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Standardization of light transmittance aggregometry for monitoring antiplatelet therapy: An adjustment for platelet count is not necessary blood pressure chart dental treatment generic 75mg triamterene with mastercard. Centrifuge at 1700 g for 10 minutes arteria yugular order 75mg triamterene, pool as appropriate pulse pressure and kidney disease discount triamterene 75 mg on-line, and store at 55C pending viral test results heart attack jokes generic triamterene 75 mg overnight delivery. Ensure that the above two steps and this step are completed within three to four minutes to prevent plasma thaw commencing. If partial thaw occurs, material will froth and freeze dry poorly, and it must be discarded. It has contributed to improvements in standardization and facilitating tests that demand specifc training and special working conditions, so that laboratories may improve their effciency and repertoire. Manual methods based on visual detection of the fibrin clot and using incubators at 37C were once the only techniques for coagulation studies. Then, in the 1970s, new semi-automatic equipment appeared based on photometric or mechanical principles to detect fibrin. More recently, fully automated instruments have become common in modern laboratories. Today, new equipment connected to specific data processing systems can undertake clotting, chromogenic, and immunological tests. The frst uses an electromagnetic feld applied to test cuvettes that detects movement within a stainless steel sphere placed in the plasma sample. The steel sphere follows a pendulum movement, swinging from one side to the other in a plasma reagent solution with a constant movement. As the fbrin begins to form, viscosity increases and the spheres movement is delayed. When the spheres oscillation movement reaches a predetermined level, the chronometer stops, indicating the time of plasma coagulation. A second mechanical detection method also uses a stainless steel sphere, located this time in a single point slot. When fbrin is formed, the clot captures the sphere, moving it from its original position. As it moves outside the sensors range, the circuit is interrupted and the chronometer stops (Thomas et al. As the clot is formed, there are changes in the optical characteristics from the initial reading of the plasma/reagents. These changes are monitored and used to derive the time taken for a particular degree of change to occur. In coagulation assays, a monochromatic laser light source is transmitted for example, by fbre optics. The light dispersion readings are made possible by a sensor that may be installed at 90 or 180 degrees from the light path, depending on the particular system, which then measures scattered light at an angle or records the change in light transmission. When the light reaches insoluble complexes such as fbrin fbres, it disperses in forward scattered angles (180 degrees) and lateral scattered angles (90 degrees). The chronometer stops when the amount of scattered light or transmitted light reaches a specifc predetermined level. The difference between light scattered or transmitted before and after the clot formation is normally proportional to the amount of fbrin formed. The frst coagulation equipment could only provide a single defnition parameter, such as a mechanical or photo-optical one. The photo-optical tools were initially designed for readings at a single wavelength (for example, 500 nm or 600 nm) that could only be used for the detection of clot formation. In the 1990s, a number of manufacturers successfully included multiple detection methods, which now give a single laboratory the possibility of applying different methodologies using the same equipment. Immunological principle Latex microparticles coated with a specifc antibody are generally used against the analyte (antigen) being measured. When the wavelength is greater than the suspension particle diameter, the particles absorb a small amount of light. Yet, when the specifc antibody-coated latex microparticles come in contact with the antigen present in the solution, they adhere to the antibody, forming links between the particles, which produces agglutination. When the particles diameter approaches the wavelength of the monochromatic light beam, a greater amount of light is absorbed. This increase in light absorbance is proportional to the agglutination, which, in turn, is proportional to the amount of the antigen present in the sample. This type of technology is available in more sophisticated coagulation analysers introduced in the market in the 1990s. Usually time-consuming standard immunological assays can be performed in minutes when using any of these automated tools. In the past, manual coagulation tests were inaccurate, with variation coeffcients greater than 20%; the semi-automatic equipment provided greater accuracy in coagulation testing. However, with manual dispatch of samples and reagents, testing has to be done in duplicate. With totally automated equipment accuracy improved, attaining variation coeffcients of less than 5%, and even 1% for some tests. This has led authors to introduce the notion of single tests and the possibility of reducing reagent costs and cuvettes by half. Permits sampling from a closed tube, which improves safety and effciency in coagulation tests. This reduces, to a great extent, the possibility of exposing the operator to sprays or patient sample spills, or mistakes in labelling. The equipment can be programmed for additional dilutions if the initial results escape the methods linearity. It can also automatically carry out other tests without the operators intervention if clinically indicated or because of initial run results. Most analysers include alarm systems that warn the operator of excess in pre-established readings, which may identify equipment problem. The different methodological types available have advantages and disadvantages that should be known and understood in order to guarantee precision and validity of test results. It is important to consider that laboratories are responsible for trustworthy results. A laboratorys main concern is to select the coagulation equipment that will generate appropriate results in spite of budget restraints. Such instruments demand regular technical maintenance, permanent knowledge, and system control, since a mistake or failure may decisively infiuence a number of results. Many laboratories may be fortunate enough to be able to evaluate equipment before purchasing. If this is not possible, it is very important to obtain adequate information and advice from a reference laboratory. Technology is on the rise and growing daily demands generate the need for instruments of this nature in the laboratory. They will constitute a great step forward in the lab feld, given the possibility of undertaking tests in a reliable, accurate, and precise manner, and delivering results in a shorter time period and under better control. Technology is continuously advancing to meet new developments in the feld and to reduce turnaround times, allowing tests to be reliable, accurate, and precise, while maintaining quality. Characteristics of specialized equipment Source: Rodak, 1995 Characteristics Description Random access With patients sample, various different tests are possible in any order and at the same time. Sample primary tube Plasma sample is directly taken by aspiration in an opened collection tube placed in the analyser. Penetrating plug and the analyser vacuums the plasma sample within the closed sampling tube collection tube with the rubber plug in place. Barcode Allows identi cation of reagent, patient samples, or both by means of a barcode. Bidirectional the analyser queries a centralized computer to determine inter-phase the requested number of tests. Liquid level sensor Warns the operator of insuf cient sample or reagent volume for adequate testing, or if the equipment did not vacuum enough from sample to perform the requested test. Integrated quality Instruments computer program stores and organizes control programs quality control data. It may include the complete application of Westgaard rules to indicate off-limit results. Refrigeration capacity Preserves the integrity of samples, reagent, or both during of integrated samples the veri cation process.

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Infected newborn infants may be IgM and IgA positive blood pressure emergency room purchase generic triamterene on line, IgM positive but IgA negative hypertension canada purchase triamterene 75mg otc, IgM negative but IgA positive heart attack vol 1 pt 2 order triamterene no prescription, or IgM and IgA negative hypertensive urgency guidelines order triamterene overnight. Although placental leak occasionally can lead to false-positive IgM or IgA reactions in the newborn infant, repeat testing after approximately 10 days of life can help confrm the diagnosis, because the half-life of these immunoglobulins is short and the titers in an infant who is not infected should decrease rapidly. Previously seropositive patients may have changes in their IgG titers in any direction (increase, decrease, or no change) without any clinical relevance. In this group of patients, other organisms, such as invasive mold infections and nocardia, should be considered before beginning an empiric trial of anti-T gondii therapy. Confrmatory testing for IgM may yield positive results in situations in which eye lesions are the result of a concomitant acute T gondii infection rather than reactivation of a chronic infection. When indicated (eg, chorioretinitis or signifcant organ damage), the combination of pyrimethamine and sulfadiazine, with supplemental 1 leucovorin (folinic acid) to minimize pyrimethamine-associated hematologic toxicity, is the regimen most widely accepted for children and adults with acute symptomatic disease (see Drugs for Parasitic Infections, p 848). In addition, pyrimethamine can be used in combination with clindamycin, atovaquone, or azithromycin if the patient does not tolerate sulfonamide compounds. Maternal therapy may decrease the severity of sequelae in the fetus once congenital toxoplasmosis has occurred. Oral ingestion of viable T gondii can be avoided by: (1) avoiding consumption of raw or undercooked meat and cooking meat particularly pork, lamb, and venison to an internal temperature of 65. At least 5 species capable of infecting only warm-blooded animals have been identifed. Commercial and home-raised pork remain a source of human infections, but meats other than pork, such as venison, horse meat, and particularly meats from wild carnivorous or omnivorous game (bear, boar, seal, and walrus) now are common sources of infection. Increases in concentrations of muscle enzymes, such as creatinine phosphokinase and lactic dehydrogenase, occur. Encapsulated larvae in a skeletal muscle biopsy specimen (particularly deltoid and gastrocnemius) can be visualized microscopically beginning 2 weeks after infection by examining hematoxylin-eosin stained slides or sediment from digested muscle tissue. Serologic tests are available through commercial and state laboratories and the Centers for Disease Control and Prevention. The public should be educated about the necessity of cooking pork and meat of wild animals thoroughly (>160F [71C] internal temperature). However, Trichinella organisms in wild animals, such as bears and raccoons, are resistant to freezing. People known to have ingested contaminated meat recently should be treated with albendazole (or mebendazole). Vaginal discharge usually is yellow-green in color and may have a disagreeable odor. The presence of symptoms and the identifcation of the organism are related directly to the number of organisms. If treatment failure occurs with metronidazole and reinfection is excluded, either metronidazole (either 250 mg, 3 times daily for 7 days, or 375 mg, 2 times daily for 7 days) or tinidazole (2 g, orally, in a single dose) can be used. Use of metronidazole (2 g, in a single dose) may be used at any stage of pregnancy. In the United States, trichuriasis no longer is a public health problem, although migrants from tropical areas may be infected. Mass treatment of infected school-aged populations can reduce whipworm transmission in communities with endemic infection. The rapidity and severity of clinical manifestations vary with the infecting subspecies. It is caused by the protozoan parasite Trypanosoma brucei, transmitted by bloodfeeding tsetse fies. The west and central African (Gambian) form is endemic and is caused by T brucei gambiense. The east and southern African (Rhodesian) form is more acute and is caused by T brucei rhodesiense. Both are extracellular protozoan hemofagellates that live in blood and tissue of the human host. The incubation period for T brucei rhodesiense infection is 3 to 21 days and usually is 5 to 14 days; for T brucei gambiense infection, the incubation period usually is longer but is not well defned. The symptoms of acute Chagas disease resolve without treatment within 3 months, and patients pass into the chronic phase of the infection. Patients with Chagas cardiomyopathy may die suddenly from ventricular arrhythmias, complete heart block, or emboli phenomena; death also may occur from intractable congestive heart failure. Reactivation of chronic T cruzi infection may occur in immunocompromised people, including people infected with human immunodefciency virus and those who are immunosuppressed after transplantation. Vectorborne transmission of the disease is limited to the Western hemisphere, predominantly Mexico and Central and South America. Nevertheless, most T cruzi-infected individuals in the United States are immigrants from areas of Latin America with endemic infection. The disease is an important cause of morbidity and death in Latin America, where an estimated 8 to 10 million people are infected, of whom 30% to 40% either have or will develop cardiomyopathy. When tuberculosis disease does occur, clinical manifestations most often appear 1 to 6 months after infection and include fever, weight loss, or poor weight gain and possibly growth delay, cough, night sweats, and chills. Renal tuberculosis and progression to disease from latent tuberculosis infection (adult-type pulmonary tuberculosis) are unusual in younger children but can occur in adolescents. In addition, chronic abdominal pain with intermittent partial intestinal obstruction can be present in disease caused by M bovis. Tuberculin reactivity appears 2 to 10 weeks after initial infection; the median interval is 3 to 4 weeks (see Tuberculin Testing, p 740). Infectious tuberculosis refers to tuberculosis disease of the lungs or larynx in a person who has the potential to transmit the infection to other people. It is defned as infection or disease caused by a strain of M tuberculosis complex that is resistant to isoniazid and rifampin, at least 1 fuoroquinolone, and at least 1 of the following parenteral drugs: amikacin, kanamycin, or capreomycin. Transmission of M tuberculosis complex is airborne, with inhalation of droplet nuclei usually produced by an adult or adolescent with contagious pulmonary or laryngeal tuberculosis disease. Unusual cases of adult-form pulmonary disease in young children and cases of congenital tuberculosis can be highly contagious. Studies have demonstrated successful collections of induced sputum from infants with pulmonary tuberculosis, but this requires special expertise. The best specimen for diagnosis of pulmonary tuberculosis in any child or adolescent in whom the cough is absent or nonproductive and sputum cannot be induced is an early-morning gastric aspirate. Gastric aspirates have the highest culture yield in young children on the frst day of collection. Creation of a palpable induration 6 to 10 mm in diameter is crucial to accurate testing. Without recent exposure, these people are not at increased risk of acquiring tuberculosis infection. Initial histories of potential exposure to tuberculosis should be included for all of these patients. Tuberculin testing at any age is not required before administration of live-virus vaccines. The diameter of induration in millimeters is measured transversely to the long axis of the forearm. Contact investigations are public-health interventions that should be coordinated through the local public health department. Dosage recommendations and the more commonly reported adverse reactions of major antituberculosis drugs are summarized in Tables 3. For treatment of tuberculosis disease, these drugs always must be used in recommended combination 1 Centers for Disease Control and Prevention. For infants and young children, isoniazid tablets can be pulverized or made into a suspension by a pharmacy. Rifampin can make oral contraceptives ineffective, so other birth-control methods should be adopted when rifampin is administered to sexually active female adolescents and adults. Rifapentine is a long-acting rifamycin that permits weekly dosing in selected adults and adolescents, but its evaluation in younger pediatric patients has been limited. In daily doses of 40 mg/kg per day or less, pyrazinamide seldom has hepatotoxic effects and is well tolerated by children. Some adolescents and many adults develop arthralgia and hyperuricemia because of inhibition of uric acid excretion.

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Nephelometry/turbidimetry A method which measures the amount or rate of particle aggregation or dispersion atrial fibrillation discount triamterene online amex, typically by antigen-antibody complexes blood pressure exercise buy triamterene online pills, particles or cells by detecting changes in light scatter and/or electrical impedence arrhythmia leads to heart failure order triamterene 75mg amex. Protein binding assay A method for the qualitative and/or quantitative detection of specific analytes by utilising the selective binding of proteins with target molecules blood pressure fluctuation causes buy triamterene 75mg with visa. Reduction/Oxidation A method for the qualitative and/or quantitative detection of a change to the oxidative state using a visual or spectrophotometric detection system. Spectrophotometry A method which measures absorbance or transmission of light by a sample at one or multiple wavelengths to determine the composition or concentration of a target substance. Stain A method for the demonstration of tissue, cellular structures, cellular products or other substances using chemical agents and/or dyes. Thin layer chromatography A method for the separation of components in a mixture using interactions with a flat adsorbent stationary phase and comparison with standard compounds to aid identification of unknown substances. Immune based methods Agglutination An immunological method where particles such as red blood cells or latex particles that have a specific antigenic determinant or antibody coating are clumped or aggregate together using a corresponding antigen or antibody in solution. Detection of agglutination may be manual, automated or using column agglutination technology. Chemiluminescent A method for the qualitative and/or quantitative immunoassay detection of antigens or antibodies in a specimen through the formation of immune complexes, using a chemiluminescent detection system. Immunoblot A method to detect the presence of specific protein or nucleic acid sequences in a specimen using electrophoretic separation and detection by hybridisation or an immunological probe. Fluorescent immunoassay A method for the qualitative and/or quantitative detection of antigens or antibodies in a specimen through the formation of immune complexes, using a fluorescent-labelled detection system. Multiplex An immunological technique for the qualitative and/or quantitative detection of multiple analytes from a single specimen using antibody coated microparticles and a laser detection system. Precipitation/ A method to detect the random spreading movement of immunodiffusion antigen or antibody (or both) through a support medium by the formation of immune complexes. Radioimmunoassay A method for the qualitative and/or quantitative detection of antigens or antibodies in a specimen through the formation of immune complexes, using a radioactive-labelled detection system. A number of analytes are provided for each collective term to indicate the base concepts used to form the range of preferred terms grouped by that collective term, and the risk classification it will be acceptable to be used for. All analytes as represented in Level 2 and Level 3 clinical chemistry collective terms. Biological fluid occult blood, vaginal pH, faecal screening tests for faecal (meconuim) albumin, faecal fat, faecal occult blood, faecal reducing substance, and urine screening tests for bilirubin, blood, creatinine, glucose, ketone, leukocyte, nitrite, pH, protein, sediment, specific gravity, urobilinogen. Screening for faecal (meconuim) albumin, faecal fat, faecal occult blood, faecal reducing substance. Screening for multiple urine analytes, including bilirubin, blood, creatinine, glucose, ketone, leukocyte, nitrite, pH, protein, sediment, specific gravity, urobilinogen. Estradiol (oestradiol) (E2), estriol-16-alpha-glucuronide, estrogen receptor, estrone, estrone-3-glucuronide, free estriol, total estriol. Glucose/haemoglobin, glucose/ketones/lipid profile, multiple blood gas/haemoximetry/electrolyte analytes, multiple clinical chemistry analytes, multiple gastrointestinal disease markers. Amoxapine, carbamazepine, chlorpromazine, clomipramine/norclomipramine, desipramine, escitalopram, ethosuximide, haloperidol (haldol), hydroxyzine chloride (atarax), imipramine, lithium, methsuximide, phenobarbital, phenothiazine, phenytoin (dilantin), primidone, valproic acid, zonisamide. Cyclosporin A/cyclosporine, mycophenolate (Cellsept), rapamycin (sirolimus), tacrolimus. Folate (vitamin B9), vitamin B1 (thiamine), vitamin B12, vitamin B2 (riboflavin), vitamin B3 (niacin), vitamin B6 (pyridoxine). All analytes as represented in Level 2 and Level 3 general laboratoryware collective terms. All analytes as represented in Level 3 Antimicrobial minimum inhibitory concentration and susceptibility testing disc collective terms. Gram negative bacteria species culture isolate identification and antimicrobial susceptibility, Gram positive bacteria species culture isolate identification and antimicrobial susceptibility, Haemophilus or Neisseria bacteria species culture isolate identification and antimicrobial susceptibility, Staphylococcus aureus culture isolate identification and methicillin susceptibility, Streptococcus bacteria species culture isolate identification and antimicrobial susceptibility, Yeast species culture isolate identification and antimicrobial susceptibility. All analytes as represented in Level 2 and Level 3 Histology and Cytology collective terms. Anaplasma phagocytophilum IgG, IgM, nucleic acid; Coxiella burnetii IgG, IgM, IgA/IgG/IgM, nucleic acid, total antibody; Ehrlichia chaffeensis IgG, IgM, IgA/IgG/IgM, nucleic acid; Multiple Ehrlichia species IgG, IgM, IgA/IgG/IgM; Multiple Rickettsia species (spotted fever group) antigen, IgG, IgM, nucleic acid, total antibody; Multiple Rickettsia species (typhus group) antigen, IgG, IgM, IgA/IgG/IgM, nucleic acid, total antibody; Orientia tsutsugamushi antigen, IgG, IgA/IgG/IgM, nucleic acid; Rickettsia conorii antigen, IgG, IgM, IgA/IgG/IgM, nucleic acid, total antibody; Rickettsia prowazekii IgG, IgM, IgA/IgG/IgM, total antibody; Rickettsia rickettsii antigen, IgG, IgM, IgA/IgG/IgM, nucleic acid, total antibody; Rickettsia typhi IgG, IgM, IgA/IgG/IgM, total antibody. All analytes as represented in Level 3 parasitic infectious disease collective terms. Wuchereria bancrofti antigen, IgG, IgG/IgM; Wuchereria bancrofti/Brugia malayi IgG. Clinical laboratory information system software, Blood bank laboratory information system software. B lymphocyte magnetic separation reagent, lymphocyte separation media, lymphocyte stabilization, T lymphocyte magnetic separation reagent. They are not intended to define a standard of care and should not be construed as one. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. It is intended to assist healthcare providers in all aspects of patient care, including, but not limited to, diagnosis, treatment, and management. For patients with low back pain, we recommend that clinicians conduct a history Strong for Reviewed, and physical examination, that should include identifying and evaluating Amended neurologic deficits. For patients with low back pain, we suggest performing a mental health Weak for Reviewed, screening as part of the low back pain evaluation and taking results into New-replaced consideration during selection of treatment. For patients with low back pain, we recommend diagnostic imaging and Strong for Reviewed, appropriate laboratory testing when neurologic deficits are serious or Amended progressive or when red flag symptoms are present. For patients with low back pain greater than one month who have not improved Not Reviewed, or responded to initial treatments, there is inconclusive evidence to recommend applicable New-added for or against any diagnostic imaging. For patients with chronic low back pain, we recommend providing evidenceStrong for Reviewed, based information with regard to their expected course, advising patients to Amended remain active, and providing information about self-care options. For patients with chronic low back pain, we suggest adding a structured Weak for Reviewed, education component, including pain neurophysiology, as part of a New-added multicomponent self-management intervention. For patients with chronic low back pain, we recommend cognitive behavioral Strong for Reviewed, therapy. For patients with chronic low back pain, we suggest mindfulness-based stress Weak for Reviewed, reduction. For patients with acute low back pain, there is insufficient evidence to support Not Reviewed, the use of specific clinician-directed exercise. For patients with chronic low back pain, we suggest offering clinician-directed Weak for Reviewed, exercises. For patients with acute or chronic low back pain, we suggest offering spinal Weak for Reviewed, mobilization/manipulation as part of a multimodal program. For patients with acute low back pain, there is insufficient evidence to support Not Reviewed, the use of acupuncture. For acute or chronic low back pain, there is insufficient evidence for or against Not Reviewed, the use of lumbar supports. For patients with chronic low back pain, we suggest offering an exercise Weak for Reviewed, program, which may include Pilates, yoga, and tai chi. For patients with low back pain, there is insufficient evidence to support the use Not Reviewed, of ultrasound. For patients with low back pain, there is insufficient evidence to support the use Not Reviewed, of lumbar traction. For patients with low back pain, there is insufficient evidence to support the use Not Reviewed, of electrical muscle stimulation. For patients with acute or chronic low back pain, we recommend treating with Strong for Reviewed, nonsteroidal anti-inflammatory drugs, with consideration of patient-specific risks. For patients with chronic low back pain, we suggest offering treatment with Weak for Reviewed, duloxetine, with consideration of patient-specific risks. For patients with acute low back pain or acute exacerbations of chronic low back Weak for Reviewed, pain, we suggest offering a non-benzodiazepine muscle relaxant for short-term New-added use. For patients with chronic low back pain, we suggest against offering a nonWeak Reviewed, benzodiazepine muscle relaxant. For patients with acute or chronic low back pain with or without radiculopathy, Strong Reviewed, we recommend against the use of systemic corticosteroids (oral or intramuscular against Amended injection). For patients with low back pain, we recommend against initiating long-term Strong Reviewed, opioid therapy. For patients with acute low back pain or acute exacerbations of chronic low back Not Reviewed, pain, there is insufficient evidence to recommend for or against the use of timeapplicable New-replaced limited opioid therapy.

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Commissioners Statements arrhythmia overview cheap 75mg triamterene mastercard, Rebuttals pulse pressure nhs generic triamterene 75 mg without a prescription, and Surrebuttals 175 rights and ensure a fair process when under investigation or dismissed from the service hypertension in dogs triamterene 75 mg with mastercard. That can be done without pushing for excessive protections that obstruct accountability hypertension vascular disease buy generic triamterene 75 mg on line, and sometimes justice for the civilians unlawfully harmed by the police, and in the long run undermine the legitimacy police need in the communities they serve to successfully to prevent and solve crimes. Police unions who believe that the problem of excessive use of force against marginalized groups is limited to a few bad apples and do not want to be unfairly painted with the same broad strokes as those who commit misconduct need to spearhead efforts to weed out those outliers and 955 make it easier to identify recurring perpetrators and dismiss them from service. It is in their best interests to support reforms necessary to protect police integrity and reestablish community 956 trust. By creating special protections and privileges for officers suspected of wrongdoing, these policies suggest that the law isnt a body of rules binding on all of us, but something [police] impose on 957 others, heightening the image of police as outside soldiers, so unattached to the neighborhoods they patrol that they are not even governed by the same laws or consequences. In order to rehabilitate police-community relations and re-instill faith in officers as community guardians, it is crucial that unions support programs geared towards eliminating racial prejudices, as well as educating officers on de-escalating hostile situations before using force as an absolute last-resort 958 measure. Unions should support and encourage the officers who hold each other accountable and honor those who invest in building community trust. Police and their unions have a legitimate concern when reforms are developed without their input. In my work over the years on racial profiling, I have observed that there is often a gap between police chiefs and the police on the beat. Community stakeholders need to understand that for real change to happen, everyone needs to be at the table having candid and hard conversations. I think you heard Sean Smoot talk early today about the union needs to be at the table. They want safe neighborhoods and neighborhoods where people can see their kids playing out in the street or they can walk to the grocery store without worrying about being shot or harassed by police, and so as they start to learn that from each 955 Andrew Cohen, How Bad Apples Spoil the Whole Bunch, Marshall Project, Sept. Some conservatives take a dim view of the federal government and, in particular, the role of the Department of Justice, in interceding in what they view as local prerogatives. In fact, as we heard 960 at our hearing, and as many chiefs of police who seek to modernize their approach to policing, have said, the Department of Justice has an important role to play. Chief of Police): the process of having a consent decree can actually be a benefit to your department. You can leverage the Justice Department to get some things that you desperately need. When I was chief at the Metropolitan Police Department in Washington, we would not have been able to make the changes we made without the consent decree. We would have encountered pushback from the union, and we would not have obtained the funding needed to develop an early intervention system and underlying technology infrastructure to support it. When they announced their desire to enter into a consent decree, it seemed intimidating at first. But I could see that they opened a door for me that my labor union had 959 Briefing Transcript at 285-88. And the door they opened included funding and political support for all my 963 initiatives for the department. We did not put anything in place that we were not going to do eventually in any case. But putting the force of a court order behind it created a 964 momentum that would not have otherwise existed. For example, police often misunderstand 967 the body language and facial expressions of deaf people and resort to using force on them. To combat this problem, training on how to interact with persons with mental health needs or other 968 disabilities is absolutely critical. The police and community should be willing to invest in the cost of the training and ensuring there are enough police hired to make it possible for everyone in the force to take the time for regular training. The police and the community have a shared interest in not only ensuring that encounters between officers and persons with mental health problems remain safe, but also getting at the root of the problemthe need to invest in mental health facilities and services. Community advocates know that funding mental health services will keep people with mental health needs from cycling through 969 jails and emergency rooms. Concern for police officers potentially or actually being charged for unlawfully shooting a person with a mental 971 illness has prompted police unions to argue for more funding mental health programs. And as Louis Dekmar, the president of the International Association of Chiefs of Police, stated, The real story is the failure of the mental health system. Theres just not a large political constituencies for 972 the mentally ill, unless law enforcement or family members advocate. Police are, in effect, asked to do more with less funding and inadequate training when answering calls involving people with mental health challenges. And without the training needed to prepare law enforcement for this responsibility, police have reacted with force in situations where it was unwarranted, mistaking behaviors associated with disability with threats to their safety and 975 authority. The combination of a large population of people suffering from inadequately treated mental health problems and some police departments inadequately prepared to respond to such emergencies has resulted in the disproportionate use of force against persons with disabilities, with around 25% of 976 all police killings targeted against people with mental health problems. While some departments have recognized the need to properly educate their officers on mental illnesses and how to act in interactions with persons undergoing a mental health crisis, the necessary training has by no means 977 been universally implemented. A majority of departments that do have education programs only 978 require 8 hours for mental health training, compared to 58 hours mandated for firearms training. The Department of Justice can help by working with law enforcement to convene mental health experts, disability advocates, police unions, and police chiefs to identify effective trainings and jail (arguing for community-based resources to prevent people with mental illnesses from going to jail or emergency rooms). Commissioners Statements, Rebuttals, and Surrebuttals 179 979 trainers and help develop best practices. Congress can help by appropriating funding to enable more law enforcement to be trained at a more rapid pace as well as by working to address the crisis 980 in mental health funding and support systems. It took the deaths of many people and the advent of cell phone cameras to expose the too frequent unjustified and unaccountable uses of force. More than fifty years ago, people were outraged by images of police officers beating black 981 protesters at Selma, just as they were outraged in 1991 by footage of officers beating Rodney 982 King in Los Angeles, and just as they were outraged in 2014 by reports of the police shooting 983 of Michael Brown in Ferguson. This problem of excessive police use of force is not a new one, but that does not mean the issue is unsolvable. Some police departments have begun to make the changes necessary to rebuild community trust by implementing key reforms and training. Congress as well as state and local governments can and should provide the resources to departments to make reforms and provide training. And the Department of Justice can help foster and disseminate best practices, provide technical assistance and help facilitate the necessary discussions among stakeholders and hold accountable police departments whose practices violate modern policing principles. No more lives should be lost before meaningful change happens, and before communities of color and law enforcement become partners in building safe and vibrant communities. Swedish sociologist and Nobel Laureate Gunnar Myrdal exposed their neglect in his influential 1944 book, An American 984 Dilemma: the Negro Problem and Modern Democracy: It is part of the Southern tradition to assume that Negroes are disorderly and lack elementary morals, and to show great indulgence toward Negro violence and disorderliness when they are among themselves. As long as only Negroes are concerned and no whites are disturbed, great leniency will be shown in most cases. This is particularly true in minor cases which are often treated in a humorous or disdainful manner. The sentences for even major crimes are ordinarily reduced when the victim is another Negro. Attorneys are heard to plead [to] juries: Their code of ethics is a different one from ours. Yet the Southern Negro community is not at all happy about this double standard of justice in favor of Negro offenders. Law-abiding Negroes point out that there are criminal and treacherous Negroes who secure immunity from punishment because they are fawning and submissive toward whites. Murphy, who wrote in 1904: Petty crimes are often forgiven him, and in countless instances the small offences for which white men are quickly apprehended are, in the negro, habitually ignored. The world hears broadly and repeatedly of the cases of injustice, it hears little of those more frequent instances in which the weaknesses of a child-race are accorded only an amused indifference or a patient tolerance by their stronger neighbors. Myrdal quotes a letter he received from a white lawyer in the Upper South: I have noted that cases between Negro and Negro are handled somewhat differently than cases between white and white. I mean a spirit of levity, an expectation of something comical appears to exist. As you know, it is a rare case indeed in which a Negro who has murdered a Negro receives the extreme penalty, either death or life imprisonment here, regardless of the facts. Only the other day in a local case a Negro who murdered another with robbery as motive, a charge that would have been as between white and white, or Negro and white victim, good for the electric chair, was disposed of by a jury with a 15-year sentence.

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