stress disorder among American Legionnaires in relation to combat experience in Vietnam: Associated and contributing factors. A soft tissue sarcoma case-control study in a large multi-chemical manufacturing facility. Effect of developmental dioxin exposure on methylation and expression of specific imprinted genes in mice. Genome-wide profiling of 5-formylcytosine reveals its roles in epigenetic priming. Attenuating effect of lycopene and ellagic acid on 2,3,7,8-tetrachlorodibenzo-p-dioxin-induced spermiotoxicity and testicular apoptosis. Plasma polychlorinated biphenyl concentrations and immune function in postmenopausal women. The role of the aryl hydrocarbon receptor in the development of cells with the molecular and functional characteristics of cancer stem-like cells. Pesticide use and incident diabetes among wives of farmers in the Agricultural Health Study. Cancer, heart disease, and diabetes in workers exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin. A pilot epidemiologic study of possible health effects associated with 2,3,7,8-tetrachlorodibenzo-p-dioxin contaminations in Missouri. Individual differences in arsenic metabolism and lung cancer in a case-control study in Cordoba, Argentina. Aryl hydrocarbon receptor and aryl hydrocarbon nuclear translocator expression in human and rat placentas and transcription activity in human trophoblast cultures. Social and behavioral consequences of the Vietnam experience among American Legionnaires. Estimation of exposure to Agent Orange and other defoliants among American troops in Vietnam: A methodological approach. Exposure estimates in epidemiological studies of Korean veterans of the Vietnam War. Combat and herbicide exposures in Vietnam among a sample of American Legionnaires. Health and reproductive outcomes among American Legionnaires in relation to combat and herbicide exposure in Vietnam. Prenatal exposure to polychlorinated biphenyls and dioxins is associated with increased risk of wheeze and infections in infants. Growth and thyroid function in children with in utero exposure to dioxin: A 5-year follow-up study. In utero and lactational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin modulates dysregulation of the lipid metabolism in mouse offspring fed a high-calorie diet. Effects of cytochrome p450 inducers on the gene expression of ocular xenobiotic metabolizing enzymes in rats. Influence of dioxin exposure upon levels of prostate-specific antigen and steroid hormones in Vietnamese men. The relationship between dioxins exposure and risk of prostate cancer with steroid hormone and age in Vietnamese men.
A 10 mg/mL dilution may be made by adding 1 mL of this solution to 9 mL of sterile water for injection. Atropine, aztreonam, calcium gluconate, clindamycin, dexamethasone, heparin (concentrations 1 unit/mL), hydrocortisone succinate, iron dextran, isoproterenol, linezolid, metronidazole, norepinephrine, potassium chloride, procainamide, remifentanil, sodium bicarbonate, and vitamin K1. Terminal Injection Site Incompatibility Ampicillin, furosemide, heparin (concentrations >1 unit/mL), mezlocillin, nafcillin, oxacillin, penicillin G, propofol, and ticarcillin/clavulanate. Inactivation of netilmicin by penicillin-containing compounds appears to be a time-, temperature-, and concentration-dependent process. Obtain peak concentration 30 minutes after end of infusion, and trough concentration just prior to the next dose. Atropine, aztreonam, calcium gluconate, clindamycin, dexamethasone, heparin (concentrations 1 unit/mL), hydrocortisone succinate, iron 580 Micormedex NeoFax Essentials 2014 dextran, isoproterenol, linezolid, metronidazole, norepinephrine, potassium chloride, procainamide, remifentanil, sodium bicarbonate, and vitamin K1. Birth weight greater than 2 kg: 12 mg/dose orally for 3 doses in the first week of life; give first dose within 48 hours of birth, second dose 48 hours after first dose, and third dose 96 hours after second dose [1]. Zidovudine alone is appropriate for infants born to women who received antepartum/intrapartum antiretroviral therapy with effective viral suppression. The zidovudine/nelfinavir/lamivudine regimen was associated with increased toxicity (eg, neutropenia) [3]. Nevirapine is rapidly absorbed after oral administration to pregnant women and is highly lipophilic, resulting in therapeutic concentrations being readily transferred across the placenta to the fetus. Serum chemistries and liver enzyme tests may be considered based on maternal antiretroviral regimen received during pregnancy [1]. Special Considerations/Preparation Available as an oral suspension in a concentration of 10 mg/mL. Mirochnick M, Fenton T, Gagnier P et al: Pharmacokinetics of nevirapine in human immunodeficiency virus type 1-infected pregnant women and their neonates. There are no recommendations for use of nevirapine in premature neonates due to lack of safety and dosing data [1]. Special Considerations/Preparation 584 Micormedex NeoFax Essentials 2014 Available as an oral suspension in a concentration of 10 mg/mL. Product Information: Viramune(R) oral tablets, suspension, nevirapine oral tablets, suspension. Blood pressure will begin to decrease within minutes of starting the infusion, reaching half of its ultimate decrease in approximately 45 minutes. Blood pressure equilibrium will not be achieved for approximately 50 hours (adult data). Administration Intravenous: Dilute prior to administration to a concentration of 0. Contraindications/Precautions Contraindicated in patients with advanced aortic stenosis [1]. Pharmacology Nicardipine is a dihydropyridine calcium channel blocker that significantly decreases systemic vascular resistance. Following infusion in adults, nicardipine plasma concentrations decline tri-exponentially, with a rapid early distribution phase (alpha half-life of 2. Experience in neonates is limited, and there are no reported pharmacokinetic data. Freezing does not adversely affect the product, but exposure to elevated temperatures should be avoided. Amikacin, aminophylline, aztreonam, calcium gluconate, cefazolin, ceftizoxime, chloramphenicol, cimetidine, clindamycin, dobutamine, dopamine, enalaprilat, epinephrine, erythromycin lactobionate, esmolol, famotidine, fentanyl, gentamicin, heparin (concentrations of 1 unit/mL or less), hydrocortisone, lidocaine, linezolid, lorazepam, magnesium sulfate, metronidazole, midazolam, milrinone, morphine, nafcillin, nitroglycerin, norepinephrine, penicillin G potassium, piperacillin, potassium chloride, potassium phosphate, ranitidine, sodium acetate, sodium nitroprusside, tobramycin, trimethoprim/sulfamethoxazole, vancomycin, and vecuronium. Administration 587 Micormedex NeoFax Essentials 2014 Intravenous: Dilute prior to administration to a concentration of 0. Adverse Effects No adverse effects have been reported in neonates (small numbers). Monitoring Continuous monitoring of blood pressure, heart rate and rhythm during initiation of therapy, and frequently thereafter.
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