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There they spread between the serous and muscular coats and give off multiple branches to the muscle asthma symptoms lungs fluticasone 250mcg fast delivery. After passage through the muscle layer asthmatic bronchitis in toddlers discount 250 mcg fluticasone overnight delivery, they join a plexus in the submucosa asthma treatment for kid order fluticasone 250mcg with amex, which supplies the glands and villi of the mucosa asthma symptoms home remedies buy fluticasone amex. The veins follow a similar course as the arteries and drain into the superior mesenteric vein. The mucosal lymphatics form a plexus in the mucosa and submucosa that drain the villi and the solitary lymph follicles in the wall. Descending and Sigmoid Colon and Rectum the descending colon starts at the left colic flexure and ends by joining the sigmoid colon above the lesser pelvis. The posterior surface is free of peritoneum because it is attached to the perirenal fascia and the fascia of the posterior abdominal wall. Three parts may be identified: the first part lies on the posterior abdominal wall, the second runs transversely across the pelvis, and the third turns back to the midline to join the rectum. The colon lies in the sigmoid mesocolon, which is longest in the middle of the loop. Internal to the muscular layer are the usual submucosa and muscularis mucosae layers. The rectum begins where the sigmoid mesentery ends at the level of the body of the third sacral vertebra. It curves in an anteroposterior direction-the sacral flexure-before passing through the pelvic floor to join the anal canal at the anorectal junction, the site where the anal canal bends backward forming the perineal flexure. The upper part of the rectum is shaped like the sigmoid colon except that it is free of mesentery or epiploic appendixes; the lower part widens to form the rectal ampulla. Peritoneum loosely covers the anterior and lateral surfaces of the upper portion of the rectum and the anterior surface of the middle portion, forming the rectovesical pouch (the rectouterine pouch in the female). Because the rectum was once an intraperitoneal organ, the remainder is covered by the inner stratum of retroperitoneal connective tissue, the rectal fascia. The longitudinal muscle layer, associated with the teniae in the sigmoid colon, spreads out to surround the bowel but remains thicker anteriorly and posteriorly. Some of these anterior fibers in the ampulla join the perineal body, forming the rectourethralis muscle, and some of the posterior fibers attach to the coccyx as the rectococcygeal muscle. The circular layer also becomes thicker around the rectum and especially around the anal canal, where it forms the internal anal sphincter. The rectum is supported from the sacrum by a band of fascia, the rectosacral (Waldeyer) fascia, and from the posterolateral walls of the pelvis by condensations of the connective tissue associated with the middle rectal vessels that form the lateral ligaments of the rectum. It is held anteriorly behind the prostate and seminal vesicles by the rectovesical fascia. The anal canal begins after the bowel has passed through the levator ani musculature and is surrounded by the external and internal sphincters of the anus. The jejunal portion of the small intestine exhibits taller and more numerous permanent circular folds (plicae circulares), as compared to the ileum. Jejunal villi are tall, slender, and fingerlike, with a villus-to-crypt ratio of 3:1 to 5:1. The epithelium consists of goblet cells and relatively abundant tall columnar absorptive cells. The specimen was removed for symptomatic diverticulosis and recurrent diverticulitis. The sigmoid colon, when viewed endoscopically, particularly in older adults, often demonstrates luminal narrowing, thickened mucosal folds, and numerous diverticular orifices. Lamina propria invests the crypts and contains fibroblasts, macrophages, neuroendocrine cells, plasma cells, lymphocytes, eosinophils, and mast cells. A thin but distinct layer of smooth muscle (muscularis mucosae) separates mucosal elements from the submucosal space. The submucosa contains neural plexuses, fat, blood vessels, and lymphatic vessels. The muscularis externa is composed of an inner circular and an outer longitudinal layer of smooth muscle. The next branch, the sigmoid artery, after giving off the superior rectal artery, splits into two or three inferior left colic arteries that supply the sigmoid colon. The anastomoses between these arteries appear to form a "marginal artery" near the mesenteric margin of the colon. During resection of the right colon, because the anastomosis between the left colic artery and the left branch of the middle colic artery may be highly variable, the main trunk of the middle colic artery should be left to supply the transverse colon up to the left colic flexure. By dividing a major vessel close to its origin, circulation through the arcades formed by the "marginal artery" can be exploited. Rectum the rectum and upper half of the anal canal receive blood from the most distal branch of the inferior mesenteric artery, the superior rectal (hemorrhoidal) artery. These structures are also supplied by the middle rectal (hemorrhoidal) artery, a branch of the posterior division of the internal iliac artery, and the inferior rectal artery, a branch of the internal pudendal artery. Venous drainage accompanies the arteries; that going with the superior rectal artery drains into the portal system. The lymphatics from the rectum accompany the superior rectal and inferior mesenteric arteries to the aortic nodes, while those from the anus drain to the superficial inguinal nodes. Jejunum, Ileum, and Ascending and Transverse Colon That portion of the intestinal tract originating from the midgut and supplied by the superior mesenteric artery receives sympathetic innervation from the celiac and superior mesenteric ganglia, and parasympathetic innervation from the vagus and splanchnic nerves. The neurons innervate the myenteric plexus composed of nerves and ganglia that lie between the outer and inner layers of the muscular coat of the bowel. From this plexus, nerves pass to a submucous plexus to supply the muscularis mucosae and the mucosa. Both sympathetic (inhibitory to peristalsis and stimulatory to the sphincters) and parasympathetic (with an opposite action, plus stimulatory for secretion) are present in the ileal wall.

Sympathetic ganglia are present not only in the sympathetic trunk but in the autonomic plexuses and in subsidiary ganglia that lie in large plexuses such as the celiac and superior and inferior mesenteric asthma definition and causes 500 mcg fluticasone for sale. Parasympathetic Division Cranial nerve 10 provides some innervation to the kidney through the renal plexus (dotted and double lines in asthmatic bronchitis 38 generic fluticasone 500 mcg free shipping. Those preganglionic neurons from the sacral portion of the cord (S2 asthma definition 38th purchase genuine fluticasone, 3 asthma definition and explanation cheap fluticasone line, and 4) are concerned with the pelvic organs and form the pelvic (splanchnic) nerves that join the inferior hypogastric (pelvic) plexus. Through the plexus, preganglionic fibers continue to ganglia adjacent to or within the walls of the organs. The bladder is provided with motor fibers and the urethral sphincter with inhibitory fibers. The penis and clitoris are supplied with vasodilatory fibers, as are the testes, ovaries, and uterus. The prostate, lower colon, rectum, and reproductive organs are also supplied with parasympathetic fibers. Anatomic Distribution of Autonomic Nerves Interconnections among the sympathetic and parasympathetic preganglionic and postganglionic neurons occur in plexuses connected with the ganglia distributed along the preaortic and presacral areas (see Table 4-2). Although at dissection the autonomic nerves and their plexuses are not as discrete as anatomic descriptions would lead one to believe, the aortic, inferior mesenteric, superior hypogastric, and inferior hypogastric (pelvic) plexuses can be identified. The celiac plexus, the largest of the abdominal plexuses, lies at the level of the lower margin of the 12th thoracic vertebra. This ganglion, in turn, supplies the renal plexus that lies at the base of the renal arteries. It is connected above with the inferior mesenteric plexus and below with the bipartite inferior hypogastric (pelvic) plexus, which contain the hypogastric ganglia. The plexiform connection between the superior hypogastric plexus and the inferior hypogastric (pelvic) plexuses is known as the hypogastric or presacral nerve. The inferior hypogastric plexus connects with the vesical plexus, the prostatic plexus, and in the female, the uterovaginal plexus. Sensory Innervation of the Ventral Body Surface Cutaneous Nerves the pattern of innervation of the body wall is described in Chapter 8; Fig 8-20. Projections on the skin of the several spinal levels are useful not only to predict the effects of injury to or sectioning of a peripheral nerve but also for harvesting pedicle flaps. The cutaneous innervation by the ventral rami of the spinal nerves is outlined in. They include the lateral cutaneous rami of the 7th to 12th intercostal nerves, which supply the lateral side of the thorax to a level below the 12th rib, and the anterior rami, which supply a smaller strip over the rectus. The iliohypogastric nerve divides as it passes between the transversus abdominis and the internal oblique into a lateral cutaneous ramus that supplies the gluteal region and an anterior cutaneous ramus going to the abdominal surface above the pubis. The ilioinguinal nerve supplies the skin of the upper thigh, the skin about the base of the penis, and the upper part of the scrotum. The genital ramus of the genitofemoral nerve supplies the cremaster and the lower part of the scrotum. The femoral ramus of the genitofemoral nerve supplies the skin over the upper part of the femoral triangle. The lateral femoral cutaneous nerve supplies the anterior and lateral surfaces of the upper leg. The intermediate and medial femoral cutaneous nerves supply the front of the thigh to the knee. Spinal segmental distribution to the skin is directly related to innervation of the internal organs. This is important for evaluating bladder innervation and for treating losses with electronic pacemakers. Effects on bladder innervation from stimulation, excision, or injury of sacral spinal nerves 2, 3, and 4 can be determined from changes in the cutaneous innervation of the posterior thigh and perianal regions. The segments curve around the body obliquely, starting with the 10th thoracic nerve that supplies the umbilical segment. The distribution of the lateral femoral cutaneous nerve extends posteriorly on the thigh. The segmental innervation is illustrated, showing the sacral elements innervating the perineum. Betwixt the fleshy membrane and the skinne runne certaine vessels called skin-veines. The unexposed surface adheres by a basement membrane to the underlying connective tissue that supplies blood to the surface cells. The cells are held in apposition by intercellular substance and, if damaged, are readily replaced by new ones. Epithelia may be one cell thick (simple) or appear as more than one cell thick but with all cells adherent to the basement membrane (pseudostratified), or they may be made up of many cells (stratified). The cells may be flattened (squamous), of the same height and width (cuboidal), higher than wide (columnar), or able to change shape with stretching (transitional). The skin, as the surface in contact with the environment, facilitates body movement and furnishes contacts for sensory and emotional responses. The dermis has a separate origin, developing from the mesoderm of the somatic layer of the dermatomes of the lateral walls of the somites. After 3 months of fetal life, the dermis can be identified as a mesodermal condensation under the epidermis. Hair bulbs and papillae appear as ingrowths of the epidermis into the dermis, and later, the sudoriferous and sebaceous glands are similarly formed by ingrowth. Epidermis Papillary dermis Reticular dermis Sebaceous glands Hair follicle Composition of the Skin the skin has two layers-(1) the epidermis, arising from the ectoderm, and (2) the dermis, or corium, from the mesoderm. The dermis overlies areolar and fatty connective tissue, the subcutaneous layer. Epidermis the epidermis covers the entire body with a layer of stratified squamous epithelium.

It is continuous over the penis as the superficial fascia of the penis asthma treatment 4x4x4 cheap 500mcg fluticasone with mastercard, the dartos layer new asthma treatment 2013 discount 250mcg fluticasone mastercard, and it follows the spermatic cord into the scrotum as the membranous layer of the superficial fascia (dartos tunic) asthma treatment using onion discount fluticasone 250mcg line. Bony Pelvis Before describing the soft tissues asthma 24 hour medication cheap 250mcg fluticasone free shipping, the bony surfaces and landmarks of the public portion of the pelvis are presented as a framework for attachment of the fascial structures about the inguinal canal. The lateral head of the rectus abdominis arises from its lateral part; the medial part of the rectus crosses its medial part before attaching to the symphysis and adjacent pubis. The pubic tubercle lies near the medial end of the pubis and is an important landmark in surgery of the groin because it indicates the medial attachment of the inguinal ligament. The joint between the pubic bones, the pubic symphysis, has a thickness of 2 to 3 mm and is composed of hyaline and fibrous cartilage. It is connected by a heavy anterior pubic ligament and a smaller posterior pubic ligament, structures that are more likely to pull off from the bone rather than rupture. External Oblique Layer Each of the three muscles of the anterior abdominal wall is covered on both sides with investing fascia. The layer covering the external surface of the external oblique, the innominate fascia of Gallaudet, is the thickest and becomes the fascia lata in the thigh. The internal surface of the muscle has a thinner fascial coat and both the inner and outer fascias fuse at the inferior, free border, where the external oblique forms the inguinal ligament. The aponeurosis is also attached medially to the upper border of the pubic symphysis and to the pubic crest as far as the pubic tubercle. It forms the anterior wall of the inguinal canal, supplemented laterally by fibers of the internal oblique aponeurosis that attach to the lateral part of the inguinal ligament. The external spermatic fascia results from fusion of the innominate fascia and the fascia associated with the internal surface of the external oblique and its aponeurosis. It is important surgically during exposure of the spermatic cord: If this fascia is incised along with the underlying external oblique aponeurosis to the point where its sheath widens near the upper pole of the testis, the scrotal contents, even if enlarged, may be drawn into the wound. The superficial inguinal ring is the most medial of the three inguinal rings (superficial, external, and internal) that provide passage for the spermatic cord while preventing herniation of the peritoneum and its contents. Its sides are the medial and lateral crura formed by the edges of the external oblique aponeurosis as that structure splits to join the crest. The lateral edge, as the inferior or lateral crus, is the inguinal ligament itself reinforced by the intercrural fibers that come from the innominate fascia. The intercrural fibers run at right angles to the fibers of the aponeurosis and may arch over the superficial ring. Inguinal Ligament the inferior margin of the aponeurosis of the external oblique extends between the anterior superior iliac spine, where it is attached to the iliopsoas fascia, and the pectineus fascia at the pectineal line on the inner aspect of the pubis. The aponeurosis becomes somewhat thicker as it arches over the femoral nerve, vessels, and canal and folds internally on itself before ending as a free edge. This inward fold forms a shelf along its inner aspect, the inguinal ligament (Poupart). The ligament is rounder laterally but becomes flatter medially as it joins the pubic tubercle. The fibers of the external oblique aponeurosis change their oblique course to a more transverse direction to follow the line of the ligament. The reflected inguinal ligament is usually poorly developed, if it is present at all, and is not of use in hernia repair. It is a triangular continuation of the external oblique aponeurosis, extending from the medial part of the inguinal ligament to the medial end of the pectineal line (also see. Its base is concave and thin, and usually does not take part in the formation of the femoral sheath. The lacunar ligament serves to broaden the area of insertion of the inguinal ligament (also see. As a result of this configuration, the external oblique aponeurosis covers the anterior, the inferior, and part of the posterior portions of the cord. The inferior margin of the external oblique aponeurosis folds dorsally to form the inguinal ligament. The femoral (crural) sheath is composed anteriorly of a layer from the transversalis fascia as it extends caudal to the inguinal ligament and posteriorly from slips from the iliopsoas and pectineus fascia as the sheath passes behind the inguinal ligament. It is covered by the fascia lata, which has an opening, the fossa ovalis, which, in turn, is covered by the cribriform fascia, to accommodate the superficial vessels and saphenous vein. A third, neuromuscular compartment, containing the femoral nerve and the iliopsoas, lies laterally, outside the sheath. In section, the space between the inguinal ligament and iliopsoas fascia and the bony pelvis may be seen to contain three compartments. Starting laterally, Relations of the Inguinal and Femoral Canals the femoral triangle (Scarpa) is bounded laterally by the medial margin of the sartorius. The floor is composed laterally of the fascia of the iliacus and psoas major and medially of the fascia of the pectineus and adductor longus. It contains the iliopsoas, formed from fusion of the iliac and psoas muscles, and the femoral nerve. The iliopectineal ligament separates this compartment from the vascular compartment. More medially, the femoral artery and femoral vein pass through the vascular compartment, which is surrounded by loose fibrofatty tissue that is continuous with that of the outer stratum of the retroperitoneal connective tissue. The femoral branch of the genitofemoral nerve enters the vertical lateral wall, and the lymphatics leave the medial wall. The third compartment, the femoral canal, lies next to the iliopubic tract, medial to the other two. It is funnel-shaped, with the wide end at the inguinal ligament, tapering to obliteration about 4 cm below the ligament, where it fuses with the fascial coverings of the femoral vessels. It contains the femoral septum in which lie lymph channels that connect the deep inguinal to the external iliac lymph nodes. The inlet of the femoral canal is the femoral ring, which is bounded medially and anteriorly by the iliopubic tract, posteriorly by the pectineal ligament, and laterally by the iliopectineal arch.

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The effect of four interventions on the informational content of histopathology reports of resected colorectal carcinomas. Development of Evidence-Based Diagnostic Criteria and Prognostic/ Predictive Models: Experience at Cedars Sinai Medical Center Alberto M. This paradigm can help guide the review of information in the pathology literature and help formulate the experimental design of clinico-pathologic studies. The paradigm is based on six general assumptions: (a) clinico-pathologic problems are best approached by explicitly formulating answerable patient-based questions that need to be investigated using the literature and personal experience, (b) data trumps authority and A. Frame specific patient-based questions regarding particular diagnoses or other problems of interest 1. Estimate quantitatively or qualitatively the pre-test probabilities of the pathologic findings or test results of interest 2. Estimate quantitatively or qualitatively the post-test probabilities of the pathologic findings or test results of interest E. The results and conclusions of a study need to be appraised over time and updated as more data becomes available A. Pathologists striving to diagnose their cases using the latest classification schema and latest information regarding the latest immunostains, molecular tests, and other information need to hone their skills at asking relevant answerable clinico-pathologic questions and at developing strategies designed to find this information in the literature and integrate it with their personal experience [2, 3]. Unfortunately, these are not skills that are generally emphasized or formally taught during pathology residency training. They are formulated using a question root such as who, what, where, when, how, why, followed by a verb. Background questions generally address a specific disease, pathologic entity, test, or other aspect of health care. Examples of background type question are as follows: What is the etiology of diffuse alveolar damage They have four essential components: (1) patient-specific problem, (2) intervention or exposure, (3) comparison if relevant, and (4) clinical outcomes, including time frame if relevant. In anatomic pathology, the four components of foreground questions can probably be simplified into three: patient-specific problem, pathologic examination or laboratory test, and relevance for patient care (prognosis or prediction of response to specific therapy). Examples of background type question are as follows: Which immunostains should be used during the evaluation of transbronchial biopsy to differentiate adenocarcinoma from squamous cell carcinoma How many immunostains should be used to distinguish malignant mesothelioma from adenocarcinoma Most of these concepts probably apply to the practice and learning of anatomic pathology and laboratory medicine. A detailed discussion of the arguments for each of these competing views of the current practice of medicine is beyond the scope of this chapter. Pathologists, a particularly conservative group of physicians, have generally ignored this debate and continued pursuing the testing of various specimens with the latest available technology and using in their daily practice various disease classification schemas developed years ago by groups of experts and updated over time. Diagnostic classes tend to be split over into multiple subclasses with limited debate regarding their diagnostic reproducibility and clinical applicability. These efforts will hopefully advance anatomic pathology and laboratory medicine into more scientific endeavors, although it is fully recognized that there is a considerable "art" component in the practice of pathology related to the nature of the field and the variable ability and clinical experience of different practitioners. Generations of pathologists have been trained by eminent experts to evaluate thymomas very carefully for the presence of microscopic transcapsular invasion [25]. Indeed, a previous classification schema of thymomas advocated the classification of the tumors into benign or malignant thymomas based on the absence or presence of local invasion [25]. In addition, thymomas that exhibit microscopic transcapsular invasion have been classified by Masaoka et al. In summary, this is a simple example of how certain concepts that had been taught by eminent physicians for many years to the point of becoming a "tradition" are found to lack best evidence to support them. The discussion included the pathology-specific scale of evidence levels shown in Table 13. Gupta the Importance of Disclosing the Potential Flaws of the Interpretations of Results the formulation of patient-centered questions can help evaluate the validity of the conclusions of a study and suggest future investigations. This was recently investigated using another systematic review of best evidence with meta-analysis [35]. A similar problem was encountered in a recent study evaluating the prognostic significance of isolated tumor cells and micrometastases in the intrathoracic lymph nodes of patients with adenocarcinoma and other nonsmall cell carcinomas of the lung [37]. The study was the largest to date and included review of 4,148 lymph nodes from 266 of our own patients and meta-analysis of all cases reported in the English literature.

Adoption of electronic medical 14 Evaluation and Reduction of Diagnostic Errors in Pathology Using an Evidence-Based Approach 239 records appears to be underway in medium and large hospitals and laboratory systems asthmatic bronchitis fatigue order fluticasone uk. Over time asthma symptoms voice purchase on line fluticasone, developments of secure internet based technology solutions are likely to facilitate the electronic medical record hidden asthma definition generic fluticasone 250mcg with amex. One method that has been shown to improve patient identification and could improved clinical information is remote order entry [14] asthma definition esoteric purchase fluticasone without prescription. Functionality that would force the inclusion of the clinical history before a specimen can be entered into the laboratory system could be adopted. Another potential solution could be the automatic inclusion of the clinical note of the physician that obtains the tissue. Of course these solutions are not possible without the presence of robust computer systems. First, lean aims to either eliminate steps when possible or better alien steps so that processes are smoother and less disruptive (reduce complexity). Second, lean redesigns of surgical pathology introduces the judicial use of technology with the use of barcodes or other technologies to eliminate redundant steps such as reentry of identification data on slides and blocks. The introduction of technology addresses issues of inconsistency in hand writing or data reentry and in other processes such as staining with the introduction of automatic stainers. Third, lean redesign results in standardization of processes and the elimination of conflicting procedures and the need to train in multiple procedures. Complexity Inconsistency There is a greater chance of mishap with greater complexity. Intuitively, it seems obvious that a process with many steps has a greater chance of error than a similar process with only one or two steps. This can actually be demonstrated mathematically in hypothetical and real situations. If a process has one step in it and has a 1% chance of error, a similar process with 25 steps and a 1% error at each step bring that total error risk to 22% [5]. Surgical pathology errors have not been measured at every step, but surgical pathology is a complex process requiring numerous steps within the laboratory to complete tissue processing and diagnosis with endless variations that may lead to error. This is the reason why many have used lean production techniques to improve histologic processes, gain efficiency, and reduce errors. Although variable results have been achieved, at this time, lean redesign with selective introducInconsistency can be demonstrated as a source of error in at least two ways in surgical pathology. During the past couple of decades dramatic improvements have been made in the adoption of standardization in diagnostic criteria and in the adoption of standardized cancer reports. The following example demonstrates the effect of the use of standardized diagnostic criteria on the level of diagnostic agreement. Rosai conducted a study which strongly suggested that inter-observer concordance in the classification of breast ductal proliferative disease was unacceptably low [29]. Rosai asked a panel of experts to review the same set of cases and render their diagnoses. This is particularly important in oncology where different treatment options are available and are dependent on pathologic grading, staging, and tumor marker expression [33, 34]. The adoption of national standards in the form of standard grading and staging of tumors has greatly facilitated and accelerated national treatment trials in the evaluation of potential therapies. This has been further accentuated with the use of standardized computer based forms that have been shown in multiple studies but none as eloquently as in a randomized prospective examination of pathology reports in a study by Branston et al. The control arm of the study included eight hospitals that did not use computer based cancer reports (checklists) and the study arm included eight hospitals that used computer based cancer reports (checklists). This study concluded that reports in the hospitals with the computer checklists were more complete 28% of the time. The study also found that clinicians found these reports preferable while pathologists found them acceptable. One aspect of reports that should be considered is the ability of clinicians to derive the information that they need to treat the patient from the report. Factors that were cited to be associated with improvement of this gap included familiarity with report format and clinical experience. Valenstine in a review of pathology report formatting suggests that four evidencebased and time-tested principles may be helpful in formatting reports for more effective communication. These include: (1) the use of diagnostic headlines to emphasize key points, (2) mainte- nance of layout continuity with other reports and over time, (3) optimization of information density, and (4) reduction of extraneous information [36]. Valenstine based his conclusion by extension of research performed in other fields outside of medicine including cockpit design in aviation and newspaper print effectiveness. Human Intervention Surgical pathology remains a process that is heavily dependent on human physical and intellectual activity. With the exception of very short segments of the test cycle, surgical pathology is most assuredly dependent on humans doing their jobs. As in other areas of health care, a systems approach to quality management in surgical pathology has been recommended to reduce errors [37, 38]. At its core, this management style advocates design of processes with two features in mind; prevention of errors and detection of errors. First, introduction of automation whenever possible works well where information must be re-inputted into the system [15]. The use of slide and block labelers as well as the use of barcode technology are good examples where human intervention in the form of reentering information may be avoided with the use of automated equipment thus reducing the potential for error. Automation may be used to simplify a process in the sense that a machine will do multiple steps, whereas from the human perspective the process is reduced to one or two steps. Machines also have the added advantage of reducing procedural variations because machines operate at a tight range of specification and are not subject to distraction. Reducing cognitive errors at the point of diagnosis has been challenging, but methods have emerged that reduce or detect error. The principle method of error prevention has been redundancy in the form of review of cases before or after cases are verified or signed out.

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