Zetia

Tran H. Tran, PharmD, BCPS

• Associate Professor, Department of Pharmacy Practice, Chicago College of Pharmacy, Midwestern University, Downers Grove
• Clinical Pharmacist, Loyola University Medical Center, Maywood, Illinois

Menorrhagia I: measured blood loss cholesterol test reliability cheap 10 mg zetia with amex, clinical features nutrition top 10 cholesterol lowering foods buy cheap zetia 10 mg on-line, and the Authors outcome in women with heavy periods: a survey with follow-up data cholesterol research buy zetia with a visa. J Reprod tute cholesterol hdl ratio discount 10 mg zetia fast delivery, and is on the faculty at the Carilion Clinic Family Medicine Residency Med. The effect of the levonorgestrel releas of risk factors for endometrial hyperplasia in premenopausal women ing intrauterine system on endometrial hyperplasia: an Australian study with abnormal menstrual bleeding. Nonsteroidal anti-infam ebrand disease in women with menorrhagia: a systematic review. Con Willebrand disease: key points from the 2008 National Heart, Lung, and trol of menorrhagia by the cyclo-oxygenase inhibitors naproxen sodium Blood Institute guidelines. Antifbrinolytics for heavy menstrual for identifying women with menorrhagia for hemostatic evaluation. Obstet Gyne Comparison of transvaginal sonography, saline infusion sonography, col. Endometrial carcinoma risk tional uterine bleeding: a randomized controlled trial. Concurrent endometrial carcinoma with the levonorgestrel-releasing intrauterine system or hysterectomy in women with a biopsy diagnosis of atypical endometrial hyperplasia: for treatment of menorrhagia: randomized trial 5-year follow-up. In the event of pregnancy the endometrium provides a place for the fertilized egg to attach and develop. The decision to recommend such a biopsy may come from an abnormal Pap smear result, abnormal bleeding patterns, bleeding after menopause, and evaluation of infertile couples, unusual vaginal discharge or concerns for an infection. The results of this test may give your provider information on how best to treat you. When your healthcare provider performs such a biopsy, he or she will need to place a speculum in the vagina; the same way a pap smear is collected, in order to see the cervix. Your provider may advise you not to have sexual relations, douche or use tampons for a few days after. More serious risks include heavy bleeding from the uterus, infection in the uterus, or putting a hole in the uterus with the biopsy instrument. Please let your provider know if you are experiencing increased bleeding or fever, or if you have worsening abdominal pain or other concerns in the days following your biopsy. The biopsy instrument needs to be passed through the opening in the cervix (the endocervical canal) and into the uterine cavity. This may be attempted with cervical dilators which are small plastic or metal rods of varying size. This may cause more cramping than usual and require an injection of numbing medicine in the cervix. Please inform your provider if you have other serious medical conditions such as heart disease, bleeding disorders or other serious health problems. Last Reviewed: April 2010 this information was reviewed and approved for content in April 2010. The uterus is where muscles) to help restore tone to the muscle a baby grows when a woman is pregnant. Your insert a pessary (rubber or plastic object) into doctor may also remove your fallopian tubes and your vagina to hold your uterus in place. Your doctor A: Sometimes a hysterectomy may be medically can prescribe medicine or do surgery to remove necessary. But sometimes you can try medicines or the scar tissue or growths without harming other treatments frst. Uterine fbroids are walls thicken and cause severe pain and heavy noncancerous growths in the uterine wall. Your doctor may also try other procedures, like be the best option if you have cancer in myomectomy or endometrial ablation, before these organs. Hormonal A: All women who have a hysterectomy will stop birth control may help to lighten heavy bleeding, getting their period. This is more common in women who have had If you keep your ovaries during the hysterectomy, several vaginal births, but it can also happen you should not have other menopausal symptoms after menopause or because of obesity. Some women have you will no longer have periods and you may have vaginal dryness or less interest in sex after a other menopausal symptoms right away. Talk to your doctor about how A: Hysterectomy is a major surgery, so recovery can to prevent these problems. If your ovaries are removed during the hysterectomy, once enjoyed, or less energy, that last longer than you may have other menopause symptoms. This clinical care standard describes the care you should be offered if you have heavy menstrual bleeding. You can use this information to help you make informed decisions in partnership with your clinician. Assessment and diagnosis What the standard says the initial assessment of a woman presenting with heavy menstrual bleeding includes a detailed medical history, assessment of impact on quality of life, a physical examination, and exclusion of pregnancy, iron defciency and anaemia. They will ask about your past general health and family medical problems, your sexual health, previous pregnancies and births, current sexual activity, and whether you wish to become pregnant. With your consent, your clinician will carry out an internal physical examination to feel your uterus by placing their fngers inside your vagina. Whether you need any other tests will depend on your individual assessment, but these may include blood tests, a cervical screening test, or an ultrasound. Informed choice and shared decision making What the standard says A woman with heavy menstrual bleeding is provided with consumer-focused information about her treatment options and their potential benefts and risks. She is asked about her preferences in order to support shared decision making for her clinical situation. When discussing your treatment, your clinician will give you information about your condition and the options available to you, using plain, non-medical language. Your preferences are an important part of the decision-making process which should involve both you and your clinician. Heavy Menstrual Bleeding Clinical Care Standard Consumer Fact Sheet | Published October 2017 Initial treatment is pharmaceutical What the standard says A woman with heavy menstrual bleeding is offered pharmaceutical treatment, taking into account evidence-based guidelines, her individual needs and any associated symptoms. Initial treatment is provided to a woman who is undergoing further investigations to exclude malignancy and signifcant pathology. Which medicine is suitable for you will depend on several factors such as whether your period is regular, whether you need contraception and your other health conditions. There are several options, including medicines that are swallowed and those delivered in other ways, such as from a small device placed inside your uterus. If the frst medicine you try is not satisfactory, you can return to your clinician to discuss other options. If tests are recommended, the treatment provided may be temporary, but should give you relief while you are waiting for the necessary medical appointments. One method involves the ultrasound operator placing a narrow ultrasound probe in your vagina. This is called a transvaginal ultrasound, and is preferred because it provides a better view of the uterus and pelvic structures. The second method involves using the ultrasound probe on the outside of your lower abdomen (tummy), while you have a full bladder. However a transvaginal ultrasound may not be possible or you may choose not to have the ultrasound this way.

Survivors or responders who show distressing symptoms or disturbed behavior should be educated to understand that their reactions are common cholesterol nuts zetia 10 mg without a prescription, normal responses to the extreme events cholesterol lowering foods omega 3 cheap zetia 10 mg with visa. Normalization is undermined if survivors or responders who are not experiencing disruptive distress show a derogatory or punitive attitude to others who are what causes cholesterol in shrimp order zetia 10mg free shipping. Pre and post-trauma education should include helping the asymptomatic trauma survivor or responder understand that the acute stress reactions of other people are common and probably transient and do not indicate personal failure or weakness cholesterol levels nz normal range generic zetia 10mg with amex, mental illness, or health problems. Education should also include positive messages by identifying and encouraging positive ways of coping, describing simple strategies to resolve or cope with developing symptoms and problems, and setting expectations for mastery and/or recovery. Routine debriefing or formal psychotherapy is not beneficial for asymptomatic individuals and may be harmful. Also unstudied is whether reassurance of normality and likely recovery, provided by co-survivor peers or helpers, actually serves to promote normalization. Recent literature in the area of trauma has highlighted the potential for interventions to exacerbate trauma reactions. Asymptomatic survivors should not be offered services that extend beyond delivery of Psychological First Aid and education. Psychotherapy intervention may actually cause harm in persons not experiencing symptoms of acute stress (Roberts, Kitchiner et al. Screening and needs assessments for individuals, groups, and populations are important for the provision of informed early intervention following a major incident or traumatic event. When available, the evidence and supporting research are presented in evidence tables. The approach to triage in the immediate response to traumatic exposure for service members with symptoms during Ongoing Military Operations may vary from the management of civilians exposed to traumatic events. Traumatic events are events that cause a person to fear that he/she may die or be seriously injured or harmed. These events also can be traumatic when the person witnesses them happening to others. Such events often create feelings of intense fear, helplessness, or horror for those who experience them. Onset of at least some signs and symptoms may be simultaneous with the trauma itself or may follow the trauma after an interval of hours or days. Symptoms may include depression, fatigue, anxiety, decreased concentration/memory, irritability, agitation, and exaggerated startle response. There are a number of possible reactions to a traumatic situation, which are considered within the "norm" for persons experiencing traumatic stress. Cognitive/mental: amnestic or dissociative symptoms, hypervigilance, paranoia, intrusive re-experiencing d. Providers should confirm that the symptoms are not due to identified medical/surgical conditions requiring other urgent treatment. In the aftermath of any extreme stressful event, most of those suffering from acute traumatic stress reactions will be easy to spot. Among the uninjured there will also be many who look stunned, appear pale and faint, or can be seen to be shaking. Some of those who appear to be suffering from trauma may not even be the actual victims of the disaster but witnesses or rescuers who may be deeply affected by what they are seeing. Some may not be immediately identifiable as traumatized, because they may be highly active looking for others or looking after others and organizing help and rescue. Once the patient is in a safe situation, the provider should attempt to reassure the patient, encourage a professional healing relationship, encourage a feeling of safety, and identify existing social supports. Establishing safety and assurance may enable people to get back on track, and maintain their pre-trauma stable condition. Address acute medical/behavioral issues to preserve life and avoid further harm by: a. Arrange a safe, private, and comfortable environment for continuation of the evaluation: a. Maintain a supportive, non-blaming, non-judgmental stance throughout the evaluation d. Assist with the removal of any ongoing exposure to stimuli associated with the traumatic event. Evacuate to next level of care if unmanageable, if existing resources are unavailable, or if reaction is outside of the scope of expertise of the care provider. Risk factors for suicide should also be assessed, such as current depression and substance abuse. If significant suicidality is present, it must be addressed before any other treatment is initiated. Some individuals with stress reactions could be at risk for violence toward others. This can be manifested through explosivity and anger problems and may predict risk for violent behavior. Their normal shelter, clothing, and other basic resources may be destroyed or inaccessible. Early interventions should typically seek to address the needs of the individual person, with the aim of promoting normal recovery, resiliency, and personal growth and avoiding additional harm (see Table A-1 Early Interventions. Individual persons who were exposed to trauma as members of a group/unit that existed prior to the trauma event. Some of the acute interventions, such as psychoeducation, may be provided in a group format to maintain unit integrity and promote continuity with established relationships. If indicated, reduce use of alcohol, tobacco, caffeine, and illicit psychoactive substances. Assign job tasks and recreational activities that will restore focus and confidence and reinforce teamwork (limited duty). When the patient is in a safe situation, the clinician should attempt to reassure the patient and encourage a feeling of safety. The fewer traumatic stimuli people see, hear, smell, taste, or feel, the better off they will be. When possible, direct ambulatory survivors: o Away from the site of destruction o Away from severely injured survivors o Away from continuing danger. Connect: Survivors who are encountered will usually have lost connection to the world that was familiar to them. A supportive, compassionate, and nonjudgmental verbal or nonverbal exchange between you and survivors may help to give the experience of connection to the shared societal values of altruism and goodness. Help survivors connect: o To loved ones o To accurate information and appropriate resources o To locations where they will be able to receive additional support o To unit comrades and mission, fostering vertical and horizontal cohesion. However, some may require immediate crisis intervention to help manage intense feelings of panic or grief. It is included as part of the Fundamental Criteria for First Aid knowledge and skills that soldiers should be trained in order to save themselves or other soldiers in casualty situations.

Then I launched an alternative medicine practice specializing in not only vitamins and mineral the National Organization for the Reform of Marijuana Laws (norml cholesterol test not covered by insurance order zetia 10 mg with mastercard. But despite my own past experience with non-traditional therapies cholesterol of 240 discount zetia online, I was still skeptical about medicinal cannabis when it became legal in California cholesterol pills grapefruit juice discount 10 mg zetia overnight delivery. My practice had to be cash-only as insurance would only pay for prescription treatments cholesterol levels high discount zetia 10 mg fast delivery. As my practice dwindled and people became more and more dependent upon government-paid programs for their health care, I started doing some more research (in the most literal and technical sense). In the end, I was convinced that marijuana was a valuable addition to the Pharmacopoeia of medicinal products and pharmaceutical substances. My field is still a challenge, due to the refusal of the federal government to recognize the medical use of cannabis. Follow up studies by investigators demonstrated that the administration of the nonpsychotropic plant cannabinoid 2 cannabidiol also mitigated memory loss in a mouse model of the disease. Writing in the journal Neuroscience, they reported that rats treated with the compound experienced a 50 percent improvement in memory and a 40 to 50 percent reduction in inflammation 5 compared to controls. Participants experienced decreased incidences of delusions, agitation, irritability, and apathy following treatment. Safety and efficacy of medical cannabis oil for behavioral and psychological symptom of dementia: An open label, add-on, pilot study. Amyotrophic lateral sclerosis: delayed disease progression in mice by treatment with a cannabinoid. Cannabis and amyotrophic lateral sclerosis: hypothetical and practical applications, and a call for clinical trials. Can cannabinoids be a potential therapeutic tool in amyotrophic lateral sclerosis Majorities further report that cannabis possesses fewer side effects than conventional pain medications and 4 that it provides greater symptom management than opioids. In addition to these anecdotal claims, numerous clinical trials report that inhaled marijuana alleviates neuropathic pain. A recent review identifies 35 controlled studies specific to the use of cannabis or 5 cannabinoids in pain treatment, involving over 2, 000 subjects. A University of California at Davis double-blind, randomized clinical trial reported both high and low doses of inhaled cannabis reduced neuropathic pain of 9 diverse causes in subjects unresponsive to standard pain therapies. A McGill University study reported that smoked cannabis significantly improved measures of pain, sleep quality and anxiety in 10 participants with refractory pain for which conventional therapies had failed. Clinical trials also report that vaporized cannabis is effective at mitigating pain. Incorporating cannabinergic medicine topics into pain medicine education seems 17 warranted and continuing clinical research and empiric treatment trials are appropriate. Longitudinal trials have also shown cannabis therapy to be safe and effective for pain treatment. A one-year assessment of Canadian chronic pain patients reported that daily use of herbal cannabis was associated with sufficient safety and efficacy. Compared to controls, patients in the cannabis use group experienced a significant reduction in average pain intensity while reporting no increased risk of adverse cognitive or pulmonary events. Cannabis dosing also permits some chronic pain patients to significantly reduce their use of opioids. A separate University of Michigan study of 244 chronic pain subjects similarly reported that cannabis use led to 25 a 64 percent decrease in opioid consumption. A 2016 study produced by Castlight Health similarly reports that rates of unauthorized opiate use is 29 significantly lower in medical cannabis jurisdictions. Incidences of opioid-related hospitalizations 30 31 and traffic-related fatalities have also fallen, as have overall prescription drug spending. Dose-dependent effects of smoked cannabis on Capsaicin-induced pain and hyperalgesia in healthy volunteers. A randomized, placebo-controlled, crossover trial of cannabis cigarettes in neuropathic pain. Comparison of the analgesic effects of dronabinol and smoked marijuana in daily marijuana smokers. Pharmacokinetics, Efficacy, Safety, and Ease of Use of a Novel Portable Metered Dose Cannabis Inhaler in Patients With Chronic Neuropathic Pain: A Phase 1a Study. An exploratory human laboratory experiment evaluating vaporized cannabis in the treatment of neuropathic pain from spinal cord injury and disease. Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. Cannabinergic pain medicine: a concise clinical primer and survey of randomized controlled trial results. Cannabinoids for the treatment of chronic non-cancer pain: An updated systematic review of randomized controlled trials. Antihyperalgesic effect of a Cannabis sativa extract in a rat model of neuropathic pain. The effect of medicinal cannabis on pain and quality of life outcomes in chronic pain: A prospective open-label study. Medical cannabis use is associated with decreased opiate medication use in a retrospective cross-sectional survey of patients with chronic pain. Medical cannabis laws and opioid analgesic overdose mortality in the United States, 1999-2010. Medical marijuana policies and hospitalizations related to marijuana and opioid pain reliever. Medical marijuana laws and the prevalence of opioids detected among fatally injured drivers. Individuals diagnosed with type 1 diabetes (also known as juvenile diabetes) are incapable of producing pancreatic insulin and must rely on insulin medication for survival. Individuals diagnosed with type 2 diabetes (also known as adult onset diabetes) produce inadequate amounts of insulin. Over time, diabetes can lead to blindness, kidney failure, nerve damage, hardening of the arteries and death. The disease is the third leading cause of death in the United States after heart disease and cancer. Preclinical and observational studies indicate that cannabinoids are inversely associated with 1 diabetes, may modify disease progression, and that they also may provide symptomatic relief to 2-3 those suffering from the disease. Investigators reported that 86 percent of untreated control mice in the 4 study developed diabetes. Other preclinical studies show that cannabinoid administration reduces diabetic-related tactile allodynia 8-9 (pain resulting from non-injurious stimulus to the skin) and symptoms of diabetic cardiomyopathy (weakening of the heart muscle). For example, a 2015 study published in the Journal of Pain reported that vaporized, whole-plant cannabis significantly reduces diabetic neuropathy in subjects resistant to other analgesics.

Best Practices for Cleaning low cholesterol foods breakfast purchase zetia 10mg free shipping, Disinfection and Sterilization in All Health Care Settings | May 2013 44 Soak and manually clean all immersible endoscope components with water and a recommended cleaning agent prior to automated or further manual disinfection or sterilization cholesterol treatment purchase zetia 10 mg fast delivery. The following steps must be included in the disinfection/sterilization procedure: Choose a disinfectant that is compatible with the endoscope cholesterol khan academy zetia 10mg without a prescription. Depending on the intended use of the device cholesterol levels chart singapore generic zetia 10mg with amex, tap water followed by a 70-90% alcohol 41 rinse may be acceptable. High-level disinfection of cystoscopes should be followed by a sterile water 29 43 rinse. A disposable sheath/condom placed over the endoscope during use reduces the numbers of microorganisms 44 on the scope but does not eliminate the need for cleaning/disinfection/sterilization between uses. If reusable biopsy forceps/brushes are used, they must be meticulously cleaned prior to sterilization using ultrasonic cleaning. Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings | May 2013 46 14, 40 Record the endoscope number in the client/patient/resident record. Patency and integrity of the endoscope sheath shall be verified through leak testing, performed after each use. Endoscopic equipment/devices shall be rinsed and excess water removed prior to disinfection or sterilization. Semicritical endoscopes and accessories (excluding biopsy forceps and brushes) shall receive at least high-level disinfection after each use. Semicritical endoscopes shall be stored hanging vertically in a dedicated, closed, ventilated cabinet outside of the decontamination area and procedure room. Healthcare settings shall have policies in place providing a permanent record of endoscope use and reprocessing, as well as a system to track endoscopes and clients/patients/residents that includes recording the endoscope number in the client/patient/resident record. Unacceptable Methods of Disinfection/Sterilization the following methods of disinfection/sterilization are not recommended. Boiling water is inadequate for the destruction of bacterial spores and some viruses. It is not 23 an acceptable method of disinfection/sterilization for medical equipment/devices. Glass bead sterilizers are difficult to monitor for effectiveness, have inconsistent heating resulting in cold spots, and often have trapped air which affects the sterilization process. Glass bead sterilization is not an acceptable method of 23, 47 sterilization for medical equipment/devices. Chemiclaves are occasionally used in 48 dentistry, although steam sterilization is preferred due to the lack of penetration achieved in a chemiclave and 49 an overall failure rate of almost 5%. If used, a chemiclave must be monitored with mechanical, chemical and biological monitors as is any other sterilizer. Because of the environmental risks associated with formaldehyde, this method of 50 sterilization is no longer considered to be acceptable. If used, the process must be closely monitored, local regulations for hazardous waste disposal must be followed and air sampling for toxic vapours may be indicated. Home microwaves have been shown to inactivate bacteria, viruses, mycobacteria and some spores, however there may not be even 29 distribution of microwave energy over the entire device. More research and testing are required to validate the use of microwave ovens for sterilization. The use of microwave ovens for sterilization of medical 23, 29 equipment/devices is not currently acceptable. A written procedure must be established for the recall and reprocessing of improperly reprocessed medical 1, 2 equipment/devices. All equipment/devices in each processed load must be recorded to enable tracking in the event of a recall. Facilities should consider implementing commercial instrument tracking systems to facilitate identification of patients in the event of a recall. Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings | May 2013 49 Health care settings shall have a process for receiving and disseminating medical device alerts and recalls 14 originating from manufacturers or government agencies. Reusable medical devices that have been recalled due to a reprocessing failure shall be reprocessed prior to use. Health care settings shall have a process for receiving and disseminating medical device alerts and recalls originating from manufacturers or government agencies. Single-Use Medical Equipment/Devices Health care settings must not internally reprocess single use medical equipment/devices. Critical and semi critical medical equipment/devices labelled as single-use must not be reprocessed and re-used unless the 51, 52 reprocessing is done by a licensed reprocessor. If a facility enters into a contract with a 3 party reprocessor, the liability for adverse outcomes in the event of improper sterilization, or changes to equipment functionality, must be clear to both parties. In order to have single-use critical or semicritical medical equipment/devices reprocessed by one of these facilities, there must be processes for: tracking and labelling equipment/devices recalling improperly reprocessed medical equipment/devices assuring proof of sterility or high-level disinfection testing for pyrogens maintenance of equipment/device functionality and integrity quality assurance and quality control reporting adverse events provision of good manufacturing procedures. Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings | May 2013 50 Single-use medical equipment/devices are usually labelled by the manufacturer with a symbol: Whereas reusable medical equipment/devices are sold with instructions for proper cleaning and sterilization, no such instructions exist for single-use medical equipment/devices. Furthermore, manufacturers often have not provided data to determine whether the equipment/device can be thoroughly cleaned, whether the materials can withstand heat or chemical sterilization, or whether delicate mechanical and electrical components will 51 continue to function after one or more reprocessing cycles. In circumstances where the manufacturer does not approve of reuse, the facility may bear the brunt of legal responsibility in establishing when and under what conditions reuse of medical equipment/devices presents no increased risk to clients/patients/residents and that a reasonable standard of care was adhered to in the reuse of the equipment/device. This would involve written policies, extensive testing of reprocessing protocols and strict adherence to quality assurance investigations. This is a detailed and expensive process and should only be undertaken if there is a compelling reason to do so. Some examples of sharps which cannot be safely cleaned include needles, lancets, blades and glass. Further, reprocessing needles is a patient safety issue as there is no guarantee that the lumen is clean and that the reprocessing is effective. When purchasing sharps or devices with sharp components that cannot be safely cleaned, single-use devices or 1, 14 components shall be considered. This includes items such as catheters, drains and fine cannulae (excluding endoscopy equipment). These items should be designated single-use and not be reprocessed and re used, even if designated as reusable by the manufacturer. Home health care agencies may consider re-using single-use semicritical medical equipment/devices for a single client in their home when reuse is safe and the cost of replacing the equipment/device is prohibitive for the client. Best Practices for Cleaning, Disinfection and Sterilization in All Health Care Settings | May 2013 51 Recommendations 79. The health care setting must have written policies regarding single-use medical equipment/devices. It is strongly recommended that catheters, drains and other medical equipment/devices with small lumens (excluding endoscopy equipment) be designated single-use and not be reprocessed and re used, even if designated as reusable by the manufacturer. Storage and Use of Reprocessed Medical Equipment/Devices 1 the shelf life of a sterile package is event-related rather than time-related. Event-related shelf life is based on the concept that items that have been properly decontaminated, wrapped, sterilized, stored and handled will remain sterile indefinitely, unless the integrity of the package is compromised. If the integrity of the package is compromised, the item can no longer be considered to be sterile and it must be reprocessed again before use. Requirements for this area include: Adequate storage space is provided to prevent crushing or damage to packages. Those performing this inspection must be provided with education that includes: validating results of chemical tape and internal monitors, if present visually inspecting the equipment/device for discolouration or soil; if present, the item is removed from service and reprocessed checking for defective equipment/devices and removing them from use checking for dampness or wetness. Reprocessed medical equipment/devices shall be stored in a clean, dry, environmentally-controlled location in a manner that minimizes contamination or damage. Purchasing and Assessing Medical Equipment/Devices and/or Products for Disinfection or Sterilization Processes 1. Medical equipment/devices that cannot be cleaned and reprocessed according to the recommended standards shall not be purchased or should be designated single-use. When purchasing reprocessing equipment or chemical products for reprocessing, consideration shall be given to Occupational Health requirements, client/patient/resident safety and environmental safety issues. The organization shall develop and maintain policies and procedures that apply to the sending, transporting, receiving, handling and processing of loaned, shared and leased medical equipment/devices, including endoscopes.

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