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Burns disrupt the skin hypertension diet buy aldactone visa, which leads to increased fluid loss; infection; hypothermia; scarring; compromised immunity; and changes in function cardiac arrhythmia 4279 order 25 mg aldactone with mastercard, appearance blood pressure chart new safe 25 mg aldactone, and body image blood pressure kids 25 mg aldactone amex. Young chil dren and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries. Burn Depth and Breadth Depth the depth of a burn injury depends on the type of injury, causative agent, temperature of the burn agent, duration of contact with the agent, and the skin thickness. Burns are clas sified according to the depth of tissue destruction: • Superficial partial-thickness burns (similar to first-degree), such as sunburn: the epidermis and possibly a portion of the dermis are destroyed. Extent of Body Surface Area Burned How much total body surface area is burned is determined by one of the following methods: • Rule of Nines: an estimation of the total body surface area burned by assigning percentages in multiples of nine to major body surfaces. Burn Injury 109 • Palm method: used to estimate percentage of scattered B burns, using the size of the patients palm (about 1% of body surface area) to assess the extent of burn injury. Gerontologic Considerations Elderly people are at higher risk for burn injury because of reduced coordination, strength, and sensation and changes in vision. Predisposing factors and the health history in the older adult influence the complexity of care for the patient. Pul monary function is limited in the older adult and therefore airway exchange, lung elasticity, and ventilation can be affected. Decreased cardiac function and coronary artery disease increase the risk of complications in elderly patients with burn injuries. Malnutrition and presence of diabetes mellitus or other endocrine disorders present nutritional challenges and require close monitoring. Varying degrees of orientation may present themselves on admission or through the course of care making assessment of pain and anxiety a challenge for the burn team. The skin of the elderly is thinner and less elastic, which affects the depth of injury and its ability to heal. Medical Management Four major goals relating to burn management are prevention, institution of life-saving measures for the severely burned person, prevention of disability and disfigurement, and rehabilitation. Nursing Management: Emergent/ Resuscitative Phase Assessment • Focus on the major priorities of any trauma patient; the burn wound is a secondary consideration, although aseptic 110 Burn Injury management of the burn wounds and invasive lines con B tinues. Note amount of urine obtained when catheter is inserted (indicates preburn renal function and fluid status. Burn Injury 111 • Report labored respirations, decreased depth of respirations, B or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies. Maintaining Normal Body Temperature • Provide warm environment: use heat shield, space blanket, heat lights, or blankets. Minimizing Pain and Anxiety • Use a pain scale to assess pain level (ie, 1 to 10); differen tiate between restlessness due to pain and restlessness due to hypoxia. Provide individualized responses to support patient and family cop ing; explain all procedures in clear, simple terms. Administer fluid resuscitation as ordered in response to physical findings; continue monitoring fluid status. Burn Injury 113 Nursing Management: Acute/ B Intermediate Phase the acute or intermediate phase begins 48 to 72 hours after the burn injury. Assessment • Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications. Preventing Infection • Provide a clean and safe environment; protect patient from sources of crosscontamination (eg, visitors, other patients, staff, equipment. Maintaining Adequate Nutrition • Initiate oral fluids slowly when bowel sounds resume; record tolerance—if vomiting and distention do not occur, fluids 114 Burn Injury may be increased gradually and the patient may be advanced B to a normal diet or to tube feedings. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feed ings); note residual volumes. Relieving Pain and Discomfort • Frequently assess pain and discomfort; administer analgesic agents and anxiolytic medications, as prescribed, before the pain becomes severe. Assess and document the patients response to medication and any other interventions. Promoting Physical Mobility • Prevent complications of immobility (atelectasis, pneumo nia, edema, pressure ulcers, and contractures) by deep breathing, turning, and proper repositioning. When legs are involved, apply elastic pressure bandages before assisting patient to upright position. Strengthening Coping Strategies • Assist patient to develop effective coping strategies: Set spe cific expectations for behavior, promote truthful communi cation to build trust, help patient practice coping strategies, and give positive reinforcement when appropriate. Enlist a noninvolved person for patient to vent feelings without fear of retalia tion. Supporting Patient and Family Processes • Support and address the verbal and nonverbal concerns of the patient and family. Assess and consider preferred learning styles; assess ability to grasp and cope with the information; determine barriers to learning when planning and executing teaching. Monitoring and Managing Potential Complications • Heart failure: Assess for fluid overload, decreased cardiac output, oliguria, jugular vein distention, edema, or onset of S3 or S4 heart sounds. Assess for decrease in tidal volume and lung com pliance in patients on mechanical ventilation. Fas ciotomies may be necessary to relieve swelling and ischemia in the muscles and fascia; monitor patient for excessive blood loss and hypovolemia after fasciotomy. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status continue to be important. Assessment • In early assessment, obtain information about patients educational level, occupation, leisure activities, cultural background, religion, and family interactions. Nursing Interventions Promoting Activity Tolerance • Schedule care to allow periods of uninterrupted sleep. Monitor fatigue, pain, and fever to determine amount of activity to be encouraged daily. Improving Body Image and Self-Concept • Take time to listen to patients concerns and provide real istic support; refer patient to a support group to develop coping strategies to deal with losses. Promote a healthy body image and self-concept by help ing patient practice responses to people who stare or ask about the injury. Burn Injury 119 • Teach patient ways to direct attention away from a disfig B ured body to the self within. Monitoring and Managing Potential Complications • Contractures: Provide early and aggressive physical and occupational therapy; support patient if surgery is needed to achieve full range of motion. Evaluation Expected Patient Outcomes • Demonstrates activity tolerance required for desired daily activities 120 Burn Injury • Adapts to altered body image B • Demonstrates knowledge of required self-care and follow up care • Exhibits no complications For more information, see Chapter 57 in Smeltzer, S. Pathophysiology the abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth-regulating signals in the envi ronment surrounding the cell. The cells acquire invasive char acteristics, and changes occur in surrounding tissues. The cells infiltrate these tissues and gain access to lymph and blood ves sels, which carry the cells to other areas of the body. This phe nomenon is called metastasis (cancer spread to other parts of the body. Cancerous cells are described as malignant neoplasms and are classified and named by tissue of origin. The failure of the immune system to promptly destroy abnormal cells permits these cells to grow too large to be managed by normal immune mechanisms. Certain categories of agents or factors implicated in carcinogenesis (malignant transformation) include viruses and bacteria, physical agents, chemical agents, genetic or familial factors, dietary factors, and hormonal agents. Cancer is the second leading cause of death in the United States, with most cancers occurring in men and in people older than 65 years. Clinical Manifestations • Cancerous cells spread from one organ or body part to another by invasion and metastasis; therefore, manifesta tions are related to the system affected and degree of dis ruption (see the specific type of cancer. Assessment and Diagnostic Methods Screening to detect early cancer usually focuses on cancers with the highest incidence or those that have improved sur vival rates if diagnosed early. Examples of these cancers include breast, colorectal, cervical, endometrial, testicular, skin, and oropharyngeal cancers. Patients with suspected can cer undergo extensive testing to • Determine the presence and extent of tumor.

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Acceleration-deceleration injury: Brain rapidly acceler sion pulse pressure and stroke volume relationship buy generic aldactone pills, contusion blood pressure chart age nhs cheap 100 mg aldactone amex, laceration heart attack untreated buy 100mg aldactone visa, hemorrhage arrhythmia xanax purchase cheap aldactone, or skull fractures. Concussion: most minor and most common form of the skull, causing tearing of neuronal tissue and cerebral head injury blood vessels. Rotational acceleration-deceleration injury: Forces brain (intracerebral) or surrounding structures affected, cause the brain to twist within the skull, resulting in tor such as subdural, epidural, subarachnoid, brainstem sion and shearing of nerve tissue and blood vessels. Secondary brain injury (Granacher, 2003) other brain injuries, particularly contusions, with i. Thought to involve inflammation and the natural signs and symptoms dependent on the size and loca process of programmed cell death (apoptosis) tion and may be apparent immediately or develop ii. Acute subdural hematoma: caused by venous bleed brain, or stretching or shearing of blood vessels from ing when bridging veins are torn, occurring in 5% to the same forces, producing hemorrhage 25% of all severe head injuries involving a contusion iii. Systemic or neurological complications can also cause or or laceration and often accompanying intracerebral exacerbate secondary brain injury—hypotension, hy bleeding (Reddy, 2006); signs and symptoms present poxia, hypercapnia, intracranial hypertension, acid-base almost immediately and increase rapidly. Epidural hematoma: arterial bleeding usually from hyperthermia, infection, cerebral ischemia, seizures, and the middle meningeal artery in the temporal region, hypoglycemia or hyperglycemia. Falls: 28%, highest for children aged 0 to 4 and those individuals incur neurological deterioration (Reddy, aged 75 or older 2006. Gunshot wound head trauma is the cause 2002–2006, on average, annually approximately 1. Apraxia: Inability to perform complex or skilled movement Hematoma, intracranial: Collection of blood within the skull or use objects properly in the absence of sensory or motor caused by ruptured blood vessels, which may be localized in impairments. Hemiparesis: Weakness or partial paralysis of one side of the Closed head injury: Blunt trauma to the brain or brain structures body. Long-term physical, mental, social, or occu such as blow to the head or sudden deceleration, causing tem pational consequences often result (Bay, 2007. Care Setting Related Concerns this plan of care focuses on acute care and acute inpatient Brain infections: meningitis and encephalitis, page 229 rehabilitation. Thrombophlebitis: venous thromboembolism (including pulmonary emboli considerations), page 109 Total nutritional support: parenteral/enteral feeding, page 437 Upper gastrointestinal/esophageal bleeding, page 281 Client Assessment Database Data depend on type, location, and severity of injury and may be complicated by additional injury to other vital organs. Behavior or personality changes (subtle to dramatic) may in changes and behavioral problems are the most difficult clude depression, apathy, anxiety, irritability, impulsivity, anger, disabilities to handle. Pupillary changes—response to light and symmetry; deviation • Amnesia surrounding trauma events of eyes, inability to follow • Visual changes, such as double vision, movement of print or. Facial asymmetry stationary objects such as walls and floor; eye strain and visual. Heightened sensitivity to touch and movement—can be painful • Tingling, numbness in extremities and/or initiate storming • Loss of or changes in senses of taste or smell. Apraxia, hemiparesis, quadriparesis • Proprioception • Difficulty with hand-eye coordination • Mental status changes, including altered orientation, alertness or responsiveness, attention, concentration, problem-solving, emotional affect or behavior, and memory. Withdrawal response to painful stimulus • Other body pain, especially when brain injury is a component. With contu sions, may reveal progressive abnormalities and lack of tissue repair by the appearance of abnormal waves. Sodium, potassium, calcium, and magnesium are common aphoresis can result in elevated sodium (hypernatremia. Condition, prognosis, complications, and treatment regi men understood and available resources identified. These levels do not require cooperation from the client and are based on clients response to environmental stimuli and a range of behav ioral responses, including no response, confused-agitated, and purposeful-appropriate. Assess verbal response; note whether client is alert, oriented Measures appropriateness of speech and content of conscious to person, place, and time, or is confused, uses inappro ness. If minimal damage has occurred in the cerebral cor priate words and phrases that make little sense. More extensive damage to the cerebral cortex may be displayed by slow response to com mands, lapsing into sleep when not stimulated, disorienta tion, and stupor. Damage to midbrain, pons, and medulla is manifested by lack of appropriate responses to stimuli. Assess motor response to simple commands, noting pur Measures overall awareness and ability to respond to external poseful (obeys command, attempts to push stimulus stimuli. Best indicator of state of consciousness in a client away) and nonpurposeful (posturing) movement. Note limb movement and document right and left Consciousness and involuntary movement are integrated if sides separately. Purposeful movement can include grimacing or withdrawing from painful stimuli or movements that the client desires, such as sitting up. Other movements (posturing and abnormal flexion of extremities) usually indi cate diffuse cortical damage. Absence of spontaneous move ment on one side of the body indicates damage to the motor tracts in the opposite cerebral hemisphere. Hypo volemia or hypotension associated with multiple trauma may also result in cerebral ischemia and damage. Heart rate and rhythm, noting bradycardia, alternating Changes in rate (most often bradycardia) and dysrhythmias bradycardia and tachycardia, and other dysrhythmias may develop without impacting hemodynamic stability. However, dysrhythmias can reflect brainstem pressure or injury in the absence of underlying cardiac disease. Tachy cardia can reflect hydration status, fever or hypermetabolic state, and sympathetic storming. Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation. Assess position and movement of eyes, noting whether in Position and movement of eyes help localize area of brain in midposition or deviated to side or downward. Loss of dolls eyes indicates deterioration in brainstem function and poor prognosis. Note presence or absence of reflexes—blink, cough, gag, and Altered reflexes reflect injury at level of midbrain or brainstem Babinski. Pres ence of Babinski reflex indicates injury along pyramidal pathways in the brain. Limit use of blankets; administer tepid sponge bolic needs and oxygen consumption occur (especially with bath in presence of fever. Note skin Useful indicators of total body water, which is an integral part turgor and status of mucous membranes. Alterations may lead to hypo volemia or vascular engorgement, either of which can negatively affect cerebral pressure. Support Turning head to one side compresses the jugular veins and with small towel rolls and pillows. Periodically check position and fit of cervical Tight-fitting collar and ties can also limit jugular venous collar or tracheostomy ties when used. Help client avoid or limit coughing, vomiting, and straining these activities increase intrathoracic and intra-abdominal at stool or bearing down, when possible. Note: Cautious use may be indicated to prevent injury to client when other measures, including medications, are ineffective. Limit number and duration of suctioning passes, for example, Prevents hypoxia and associated vasoconstriction that can im two passes less than 10 seconds each. Assess for nuchal rigidity, twitching, increased restlessness, Indicative of meningeal irritation, which may occur because of irritability, and onset of seizure activity. Note: Presence of hypotension can compromise cerebral perfu sion pressure, negating beneficial effect of elevating head of bed. Determines respiratory sufficiency (presence of hypoxia and acidosis) and indicates therapy needs. Indi viduals being treated with mannitol must receive adequate fluid resuscitation to prevent hypovolemia and hypotension. The purpose of the therapy is to protect neurons by decreasing the cerebral metabolic rate, altering vascular tone, and in hibiting some of the biochemical intracellular events known to cause secondary brain injury. Because this therapy causes respiratory depression, it should only be used while client is on a ventilator. Note: Use of sedatives and opioids for cerebral protection can suppress signs and symptoms of sympathetic storming. The onset of storming episodes fre quently coincides with being weaned off these medications.

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The further role of the stewardship state with respect to responding to inequalities provides clear justification for state action in combating discrimination and in actively promoting a fair society heart attack purchase cheapest aldactone. We suggest that this understanding of the stewardship role of the state provides strong justification for action on the part of the state with respect to the ?demand side? factors that influence why people consider having a cosmetic procedure in the first place heart attack 70 blockage discount aldactone 25mg with mastercard, and which can be associated with discriminatory practices and harm to public health arteria espinal anterior order aldactone overnight delivery. Such action needs to be proportionate arteria ophthalmica buy generic aldactone on line, taking into account the need to justify potential intrusion into the rights and freedom of individuals. The social responsibilities of the business sector are not necessarily limited to complying with regulatory requirements. Where business takes such social responsibilities seriously, then the need for state action may be diminished: a self-regulatory system that operates well, for example, may be as effective in protecting individuals from public health harms or discrimination as a statutory system. The cosmetic procedures industry is not solely responsible for creating the appearance ideals that have been critiqued in this report. The stewardship role of the state also clearly justifies action to ensure that individuals are not put at the risk of unnecessary and avoidable harm. It is thus relatively uncontentious to argue for the setting and policing of standards across the sector that ensure that patients are treated in safe surroundings, with products or procedures that meet at least minimum safety requirements, and by practitioners who have the necessary skills and experience. In the regulation of therapeutic procedures, scope for benefit and the possibility of adverse outcome are weighed against each other, and risk is in some respects accepted in the context of potential health benefits. In the context of cosmetic procedures, we suggest that the appropriate level of physical risk to which patients / users should be exposed is considerably lower. We therefore suggest that, in the absence of physical health benefits, the regulation of invasive cosmetic procedures should start from the requirement proactively to demonstrate both user safety and effectiveness with respect to their claimed outcomes. The responsibility of the state to take action to enable adults to live healthy lives, and to protect them where possible from avoidable harms, is even stronger with respect to the protection of children and young people. While there is an increasing focus on the importance of children and young people participating in healthcare decision-making, this is premised on the assumption that the proposed treatment is recommended by a health professional, and is in the child?s best interests. Similarly, parental discretion with respect to the decisions parents take on behalf of children is not boundless. The fact that a parent consents to a cosmetic procedure on behalf of their child, or even initiates consideration of that procedure, does not necessarily mean that it is ethically acceptable for a professional to provide it. For pragmatic reasons, both law and policy frequently need to draw ?bright line? distinctions based on age, including determining the age at which in law, childhood and the associated parental responsibility comes to an end. We suggest that there are strong justifications for limiting access to cosmetic procedures to people over the age of 18, other than in exceptional cases. Some of the ethical challenges that arise in connection with the provision and use of cosmetic procedures fall outside the sphere of influence of individual practitioners. Nor are they responsible for the inadequate and patchwork nature of regulation in this field or for the failures of some parts of the industry to demonstrate corporate social responsibility. An ethical approach would include: Acting first and foremost in the best interests of their users / patients, and not taking on the role of a salesperson. The fact that cosmetic procedures constitute a physical intervention whose hoped-for benefits are primarily psychological highlights the importance of practitioners, at the very least, having access to psychological expertise, through multidisciplinary working or other forms of professional and peer support. Practitioners should not hesitate to probe in some depth what users hope to achieve, and be frank about the evidence as to how likely these aims are to be realised. This includes discussing alternative interventions where the evidence suggests that these are more likely to be effective. While ethical engagement between practitioner and user of cosmetic procedures cannot be reduced simply to the question of informed consent, nevertheless the approach taken to consent is a key element in that encounter. We suggest that in this context shared decision making where users or patients play an active role in decisions about their treatment or care may prove a better model than the traditional consent process, where patients are asked only to accept or refuse a treatment offered by their doctor. In genuinely shared decision-making, consultations should be partnerships between practitioner and user, in contrast both with the traditional understandings of the doctor / patient relationship and with models of consumer choice and high-pressure sales. Changes to promote more ethical practice are needed both on the ?demand? and on the ?supply? side, and two issues have emerged repeatedly throughout this inquiry that are significant in considering practical ways forward: the absence of high quality data with respect to many of the issues touched upon by this report; and the delays and failures of successive governments in responding to the series of major reports over the past decade that have laid bare the inadequate state of regulation of the cosmetic procedures industry. We therefore highlight where further work is urgently required to improve the information and research base. We also distinguish what, in our view, would be ideal and should be achieved in the long-term, and what may be more immediately achievable in the current regulatory environment. The ?stewardship? role of the state includes positive public action to enable people to flourish with respect to both their physical and their mental health. Such public action is justified to counteract both the specific claims made about the positive effects of cosmetic procedures, and more generally to counter the effects of broader visual and media cultures in which choices about cosmetic procedures are embedded. It also justifies action in response to inequality and discrimination: the development and marketing of cosmetic procedures has the scope to contribute to discriminatory attitudes by endorsing particular appearance ideals and offering technical ?fixes? to achieve them. Such responsibilities go wider than state actors, and we identify specific action that could be taken by industry both in the images and claims promulgated through advertising and in the wider role played by social and traditional media. In 2016, Transport for London (TfL) amended its advertising policy in order to refuse advertising that ?could reasonably be seen as likely to cause pressure to conform to an unrealistic or unhealthy body shape, or as likely to create body confidence issues particularly among young people?. Recommendation 3: We further recommend that the Advertising Standards Authority works proactively to monitor compliance with such standards, in line with its recent commitments to devote more resources to proactive review of advertisements and its ongoing work on body image. We welcome the fact that social media companies such as Facebook / Instagram are beginning to include concerns about body image in the campaigning and educational work they undertake among adolescents. In the light of the increasing concerns emerging with respect to correlations between social media use and such body image issues, we suggest that collaborative work across the sector to tackle these issues falls squarely within the remit of their corporate social responsibilities. Similarly, we suggest that marketing apps designed for children as young as nine that encourage them to ?play? at having cosmetic surgery makeovers, is clearly inappropriate and irresponsible. We endorse the campaign by Endangered Bodies which has established a petition to Apple, Google and Amazon requesting them to exclude xxvii C o s m e t i c p r o c e d u r e s : e t h i c a l i s s u e s from their app stores any cosmetic surgery games targeted at children. Broadcast media have also played a part in influencing how cosmetic procedures are perceived, particularly through the growth and popularity of cosmetic surgery makeover shows. While there is considerable diversity within the genre with respect to attitudes to body image and appearance ideals, a common feature conveyed by many is the idea that surgical ?fixes? to problems are always available. Recommendation 4: We recommend that the social media industry (including Facebook / Instagram, Snapchat, Twitter and YouTube) collaborate to establish and fund an independent programme of work, in order to understand better how social media contributes to appearance anxiety, and how this can be minimised; and to take action accordingly. Recommendation 5: We recommend that Ofcom review the available evidence and consider whether specific guidance to accompany its Broadcasting Code is warranted with respect to the tacit messages about body image and appearance ideals that may be conveyed by makeover shows involving invasive cosmetic procedures. Contemporary concerns about exclusion and discrimination in connection with appearance exist alongside significant momentum towards more inclusive attitudes towards diversity. The Face Equality Campaign, the BeReal campaign, and Models of Diversity, for example, all aim to promote acceptance of greater diversity of appearance in various sectors, including in business and employment. Discrimination on the grounds of appearance often coincides with, or contributes to, discrimination on other grounds, such as age, race and disability, that are already prohibited under the Equality Act 2010. Full use of existing powers, not only of enforcement, but also through advice and guidance, should be made to challenge discrimination based on appearance. Recommendation 6: We recommend that the Equality and Human Rights Commission: develop and publish specific guidance on disfigurement and appearance-related discrimination, founded on the requirements of existing equality legislation; and take discrimination related to appearance into account when monitoring discrimination relating to areas such as age, race, gender and disability. The stewardship role of the state is particularly strong in relation to its responsibilities to protect the welfare, including the mental health and well-being, of children. Given the way that many of the appearance-related pressures described in this report are embedded in xxviii C o s m e t i c p r o c e d u r e s : e t h i c a l i s s u e s technologies that are an increasingly important part of people?s lives, it is crucial to help children and young people to deal with them robustly from an early age, alongside action to challenge at source those pressures that are potentially discriminatory or harmful. We endorse the work of the Be Real campaign in developing and promoting evidence based teaching resources on body image, and emphasise the importance of all children having access to such resources. We endorse all Keogh?s recommendations, and believe that they should be implemented in full. Our recommendations seek wherever possible to make use of existing regulatory mechanisms, while also highlighting where we believe legislative change to be essential. We also urge the Royal College of Surgeons to consider how best to continue taking a leadership role with respect to promoting and supporting high standards in cosmetic surgery. In order to maintain impetus with respect to high standards in this commercialised area of surgery, a dedicated and permanent resource within the Royal College will be required. The regulation of invasive cosmetic products and procedures should start from the requirement proactively to demonstrate both safety and effectiveness with respect to their claimed outcomes. Much will depend on the content of the ?common specifications? to be developed for use by those making these assessments; and on how consistently these specifications will then be applied. Recommendation 8: We recommend to the European Commission that the ?common specifications? for the clinical assessment of cosmetic devices, to be developed under the Medical Devices Regulation 2017, should be based on the need proactively to demonstrate both safety and effectiveness with respect to their claimed benefits through clinical trial data and robust outcome measures. Marketing authorisation should be dependent on commitments to collect and publish long-term outcome data. Recommendation 12: We recommend that the Royal College of Obstetricians and Gynaecologists should review its guidance to its members on female genital cosmetic surgery and emphasise the need for evidence, demonstrating safety and effectiveness with respect to claimed outcomes, before procedures are offered outside a research setting. We recognise and endorse the progress that has been made with respect to the regulation of practitioners since the publication of the Keogh report.

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