text:
|Publication number
|Publication type
|Application number
|Publication date
|Dec 30, 1980
|Filing date
|Jan 26, 1979
|Priority date
|Jan 26, 1979
|Publication number
|Daniel J. Burns
|Original Assignee
|The United States Of America As Represented By The Secretary Of The Air Force
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (2), Referenced by (64), Classifications (6)
|External Links: USPTO, USPTO Assignment, Espacenet
The invention described herein may be manufactured and used by or for the Government for governmental purposes without the payment of any royalty thereon.
The present invention relates broadly to an integrated circuit test apparatus, and in particular to the apparatus and method for testing circuit operation in an integrated circuit by modifying the normal state duty cycles in a repeating test cycle consisting of a sequence of many states to produce and observe a display which reflects circuit electrical characteristics during selectable states in the test cycle.
In the prior art, which is typified by U.S. Pat. No. 3,934,199, issued Jan. 20, 1976, a non-destructive method of testing electrical circuits on an integrated circuit utilizes a layer of liquid crystals over the circuit to provide visible indications in order that a comparison may be made between observed birefringent changes produced by the normally operating circuit. However, the prior art technique cannot be used to determine circuit node or conductor logic levels at any given instant in time during the testing sequence of a circuit. The set of logic levels present on various conductors in the circuit at a given instant in time which may be referred to as the circuit's state, binary state or digital state, most often constitute a set of binary digits which are stored or processed by the circuit. The ability to determine a circuit's state at many distinct instants in time is essential in failure analysis and design evaluation.
The present prior art test apparatus which utilized the liquid crystal technique requires that a comparison to the similar normally operating circuit be used in order to test for a faulty circuit. In other words, the prior art method operates upon observing the liquid crystal display of a good circuit and a bad circuit under the same normal excitation. What is actually observed is some pattern of light conductors on a dark background. While the observed patterns may be different for a good circuit and a bad circuit, the patterns, alone, provide no useful information about the many states the two circuits may assume at successive instants of time during their normal operation.
In fact at high clock rates (greater than 1,000 pulses/sec), a normally operating circuit may typically assume hundreds of states sequentially in time. The rate of progression from state to state is controlled by the input clock pulse rate and various other control inputs to the circuit. During this progression from state to state, there is a sequence of logic level changes on various conductors in the circuit which reflect the passing digital states. The overall response displayed in the liquid crystal (birefringent changes) is the result of an integration of these many changes over a long (≦100 ms) time period. The liquid crystal molecules respond by rotating from their initial orientation under the influence of the local electric field according to a root-mean-square (RMS) fashion. The electric field strength in the liquid crystal depends on the logic levels which are present on conductors during many hundreds of states over a relatively large time period (≦100 ms) of the normal circuit operation. Time resolution of these detailed changes in the circuit is lost in the integrating or averaging of the liquid crystal display mechanism when the circuit is operated at normal speed. If the clock pulse rate is slowed to visual rates (less than 10 pulses/sec) an effect can be observed which may be described as short flashes that may be seen in the liquid crystal display above conductors as logic levels change from 1 to 0 or 0 to 1. These flashes which last about one hundred thousands of a second, are very difficult to observe, and are not easily photographed. A determination of the logic state of the circuit 100 ms after a clock pulse has occurred by observation of the circuit display is truely impossible, since the display is no longer present. The eye simply cannot inspect the literally thousands of conductors which flash momentarily and die out in a very complex circuit. It is possible, however, to detect the presence or absence of such a flash over one or a very few particular conductors. By utilizing a good circuit, it may be possible to distinguish working and nonworking areas of the circuit. However, it is doubtful that the state of a very complex circuit with thousands of conductors could be determined by observing the flashing display, especially if the state of interest is assumed only after the application of hundreds of clock pulses. There are many types of complex circuits which simply do not operate with clock pulse frequencies of less than approximately 1,000 pulses per second. The present apparatus provides a direct static display which can be easily photographed and inspected at length to show the detailed differences between a single selected state and a reference state in a complex test state sequence. The present apparatus is used to produce static displays for many selected states with a single reference state. These static displays are recorded and compared to determine the differences between each selected state. When the set of conductor logic levels is known for the reference state, each static display shows directly the set of conductors which assume different logic levels in the selected and reference states, thus making possible a determination of the set of conductor logic levels of the selected state.
The present invention utilizes a liquid crystal in a sandwich structure display cell which is formed by the integrated circuit surface, a thin layer of liquid crystal and a glass coverplate. The liquid crystal can be a negative dielectric anisotropy type and the surfaces of the cell can be treated with lecithin and or a deposited gold layer to promote the required homeotropic (vertically aligned) molecular arrangement. Other types of liquid crystal might be used such as positive dielectric anisotropy types and those requiring twisted molecular arrangement. These other types may require different surface preparations. The coverplate may incorporate an electric field plate which allows independent external control of the electric field in the liquid crystal cell. When the RMS voltage across a conductor/field plate cell is greater than about 4.6 V, a highly visible display is produced directly above the conductor. Application of specially chosen voltage waveforms to this field plate allows new modes of operation.
A selective display is obtained which allows the user to determine the set of conductor logic levels of a selected state. The circuit is forced to cycle through a sequence of n distinct states (1, 2, 3, . . . n) in a set time period T repeatedly. During each successive cycle through the n distinct states, the circuit is caused to pause in one or more states for a specific time period different than T/n by the application and sensing of input, control, clock and output terminal waveforms. The number and duration of these pauses are determined by an analysis of the circuit function, if known, or by consideration of the total number of distinct states in the test cycle. The resulting modification of the duty cycle of the voltage waveforms on the various conductors on the circuit insures that only certain conductors' waveforms have an RMS value sufficient to cause the electro-optic effect to occur above them. The overall display on the circuit can then be recorded for later reference. At some later time, a different set of conductors can then be made to cause a bright display above them by changing the duration of the pauses and/or the states during which the pauses are made. The set of states in the sequence may also be changed. The resulting display can then be recorded and compared with previously recorded displays to yield information to be used for failure analysis, design evaluation etc.
It is one object of the present invention, therefore, to provide an improved integrated circuit test apparatus wherein RMS voltages on the conductors on the circuit surface are modified by indirectly controlling the state duty cycles.
It is another object of the invention to provide an improved integrated circuit test apparatus utilizing specifically timed pauses in the normal state to state circuit operation to present a selective visual display.
It is still another object of the invention to provide an improved integrated circuit test apparatus wherein an electrically conductive, optically transparent metal layer is applied to the surface of the coverplate in contact with the liquid crystal.
It is yet another object of the invention to provide an improved integrated circuit test apparatus wherein specially chosen voltage waveforms are applied to the field coverplate to permit selective display of the conductor lines.
These and other advantages, objects and features of the invention will become more apparent after considering the following description taken in conjunction with the illustrative embodiment in the accompanying drawings.
FIG. 1 is a schematic diagram of the integrated circuit test apparatus in accordance with the present invention;
FIG. 1a is a detailed schematic diagram of the integrated circuit under test;
FIG. 2a is a graphical representation of the normal duty cycle operation of the circuit under test;
FIG. 2b is a graphical representation of the modified duty cycle operation of the circuit under test;
FIG. 3 is a detailed schematic of a field effect coverplate;
FIG. 4 is a graphical representation of the use of the field effect coverplate to the circuit display; and,
FIGS. 5 and 6, respectively, are graphical representations of the normal and modified state duty cycle for a four-bit binary counter.
Referring now to FIG. 1, there is shown an integrated circuit test apparatus for visually displaying the electrical states of a unit under test. The integrated circuit test apparatus comprises a light source 10, a polarizer 12 and a microscope 14 in conjunction with an observer or recording means 16 and a second polarizer 18, all of which apparatus is positioned above the integrated circuit 20. The circuit under test 20 is connected to the test electronic unit 24 by an interface means 22 which may be an interface socket card. The test electronic unit comprises all the necessary power supplies, pulse generators, pattern generators, comparators, counters, and other circuitry which may be utilized to provide the normal and modified state duty cycle to the unit under test 20. Light from the light source 10 is polarized by a linear polarizer 12 and used as a light source for microscope 14. The integrated circuit under test 20 may be viewed at point 16 by either an observer or recorded on a camera through another linear polarizer 18. The polarizers 12 and 18 are crossed and then rotated together until the darkest display is obtained when focused on the integrated circuit with no voltages applied. This procedure provides the proper conditions for the highest contrast display.
The integrated circuit under test 20 is shown in greater detail in FIG. 1a wherein the lid has been removed from the integrated circuit package 30 to expose the integrated circuit chip 32. The surface of the integrated circuit chip 32 is coated by either painting or spinning on a thin layer of lecithin which is dissolved in trichloroethylene in a ratio of about 5% by weight. One surface of a glass coverplate 34 is similarly treated. These treated surfaces are then allowed to dry overnight or are baked in an oven at 125� C. for 2 hours. Excellent results may be obtained by substituting a thin transparent gold coating for the lecithin surface treatment. A drop of liquid crystal 36 such as MBBA, which is commercially available, is placed on the surface of the chip circuit 32 and the coverplate 34 is put in place on this drop. Surface tension will hold the coverplate 34 and form a thin (about 10 μm) liquid crystal display cell. The excess liquid crystal 36 may be removed by wicking with the corner of a suitable absorption means.
The glass coverplate 34 must be cut to a size which will fit inside the perimeter defined by the bonds at the end of each fly wire 38 on the surface of the integrated circuit 32.
The present integrated circuit test apparatus provides two methods of visual observation of dynamic operating voltages in various portions of an integrated circuit (IC). The means comprises a nematic liquid crystal (LC) which provides a field effect display cell and is formed by the IC under test and a coverplate. The first method utilizes observation of localized changes in the orientation of the optic axis in a thin layer of nematic, birefringent liquid crystal which is placed in contact with an operating IC. These changes are induced by the electric fields associated with the metal conductor stripes near the surface of the IC structure. The electro-optic mechanisms which produce the visible displays, are well known and understood in the prior art. The present invention utilizes a state duty cycle modification to adjust the RMS electric fields appearing in the liquid crystal layer above the various conductor stripes on the IC under test. The LC layer is known to respond in a RMS fashion to electric fields, i.e., a bright display occurs only above conductor stripes which carry signal waveforms which have RMS voltages at or above a characteristic threshold voltage (VTH) for a particular cell. This VV TH is about 3.5 V for the cells discussed herein, although 4.6 V will produce a much more easily interpreted visible effect.
A complex IC with sequential logic may typically be made to sequence through a given number of logic states repeatedly (e.g., a ring around connected shift register, a counter citcuit, a processor executing a loop of instructions, etc.). The state duty cycle modification method controls in a particular manner the time period spent in any or all of the states in the sequence. The progression from one state to the next in the loop is controlled in such a way that the duty cycle of one state is closer to 50% while the duty cycles of the rest of the states is substantially lower. The net effect is to reduce the duty cycle of all states but the one selected state at a specific instant of time. All conductors that change voltage as the circuit enters and leaves those unselected states will carry signals which have reduced RMS values. When adjusted properly, these values are made to be lower than that required to produce a visible display effect in the LC above these conductors. The one selected state will be visually apparent since the conductors changing voltage as this state is entered and left will carry signals with a higher RMS value. It should be noted that the maximum brightness corresponds to a duty cycle of 50%. This is due to charging effects on the outer surface of the glassivation layer of the IC and the RMS behavior of the LC. The effect is essentially independent of frequency between 500 Hz and 2 MHz.
There are several convenient methods which may be used to accomplish the state duty cycle modification. The clock input may be gated if permissible, special data may be loaded into the IC, an appropriate program might be executed by a processor, or the progressions from one state to the next might be otherwise controlled by applying and sensing the appropriate waveforms at the input, control and output terminals of various ICs. Special purpose clock gating circuitry may be utilized to accomplish this state duty cycle modification with ICs having various numbers of states. Thus, a selected state may be easily changed with this circuitry.
There is shown in FIGS. 2a and 2b the waveforms for a normal and a state duty cycle modification circuit at various internal circuit conductors associated with the selected and not selected states. In FIG. 2a, the states of a normal circuit are shown wherein all states are visible, the following equations apply: ##EQU1## In FIG. 2b, the states of a modified duty cycle circuit are shown wherein only the selective state is visible, the following equations apply: ##EQU2##
This method allows visual observation of portions of the circuit associated with the selected state only by brightly lighting those conductors which change from 1's to 0's or 0's to 1's as that state is lefted and entered. All other conductors on the chip will not light. Thus, circuit layout and functionality may be investigated and verified using the present method. The internal circuit nodes may be easily located and visually probed on complex ICs. The resulting display is significantly improved since conductor voltages associated with only one state contribute to the display rather than voltages associated with all states. The applications of the present apparatus and method include logic layout and implementation verification and functional checks of internal circuit nodes by simple visual means. Thus, the present invention is an alternative testing method to tedious and destructive mechanical die probing or scanning electron microscope voltage contrast techniques which are limited by beam induced charging that may degrade circuit performance.
Turning now to FIG. 3, there is shown the second improvement to the above apparatus and methods. The lower surface of the glass coverplate 40 which is used to confine the liquid crystal layer 42 may be coated with an electrically conductive, optically transparent layer 44, such as gold. One edge or corner of the coverplate is dipped in conductive paint 46 or epoxy to allow an electrical contact to the conductive layer on the top side of the coverplate. This layer serves two purposes, (a) to promote the required homeotropic alignment in the LC which is perpendicular to the surfaces of the coverplate, and (b) to allow direct control of the RMS voltage appearing in the LC cells above the conductor stribes 50 on the IC surface by contacting the conductive layer on the coverplate from above with a standard micropositioner probe 48 and applying suitable voltage waveforms. Thus, the fundamental limitations of prior art methods in testing low voltage circuitry such as TTL, IIL, NMOS, etc. can be overcome. In the prior art, the maximum RMS voltage available on 5 V circuits is (0.5)1/2 (5)=3.5 V, which is below the threshold for a usable display effect in MBBA (about 3.5 V-4.6 V). With the present field plate effect which is established by the conductively coated overplate, the electrical field above various IC metal runs can be directly controlled (either aided or opposed) to allow investigation of low voltage circuits. The prior art methods are limited to circuits which can operate on power supplies of 6.5 V or greater in order to obtain a 4.6 V RMS, 50% duty cycle square wave. The direct control of the voltage on the conductive coating of the coverplate available with the present method may be used in conjunction with, and or in place of the state duty cycle modification method described above to control the RMS field in the LC above various conductor stripes on the IC. The portion of the circuit to be visualized may be selected by applying various waveforms directly to the coverplate.
There is shown in FIG. 4 the waveforms which illustrate how to produce a display enhanced for selected conductor stripes on the IC. The application of a voltage waveform to the plate which is in or out of phase with a selected state will enhance the display above conductors carrying signals which are out of phase or in phase, respectively, with the selected state. The equation for the RMS value of the rectangular pulse train is given by:
VRMS =√duty cycle (peak voltage)
Applying the above equation to the condition shown in FIG. 4(e), the following results:
VRMS1 =√1/8(13v)=4.6 v (VISIBLE)
Applying the equation to FIG. 4(f) the following results:
VRMS2 =√2/8(6.5 v)=3.3v (DARK)
It may be noticed that the plate voltage introduces a change in the peak voltage term in the equation for RMS voltage for the selected state (linear dependence) and a change in the duty cycle term (square root dependance) for all unselected states. This control allows selective displays of 1's or 0's, which is not possible with the previous techniques. The 1's and 0's or voltages may be directly determined at internal nodes depending on the phase of the signal applied to the coverplate (e.g. CLOCK and CLOCK lines can be distinguished).
A further advantage of the present test method is that the RMS voltage on the plate can be made large enough to turn the entire area under the plate bright, yet low enough that the fields on the IC can reduce the field in the LC cell over various selected conductors to below the threshold required for a bright display. In this manner, areas which are selected appear dark and areas not selected are bright. The same options for displaying 1's or 0's exists in the present mode of operation.
In order to more fully describe the general procedure for determining how to modify the normal operation of the circuit under test to obtain the desired results, two examples will be given. The following examples will allow observation of the new effects and will illustrate (1) the general approach for obtaining a selective display of certain portions of a circuit to aid in design and layout analysis and (2) an application to the problem of visually checking for proper operation of portions of a circuit which are deep inside the circuit and not directed accessible by external package pins for electrical testing.
The following specific example illustrates the evaluation of an individual flip-flop in a four-bit binary counter which is located on a complex circuit using the state duty cycle modification process. A 4-bit binary counter has four flip fop circuits which normally are clocked or cycled through 16 states, each of which represents a unique set of voltages (0 or 1) on conductors in the four flip flop circuits. The waveforms in FIG. 5 show the expected voltages associated with certain conductors in the four flip flops during the cycle. The respective RMS voltages are also shown in FIG. 5 for a 10 V power supply and normal clocking. It may be noted that all four RMS voltages are greater than the VTH minimum of 4.6 V required for a bright display. All conductors with these voltages would be displayed, making it impossible to distinguish the V4 conductors from the others when using a test cycle with normal state duty cycle.
A display of the V4 conductors alone may be obtained by applying the following clock pulse sequence. There is shown in FIG. 6 the change in clock pulse sequence which provides a modified state duty cycle that in turn affects the RMS voltage values of V1, V2 and V3 thereby allowing the state of interest V4 to be displayed. The power supply voltage is unchanged at 10 volts. The number of time slots (T) in the cycle was determined by first setting V3RMS =3.5 for a no display condition and calculating the required duty cycle for a 10 v peak waveform. The duty cycle is then set equal to 8/x where x is determined as the cycle length. This modification results in a minimum cycle length and the highest frequency of operation.
In the above example, the liquid crystal responds as if the circuit were changing to and from state 0 and state 8 only. The V4 flip flop can easily be located since the only conductors which are displayed are the V4 conductors. The V1, V2 and V3 conductors may be similarly located by pausing in states 0 and 1, 0 and 2, and 0 and 4, respectively.
A second example is now described which results in a visual display of the contents of an internal storage register of a complex circuit such as a microprocessor. To accomplish this, a program is executed with first CLEARS (loads with 0's) the register of interest and then manipulates data and LOADS a result in the register. The program is executed repeatedly in a loop of 16 instructions. The timing of execution of the program instructions is modified as in example 1, with pauses inserted after the CLEAR and LOAD instructions. Again, the liquid crystal responds as if the CLEAR and LOAD instructions were the only two being executed and the conductors which are brightly displayed are only those associated with bits (flip flops) in the register which are being changed by the LOAD and CLEAR instructions in the cycling program. Thus, the information (data) being LOADED into a register by a certain instruction in the program can be directly read visually, and the proper operation of each flip flop in the register can be verified by observing the displays resulting from loading data which exercises each flip flop.
Although the invention has been described with reference to a particular embodiment, it will be understood to those skilled in the art that the invention is capable of a variety of alternative embodiments within the spirit and scope of the appended claims.
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|U.S. Classification
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|International Classification
|Cooperative Classification
|European Classification


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text:
Texas Instruments clock buffers make it easy to distribute clocks in any system. TI's clock buffers combine low additive jitter and skew with highly flexible input/output formats covering LVPECL, LVDS, HCSL, CML and CMOS levels. The TI WEBENCH® online clock tree design tool makes it easy to select clock buffers for specific system needs.
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text:
Devo tapped to headline Denver County Fair
Update: We just received word that tickets for Devo's performance on July 30 at the first annual Denver County Fair go on sale this morning at 10 a.m.
So that's what Barry Fey was working on. In news that's sure to inspire the nerdiest of our pals to spontaneously bust out into fits of uncontrollable glee right where they stand, Devo has been tapped to headline the first edition of the Denver County Fair. Although the dudes in the funny hats are scheduled to perform on Saturday, July 30, at 7 p.m., the festival itself kicks off on Thursday, July 28, and runs through Sunday, July 31, at the National Western Complex. Talk nerdy to me!
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Great place to get your car fixed! They always take you when your car needs repair and they always fix it right the first time. very professional and do great work.
PROS: great service!
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Business CommunicationIntégréTéléchargement
Business Communication Chapter 2 Diversity and Ethics Copyright 2010 South-Western Cengage Learning Objectives Define diversity and identify its benefits and challenges in the workplace Discuss the diversity of the U.S. population and workforce Discuss how globalization affects the workplace Standard(s) 1.0 - develop and apply concepts related to human relations, safety, career development, communications and leadership skills for a global workplace 2 Overview of Diversity Diversity benefits Diversity challenges Diversity trends Diversity Terms © Digital Vision / Getty Images A diverse workforce can help a company understand its customers. 2.1 Diversity at Work 3 Diversity Benefits Having a diverse workforce Enhances the reputation of the company Helps company attract talented employees and keep customers Can help a company understand its customers' needs Diverse workgroups may be more creative and innovative 4 Diversity Challenges Lack of attention to diversity issues can be costly Possibly lose employees who believe that their employer is indifferent or hostile to people "like them" May not understand their customers' needs/wants 5 Diversity Trends Population predictions U.S. population projected to reach 419.9 million in 2050 U.S. population will become more diverse Hispanic and Asian populations will triple over the next half century Caucasians will soon be the MINORITY! By 2030, about 1 in 5 people will be 65 or older Diverse workforce Workforce will increase to 162.3 million by THIS YEAR Women will make up close to half the labor force 2.1 Diversity at Work 6 The World as a Global Workplace Globalization: the integration of activities among nations in areas such as commerce and culture Globalization and the workforce Competing with candidates from around the world Harder to get a job Multinational companies Conducts business w/ at least 2 nations PepsiCo is available in nearly 200 countries © Beathan / Corbis Globalization affects the workforce in many ways. 2.1 Diversity at Work 7 Work/Life Balance Work/life balance: the need workers have to balance work with other aspects of life Different careers make different demands on workers and their families Consider how your career choice will affect all aspects of your life 2.1 Diversity at Work 8 Quick Review What are some benefits of having a diverse workforce? Is the U.S. workforce as a whole getting younger or older? How can globalization affect people who are looking for jobs? 9 2.1 Assignment Grab a Business Communications textbook (author THOMAS MEANS) Turn to page 39 Complete Part B – Diversity in Your State Use this website: www.cengage.com/school/bcomm/buscomm Select a Chapter: Chapter 2 Web Links USA Quick Facts Turn in when finished! 10 11 Objectives Describe examples of differences among cultures Explain the importance of respecting customs and practicing etiquette Standard(s) 1.0 - develop and apply concepts related to human relations, safety, career development, communications and leadership skills for a global workplace 12 Cultural Differences Language Body language Personal space © Stockbyte / Getty Images Greeting colleagues appropriately is important. 2.2 Differences 13 Language Most common communication barrier In the 2000 U.S. Census, nearly 11 million people indicated that they did not speak English well or at all! Don't forget that even people from different states in our country have different accents that make it difficult to understand 14 Body Language The facial expressions, gestures, or postures that accompany a person's words often have GREATER meaning than the words themselves The less people understand English, the more they rely on body language 15 Body Language Gestures are NOT the same everywhere! The "okay" symbol means worthless or zero in France Elsewhere, it is considered obscene In the US, eye contact while talking is GREAT! In many other cultures, less eye contact is more respectful Many countries and religions consider feet to be unclean Do not cross your feet at the ankles, it shows the soles of your feet, which is considered rude If you touch someone with your feet, apologize! Personal Space Most Americans appreciate personal space of 18 inches to 4 feet This of course varies for different cultures Being in someone's personal space may make some people uncomfortable When American's step back to create more space, in some cultures, this is offensive Customs and Etiquette Customs: beliefs, traditions, and practices of a group of people Etiquette: a set of rules of behavior for a particular place or situation Customs and etiquette vary from culture to culture Stereotype – certain belief about a group of people Leads to judging people as members of a group rather than individuals Prejudice – bias that prevents objective thought about a person or thing Can hinder communication 2.2 Differences 18 Quick Review Name 2 differences in culture that may be barriers to communication. How can a stereotype and prejudice hinder communication? 19 20 Objectives Describe traits and actions that indicate a person has a professional attitude Describe strategies for speaking and corresponding successfully with people from other cultures Standard(s) 1.0 - develop and apply concepts related to human relations, safety, career development, communications and leadership skills for a global workplace Professional Attitude Reduces communication barriers A person who has a professional attitude: Refrains from making judgments about others Keeps an open mind Does not make assumptions or jump to conclusions Keeps emotions in check Is slow to take offense Gives others the benefit of the doubt 2.3 Strategies for Effective Communication 22 Professional Attitude Not being offended easily is one of the MOST IMPORTANT aspects of having a professional attitude If a coworker says something that sounds offensive, stop and think. Was the offense intentional? Did you understand the remark correctly? How often has someone interpreted something you said differently than you intended? Is it possible that could be the case here, too? 23 Cross-Cultural Communication When people from different cultures share messages Guidelines Learning Language Cross-Cultural Guidelines © Digital Vision / Getty Images When language is a barrier, use visual aids that are easily understood. 2.3 Strategies for Effective Communication 24 Learning When working with people from other cultures, spend time learning about those cultures Use internet sources, read books/magazines, and see foreign movies Visit ethnic neighborhoods Enroll in diversity training 25 Language Language is the first barrier to cross-cultural communication Some companies offer foreign language courses for employees If nothing else, learn how to: greet someone, say goodbye, say please and thank you. This can open the door to good relationships with people from other cultures 26 Fairness and Sensitivity Have a professional attitude Treat everyone with respect Do not discriminate unfairly © Photodisc / Getty Images Avoid sensitive topics when talking with clients. 2.3 Strategies for Effective Communication 27 Fairness and Sensitivity Do not say: the Vietnamese patient in Room 122 Say: the patient in Room 122 Do not say: Steve is a male nurse Say: Steve is a nurse Do not say: the bagger with Down's syndrome Say: the bagger at Register 4 28 Quick Review What traits and actions indicate that a person has a professional attitude? What methods can you use to learn about other cultures? 29 EEOC EEOC: U.S. Equal Employment Opportunity Commission Questions 1. List the links that are shown under Discrimination by Type. 2. Click one of the links and read the page. TYPE a paragraph of the main points of the page that you have chosen. Save this document in YOUR DOCUMENTS! http://www.eeoc.gov/laws/types/index.cfm 2.3 Strategies for Effective Communication 30 2.3 Assignment Business Communication Textbook (MEANS) Page 51 Parts A, B, C (TYPE) Save under YOUR DOCUMENTS! After you save, right click in the My Documents folder and click COPY In order to TURN IN both assignments: Student Apps Assignment turn in Rochelle Find YOUR NAME Open folder and right click and click PASTE 31 32 Objectives Define ethics Identify ethical issues related to communication Apply ethical standards to business communication Standard(s) 1.0 - develop and apply concepts related to human relations, safety, career development, communications and leadership skills for a global workplace Ethics in Business Communication Ethics: principles of right and wrong Personal ethics are influenced by: Your experiences Your culture Code of ethics: statement of how a business or group should treat clients, employees, or members 2.4 Ethics in Business Communication 34 Communicating in an Ethical Way Honesty Confidential information Medical information Protected by law Can't share w/o written consent Other types of information Identity theft © Photodisc / Getty Images Trade secrets Be truthful when communicating Gives a business a competitive with customers. advantage These are both CRIMES 2.4 Ethics in Business Communication 35 Communicating in an Ethical Way Protecting confidential data Understand your company's policies Privacy and electronic rights Protect data stored on computers Keep passwords SECURE – see handout Remember that e-mail and text messages are not private 2.4 Ethics in Business Communication 36 Communicating in an Ethical Way Plagiarism Avoiding plagiarism – source anything you may use Copyright and fair use Copyright ©– the legal right of someone, usually the author or artist, to use or reproduce a work During the time of the copyright, if you wish to quote something from a book, you must obtain WRITTEN permission from the author Fair use – allows limited use of copyrighted material without the author's permission Cannot profit from use 37 Quick Review What factors influence personal ethics? List four types of information that are often confidential. Should you make a comment in an e-mail or instant message that you would not put in a printed letter? Why or why not? How can you avoid plagiarism? 38 Project Time!! See handout 39 Cross-Cultural Communication Guidelines Do not make assumptions Be adaptable Avoid discussing sensitive topics Be careful when using humor Maintain personal contact Listen actively Use visual aids BACK 2.3 Strategies for Effective Communication 40 Terms Related to Diversity Race The division of people into groups based on physical characteristics, such as skin or hair color Ethnicity The division of people into groups that share a common ancestry, history, or culture Culture A set of beliefs, attitudes, practices, and social customs that distinguishes a group of people Inclusion Seeing and valuing the contributions of everyone in a workplace and treating everyone fairly BACK 2.1 Diversity at Work 41


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"What a great sitter and lovely person! Dene and her daughters showed so much love and care towards..."
"Special care take for my little Scampi."
"Kim was totally amazing with my energetic puppy! Thunder is a beautiful dog that was great with my..."
"Jako was great! He kept in contact with me while we were away and sent me pictures too. "
"All went well with happy animals on return! Awesome!"
"Came home to a happy Greyhound who looked in great condition Thanks Bec for all your help and doggy ..."
"Rebecca was fantastic, Scrappy was very well cared for, he was a very happy boy and Rebecca was a..."
"Five stars Alison was great thanks so much ?"
"Jamie lee did a fantastic job, Millie looks happy and well...thank you."
" Highly recommended! "
"Great stay. Tacka was so happy when he got home! Would recommend "
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"Thanks Olena Buddy had a great time????"
"Great communication and happy all round...won't hesitate to recommend and repeat business "
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"Julie took great care of Charlie. I will definitely be using Julie again n would recommend her to..."


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95 4.0 random starting problems
Ok I got a 95 4.0 automatic sometimes it cranks and runs perfect but randomly it will crank and run really ruff if I turn it off and keep trying eventually it will crank and run perfect put a new distributor wires plugs rotor button cap and a tps
first jeep
Is it throwing any codes? When it runs rough is a cold or warm engine?
It does it hot or cold just randomly had a tps code fixed had a map code but it went away of course the ac code
Does it only do it only at startup or does it happen driving down the road? Crank sensor & a roasted o2 sensor come to mind.
I had a 91 XJ that had the same symptoms & it was the crank sensor. Turned out to be a pinched wire in the CPS harness.
Only at start up it drives perfect
OK, that has o2 sensor written all over it. The o2 heater is active until the exhaust gets up to operating temp. If the heater in the o2 sensor is bad, it will cause them to do all kinds of crazy stuff.
When it starts and runs rough, does giving it more gas help? I'm thinking it may be injector related. Do you ever run a can of cleaner through it?
No giving it gas won't help you just have to turn it off until it cranks right I already changed the cps I'll check the o2
I would go ahead and check the MAP sensor. While you're at it go ahead and check the O2 sensor. Try disconnecting the battery to reset the computer.
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Red Wing Shoes
6676 Whitmore Lake Road
Brighton, MI 48116
(810) 225-9430
(810) 225-9458 (fax)
Greater Brighton Young Professionals are a dynamic group of young movers and shakers. For more information, click here.
Inspire. Empower. Mentor.
Want to know more about the PWCM? Click here.
Thank you to our Executive Sponsor Bulldog IT Services
Ambassadors are an incredibly important asset to the Chamber. They welcome new members, attend events, and are an extension of Chamber staff, representing the GBACoC at our functions. Click here to learn more.
Business owners today recognize the value referral network groups have to offer. Learn more about our referral network groups here.


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You found probably the funniest site of the internet! Share and discover hilarious, crazy and weird videos, images or what ever you want and find people who share your sense of humour.
We suggest English as your preferred language. You can change the language next to the bendecho logo.Let it rock! ;-)
Eli's Dirty Jokes - Episode 10
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Hotel Tourist, Sorrento
- Free buffet breakfast and WiFi
Main amenities
- 40 guestrooms
- Restaurant and bar/lounge
- Outdoor pool
- Rooftop terrace
- Self parking
- 24-hour front desk
- Coffee/tea in a common area
- Air conditioning
- Daily housekeeping
- Garden
- Multilingual staff
- Free newspapers in the lobby
For families
- Cribs/infant beds (surcharge)
- Private bathroom
- Free toiletries
- Garden
- Daily housekeeping
- Hair dryer
What's around
- Heart of Sorrento
- Piazza Tasso (0.4 mi / 0.7 km)
- Marina Grande (1.1 mi / 1.7 km)
- Piazza Lauro (0.2 mi / 0.4 km)
- Museo Correale di Terranova (0.3 mi / 0.4 km)
- Sorrento Lift (0.4 mi / 0.7 km)
Hotel Tourist, Sorrentofrom $61
- Single Room
- Standard Triple Room
- Standard Triple Room
- Standard Double Room, Balcony
- Single Room
- Standard Double Room
- Standard Double Room
- Standard Double Room, Balcony
More great choices
At a glance
Key facts
Hotel size
- This hotel has 40 rooms
- This hotel is arranged over 6 floors
- 24-hour check-in
- Check-out time is 11 AM
- Express check-in/out
Required at check in
- Credit card or cash deposit required
- Government-issued photo ID required
- Minimum check-in age is 16
Travelling with others
- Children (2 years old and younger) stay free when occupying the parent or guardian's room, using existing bedding
- Pets not allowed
- Free WiFi in public areas
- Free WiFi in rooms
- Self parking *
Other information
- Resort fee included
Nearby Three Star Sorrento hotels
In the hotel
- Free buffet breakfast
- Restaurant
- Bar/lounge
- Poolside bar
- Coffee/tea in a common area
- Outdoor pool
- Bicycle rentals nearby
- Ecotours nearby
- Scooter/moped rentals nearby
- Water skiing nearby
- 24-hour front desk
- Tours/ticket assistance
- Free newspapers in lobby
- Luggage storage
- Multilingual staff
- Number of buildings/towers - 1
- Year Built 1960
- Elevator/lift
- Rooftop terrace
- Garden
- Television in common areas
- Accessible bathroom
- In-room accessibility
In the room
- In-room climate control (air conditioning)
- Air conditioning
- Blackout drapes/curtains
- Soundproofed rooms
- Private bathroom
- Shower only
- Bidet
- Free toiletries
- Hair dryer
- Satellite TV channels
- Desk
- Free WiFi
- Microwave (on request)
- Daily housekeeping
Top Sorrento hotels
Recently reviewed hotels in Sorrento
- Hotel MediterraneoFrom
"The staff at Hotel Mediterraneo went above and beyond in making our stay in Italy memorable. My husband is an above the knee amputee and Italy is not quite "handicap accessible".…"Jan 16, 2017
- Hotel PlazaFrom
"Great location, great quality of room and supreme service attitude. Unbeatable and want to repeat the experience. Thanks to Cynthia, Super Carlo at the Bar, Kind Marianne at…"Jan 16, 2017
- Eurostars Hotel ExcelsiorFrom
"Extremely beautiful and elegant hotel. The hotel and everything about it was near perfect. Only due to my personal preference, I found the bed and pillows a bit too firm. "Jan 16, 2017
- Lanfipe PalaceFrom
"Love it or hate it, one of Napoli's attractions is the controlled chaos on the streets, and there is no better time to experience that than during Christmas when we visited. Via…"Jan 15, 2017
Nearby hotels
Also popular with travelers from the USA
Hotel Tourist, Sorrento's small print
Also known as
- Hotel Tourist
- Hotel Tourist Sorrento
- Tourist Hotel
- Tourist Sorrento
All guests, including children, must be present at check-in and show their government-issued photo ID card or passport.
Cash transactions at this property cannot exceed EUR 2999.99, due to national regulations. For further details, please contact the property using information in the booking confirmation.
Only registered guests are allowed in the guestrooms.
Mandatory fees
The charges below are included in the total price displayed:
- Resort fee
Optional extras
Self parking costs EUR 15 per day
Safes in guestrooms can be used for EUR 5.00 per stay
Cribs/Infant beds are available for EUR 25 per night
We have included all charges provided to us by this hotel. However, charges can vary, for example, based on length of stay or the room you book.
Recent reviews
Good 3.5 /5 from 64 reviews
When my reservation got fouled up, they eventually fixed the problem. Had booked for three nights. They could only give me the last two. Took me down to a sister hotel five minutes away - a five-star for a four-star price. That included a super room and a terrace bar. Back at Hotel Tourist - good for the price - location, fine breakfast included, "business" center computer not hooked up to printer, but free wifi in room.
This is our second time here we Love this hotel & the staff!!
Be careful at breakfast time! - eggs have been around for a while (chicks may hatch any minute - today's tomatoes (cut) may still be around tomorrow (raw but wilted or stewed) - cheese and meats are not coming from the fridge on some ( hot) days - 60% of the time there is yellow water coming from the tap labeled orange juice - Most important: don't touch "coffee"!!!!! - Bring your own air conditioner!
The breakfast was one of the best of the 5 hotels that we stayed in during our June/July 2015 Italy trip. Luigi, night-time check-in and the breakfast service staff were great, aiming to please and trying to accommodate. The room and bathroom were large but shower was small. We intentionally selected (more $$)a room with a balcony due to the room description "1 double bed 194-sq-foot (18 sq-meter) room, balcony/patio with garden views"). Decision was based upon reviews that rooms facing the street were noisy. We were very disappointed upon check in as our room 505 faced the street. Luigi offered us another less appealing room but we opted to stay in 505 and speak with the manager the next a.m. He referred us back to hotels.com stating that we got what we paid for, a double standard room with a balcony, and that there is no guarantee of a garden view. He didn't offer anything else as they were supposedly full. With the a/c noise and being heavy sleepers, we slept well despite the traffic noise. A/c is on 24 degrees Celsius and is controlled by the desk(on/off remotely. We chose this hotel based upon proximity to the train station (10 minute walk)& late check in (24 hours). Unless you are going to use the balcony each night to traffic watch, I do not suggest paying extra for a balcony as you won't be guaranteed a garden view. Is 20 min walk to ferry (Amalfi Coast and Capri) and convenient walk to restaurants and main shopping area as well (15 minutes).
The hotel is very walkable from the station. It has a superb pool which is well-maintained. The room is comfortable, and has excellent Wi-Fi . On the whole the staff are very helpful. Breakfast was very poor. The hotel had three grown men serving the coffee or tea. Most of the time they stood around with very little to do as there was not much to do. Their work could easily have been handled by one young person. Anyway whose life revolves around breakfast?
Is the description of this hotel not correct? Tell us


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This page shows Homes For Sale in Bristol, WI. There are one Homes For Sale in Bristol, WI at this time. To view detailed information on any home, click on 'details', 'map' etc. You may add homes to your favorites and review your list of favorite homes later. You can also email the list to someone, or save it for later.
10197 160th Avenue 4 Bed Home for sale in Bristol, WI
Price: $759,000
Property ID: TF1702403
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March 18, 2014
LONG BEACH - Senior Kayla Kamaka has been named the Big West Women's Field Athlete of the Week the conference office announced Tuesday evening.
Kamaka, who is coming off a medical redshirt season, picked up an individual victory in the pole vault to help Long Beach State to three dual meet wins at the Anteater 4-Way Meet. The Roseville, Calif., native established two lifetime bests on separate tries, first clearing 12-10.75, before extending that effort with a mark of 13-01.5. That height ranks first in the Big West, second in the NCAA and ties for second all-time at LBSU. Kamaka is just the third 49er in program history to clear 13 feet.
This is the first career weekly honor for Kamaka and second for Long Beach State this season as Jason Harrell earned Big West Men's Field Athlete of the Week accolades on March 11.
LBSU is back in action this weekend at the UCI Spring Break Invitational and the Baldy Castillo Invitational.
Sport Links
- 2016 Season
- Season Bests (Updated June 13)
- Weekly Release
- 2016 Black and Gold BBQ
- 2016 Black and Gold Schedule
- 2016 Cross Country/Track and Field Banquet
- 2016 Alumni Meet Registration
- 2016 Beach Kids Meet Registration
- 2017 Annual T&F Sports Package
- Beach Invitational Homepage
- Home Meet Information
- Black & Gold Meet Results
- Official Facebook Page
- Follow on Twitter
- Recruits
- Recruiting Information
- Men's Track & Field Questionnaire
- Women's Track & Field Questionnaire
- Contact Information
- Head Coach Andy Sythe - Jumps, Multis
- Tom Walsh - Distances
- LaTanya Sheffield - Sprints, Hurdles
- Cory Loebl - Throws
- Related Links
- USA Track & Field
- Big West Conference
- TrackWire.com
Media Guides
CoversCovers & Introduction
Section 1Coaching Staff
Section 2Meet the Men's Team
Section 3Meet the Women's Team
Section 4History & Records
Section 5Welcome to the Beach
More Headlines
Shawn Winget Hired as Cross Country/Assistant...08/08/2016 - Track
Long Beach State head coach Andy Sythe has announced the hiring of Shawn Winget as the program...
Beach Track & Field Earns Team and Individual...07/28/2016 - Track
Long Beach State track & field had four individuals receive 2016 USTFCCCA All-Academic...
Long Beach State Track & Field Alums Set for U....06/30/2016 - Track
Long Beach State has four alums who qualified for the U.S. Track & Field Olympic Trials in Eugene...
Long Beach State Track & Field Signs Three More...06/13/2016 - Track
Long Beach State track & field has announced the signing of three more student-athletes to...
LBSU Track & Field Nets Three USTFCCCA...06/13/2016 - Track
Long Beach State had three individuals earn honorable mention All-America honors the U.S. Track &...
Riley Cooks Finishes 20th in Heptathlon at NCAA...06/11/2016 - Track
Junior Riley Cooks finished 20th overall with 5,372 points in the heptathlon to wrap up the NCAA ...


text:
Responding to Crisis
A Rhetorical Approach to Crisis Communication
Edited by Dan Pyle Millar Robert L. Heath
Format: Paperback
Normal Price: $86.99
Your Price: $78.29 AUD, inc. GST
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Responding to Crisis by Dan Pyle Millar
Book DescriptionIn recent years, researchers and practitioners have explored the nature, theory, and best practices that are required for effective and ethical crisis preparation and response. The consequences of being unprepared to respond quickly, appropriately, and ethically to a crisis are dramatic and well documented. For this reason, crisis consulting and the development of crisis response plans and protocols have become more than a cottage industry. Taking a rhetorical view of crisis events and utterances, this book is devoted to adding new insights to the discussion, and to describing a rhetorical approach to crisis communication. To help set the tone for that description, the opening chapter reviews a rhetorical perspective on organizational crisis. As such it raises questions and provokes issues more than it addresses and answers them definitively. The other chapters can be viewed as a series of experts participating in a panel discussion. The challenge to each of the authors is to add depth and breadth of understanding to the analysis of the rhetorical implications of a crisis, as well as to the strategies that can be used ethically and responsibly. Central to this analysis is the theoretic perspective that crisis response requires rhetorically tailored statements that satisfactorily address the narratives surrounding the crisis which are used by interested parties to define and judge it. This volume will be of value to scholars and students interested in crisis communication, and is certain to influence future work and research on responding to crises.
Buy Responding to Crisis book by Dan Pyle Millar from Australia's Online Bookstore, Boomerang Books.
Book DetailsISBN: 9780805840605
(229mm x 152mm x 19mm)
Pages: 392
Imprint: Lawrence Erlbaum Associates Inc
Publisher: Taylor & Francis Inc
Publish Date: 30-May-2003
Country of Publication: United States
Other Editions...
Books By Author Dan Pyle Millar
Responding to Crisis, Hardback (November 2003)» View all books by Dan Pyle Millar
Describing a rhetorical approach to crisis communication, this text reviews rhetorical perspective on organizational crisis, raising questions and provoking issues. It aims to add depth and a breadth of understanding to the analysis of the rhetorical implications of a crisis.
» Have you read this book? We'd like to know what you think about it - write a review about Responding to Crisis book by Dan Pyle Millar and you'll earn 50c in Boomerang Bucks loyalty dollars (you must be a member - it's free to sign up!)
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Tactics for Increasing Immunization Coverage Among Adults
Educational Learning Objectives At the conclusion of this presentation, the participant should be able to: Acknowledge the indications and recommendations for current vaccines and vaccine schedules across adult populations Address immunization barriers frequently encountered during patient/caregiver communications regarding safety, efficacy, and possible misinformation Implement strategies for improving immunization rates within one's clinical practice, taking into account current immunization schedules and guidelines
Adult Immunization Schedule: US 2011 CDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).
Vaccines For Adults Based on Medical and Other Indications 2011 CDC. MMWR Morb Mortal Wkly Rep. 2011;60(4).
Recent Updates to the Adult Immunization Schedule Influenza Pneumococcal Tdap CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(34): ACIP. Accessed Nov 2010.
HR: High Risk Adult Immunization Coverage National Health Interview Survey yrs, HR ≥ 65 yrs CDC. Accessed Nov yrs, HR yrs, HR N = 1,067Sample size→N = 1,046N = 2,444N = 8,070N = 5,275
HR: High Risk Adult Immunization Coverage National Health Interview Survey yrs ≥ 65 yrs ≥ 60 yrs CDC. Accessed Nov yrs yrs yrs yrs, HR Sample size→ N = 14,3786,5405,132N = 13,127N = 1,05212,454N = 7,335N = 1,785
These new parents (age 30) both received Td vaccine 3 years ago prior to their marriage. Should they be vaccinated with Tdap in order to protect their young son from pertussis?
Both parents should receive a single dose of Tdap promptly to protect their son from pertussis.
Tdap for Adults CDC. MMWR Morb Mortal Wkly Rep. 2009;58(14): ACIP. Accessed Nov to 64 years: single dose of Tdap in place of Td (if no previous Tdap received) Especially important for adults around young infants –Parents, grandparents, nannies ≥ 65 years (no previous Tdap) who have close contact with infants < 12 months* Tdap can be administered regardless of interval since last Td *Off-label ACIP recommendation; Medicare Part D coverage
Self-reported Tetanus and Pertussis Coverage Adults, National Health Interview Survey CDC. MMWR Morb Mortal Wkly Rep. 2010;59(40): Tetanus Preceding 10 years Adults ≥ 18 yrs Tdap 2008 Adults 18–64 yrs
25-year-olds Sexually active since age 13 Multiple partners Not previously vaccinated for HPV Not previously sexually active Now in a monogamous relationship Not previously vaccinated for HPV Should either of these women receive the HPV vaccine? Human Papillomavirus
Available HPV Vaccines Quadrivalent Merck - Gardasil ® Bivalent GSK - Cervarix ® Licensed in the US Virus-like Particle TypesHPV 6, 11, 16, 18HPV 16, 18 Protection against HPV 16/18 related CIN2+ ≥ 98%≥ 93% Protection against HPV 6/11 related genital lesions ~99%--- Hypersensitivity-related contraindication YeastLatex Licensed age range9–26 yrs10–25 yrs ACIP Recommendations Routine 11–12 yrs, catch-up 13–26 yrs Routine 11–12 yrs, catch-up 13–26 yrs Schedule 0, 2, 6 months0, 1, 6 months Markowitz L. ACIP Meeting Oct Accessed Nov CIN2+: cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ
HPV – ACIP Recommendations Quadrivalent HPV (HPV4) and Bivalent HPV (HPV2) Routine vaccination of females age 11 to 12 years –Catch-up yrs (HPV4); yrs (HPV2) ACIP: no preference for either vaccine HPV4 or HPV2 vaccination for prevention of HPV 16/18- related cervical cancers, pre-cancers, and dysplastic lesions Vaccination with HPV4 for additional prevention against genital warts, pre-invasive and invasive lesions of the vagina and vulva ACIP Schedules. Accessed Nov FDA. Accessed Nov 2010.
HPV Vaccination and Pregnancy HPV vaccines are not recommended for use in pregnant women Delay initiation of vaccination until after completion of pregnancy If a woman is found to be pregnant after initiating the vaccination series, delay remaining doses until after the pregnancy Two vaccine in pregnancy registries: –Quadrivalent HPV vaccine/pregnancy: –Bivalent HPV vaccine/pregnancy: CDC. MMWR Morb Mortal Wkly Rep. 2010;59:
HPV Quadrivalent Vaccine in Males FDA approved quadrivalent HPV vaccine for boys and men ages 9 through 26 ACIP: Permissive HPV vaccine for males CDC. MMWR Morb Mortal Wkly Rep. 2010;59:
Quadrivalent HPV Vaccine for Women 27 to 45 years Under FDA Review ACIP Considerations As women age from their mid 20s, reduced prevalence and incidence of HPV Disease outcomes (genital warts, CIN 2/3) peak among women in their mid to late 20s Questions on natural history of incident infections in adult women Greatest benefit from vaccinating females in early adolescence Clinical trial data (women 24–45 years) –Efficacy against HPV 6/11/16/18-related persistent infection, CIN, external genital lesions –Well tolerated Dunne E. hpv.pdf. Accessed Nov Haupt R. hpv.pdf. Accessed Nov CIN: cervical intraepithelial neoplasia
This 65-year-old recently recovered from a case of shingles. Is he a candidate for the zoster vaccine? If so, how long should he wait before receiving the vaccine?
Varicella-Zoster Vaccine Shingles Prevention Study Randomized, placebo-controlled, double-blind vaccine trial –Study population 38,546 volunteers at 22 sites; adults 60+ years 95% of volunteers completed study –Follow-up: median duration 3.12 years Vaccine recipients: Overall incidence of herpes zoster reduced by 51% Incidence of postherpetic neuralgia reduced by 67% Injection site reactions were more frequent in the vaccine group Oxman MN, et al. N Engl J Med. 2005;352:
Varicella-Zoster Vaccine Shingles Prevention Study Oxman MN, et al. N Engl J Med. 2005;352: Postherpetic NeuralgiaHerpes Zoster
Zoster (Shingles) Vaccine Single-dose vaccine licensed for persons 60+ years of age Shingles Postherpetic neuralgia CDC. MMWR Recomm Rep. 2008;57(RR5):1-30. CDC. Accessed Nov 2010.
Zoster Vaccine Contraindications and Precautions Contraindications –Previous severe allergic reaction to a vaccine component –Immunocompromised persons HIV, AIDS, leukemia, lymphoma, or other malignant neoplasms Persons on immunosuppressive therapy, including high-dose corticosteroids Persons receiving immune mediators/modulators –Pregnancy or planned pregnancy within 4 weeks Precautions –Moderate or severe acute illness CDC. MMWR Recomm Rep. 2008;57(RR5):1-30.
A previous case of shingles is not a contraindication for the zoster vaccine. The data are not definitive regarding how long to wait following a case of shingles to vaccinate with the zoster vaccine. Some professionals suggest 5 years.
Zoster Vaccine Cost Issues Routine vaccination not previously covered by Medicare part B –Eligible for reimbursement by Medicare part D Patient assistance programs With health care reform –Private sector health plans '1 st Dollar Coverage' –Medicare personalized prevention plan Affordable care act. Accessed Nov AAFP. Accessed Nov 2010.
VariableEstimated Annual Impact Cases24.7 million Outpatient visits31.4 million Hospitalizations334,185 Hospitalized days3.1 million Days of productivity lost due to illness44.0 million Deaths41,008 Life years lost610,656 Medical costs$10.4 billion Lost earnings due to illness and loss of life$16.3 billion Total economic burden$87.1 billion Seasonal Influenza Has a Huge Annual Impact in the United States Molinari NA, et al. Vaccine. 2007;25: Based on 2003 US population demographics
Influenza Vaccination Coverage Levels CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. Accessed Nov *Data from the Behavioral Risk Factor Surveillance System and National 2009 H1N1 Flu Survey
Annual Influenza Vaccine Is Recommended for All people* age 6 months and older! High risk groups include: Adults > 50 yrs Young children Pregnant women People with chronic comorbidities CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. * Without contraindications
2010–2011 Influenza Season Trivalent Influenza Vaccines –A/California/7/2009(H1N1)-like virus –A/Perth/16/2009(H3N2)-like virus –B/Brisbane/60/2008-like virus Current information from the CDC and FDA –http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm#ref –http://www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ ucm htm CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. Accessed Nov FDA. Accessed Nov 2010.
Seasonal Influenza Vaccines FactorLAIVTIV Route of administrationIntranasal sprayIntramuscular injection Type of vaccineLive virusKilled virus Number of included virus strains3 (2 influenza A, 1 influenza B) 3 (2 influenza A, 1 influenza B) Vaccine virus strains updatedAnnually Frequency of administrationAnnually* Approved age2–49 yrs≥ 6 mos OK for persons with medical risk factors for influenza-related complications † NoYes CDC. MMWR Morb Mortal Wkly Rep. 2010;59(RR8):1-62. TIV: trivalent inactivated influenza vaccine; LAIV: live, attenuated influenza vaccine † Includes medical conditions such as chronic pulmonary, cardiovascular, renal, hepatic, neurologic, hematologic or metabolic disorders; those who are immunosuppressed; those who are or will be pregnant during influenza season; residents of nursing homes and chronic-care facilities *Children ≥ 6 mos–8 yrs without prior influenza vaccination or who only received 1 dose of seasonal influenza vaccine should receive 2 doses
2010–2011 Influenza Season VaccineTrade NameAge Group Route of Administration TIVFluzone; sanofi ≥ 6 months Intramuscular TIVFluvirin; Novartis ≥ 4 years Intramuscular TIVFluarix; GSK ≥ 3 years Intramuscular TIVFluLaval; GSK ≥ 18 years Intramuscular TIVAfluria; CSL ≥ 6 months Intramuscular TIVFluzone High-Dose;* sanofi ≥ 65 years Intramuscular LAIVFluMist; MedImmune 2–49 yearsIntranasal TIV: trivalent inactivated influenza vaccine; LAIV: live attenuated influenza vaccine *Each 0.5 mL dose contains 60 μg each of the 3 influenza strains CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(31):
Influenza Vaccination Coverage Levels Health Care Workers (HCW) CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. CDC. MMWR Morb Mortal Wkly Rep. 2010;59(12):
Nosocomial Influenza Is Well Documented Nosocomial outbreaks documented on –Solid organ transplant units –Oncology units –Neonatal ICU –Pediatric units –Long term care facilities –General medical wards Results: morbidity for patients & staff, increased costs for institution & impaired capacity to provide care Vectors for transmission include staff, visitors, patients Stott DJ, et al. Occup Med (Lond). 2002;52: Encourage hygiene etiquette amongst staff and patients
Considerations for Those Morbidly Obese High-risk Group for Influenza For Intramuscular (IM) Injections gauge needle CDC. MMWR Recomm Rep. 2010;59(RR8):1-62. Immunization Action Coalition. Accessed Nov GroupWeightNeedle Length Adults< 130 lbs (< 60 kg)5/8" Adults lbs (60-70 kg)1" Women lbs (70-90 kg)1-1½" Men lbs ( kg)1-1½" Women> 200 lbs (> 90 kg)1½"1½" Men> 260 lbs (> 118 kg)1½"1½"
This woman is 6 months pregnant and would like to get an influenza vaccine. Should she get the trivalent inactivated vaccine, the live attenuated influenza vaccine, or neither?
Influenza vaccination is recommended for all pregnant women, due to the increased risk for influenza-related complications. She should receive the trivalent inactivated influenza vaccine. Live attenuated influenza vaccine is contraindicated during pregnancy.
Maternal Influenza Immunization and Protection of Infants Eick A, et al. Arch Pediatr Adolesc Med Oct 5. [Epub ahead of print] Nonrandomized, prospective, observational cohort study Navajo and White Mountain Apache Indian Reservations N = 1160 mother infant pairs; birth–6 months Infants Born to Vaccinated Mothers vs Unvaccinated Mothers 41% ↓ in risk of laboratory confirmed influenza virus infection RR: 0.59; 95% CI, 0.37– % ↓ in risk of influenza-like illness hospitalization RR: 0.61; 95% CI, 0.45–0.84 Higher hemagglutinin inhibition antibody titers at birth and 2–3 months
Cumulative Cases of Laboratory-Confirmed Influenza in Infants of Moms Who Received Influenza Vaccine Compared with Controls; Bangladesh Zaman K, et al. N Engl J Med. 2008;359: N = 340 mothers randomized to either inactivated influenza vaccine or 23-valent pneumococcal polysaccharide vaccine
Influenza Vaccination Coverage Levels Among Pregnant Women CDC. MMWR Morb Mortal Wkly Rep. 2010;59(47): NHIS: National Health Interview Survey PRAMS: Pregnancy Risk Assessment Monitoring System; 10 States NHIS PRAMS Sample size→N = 113N = 177N = 6,225N = 5,112
Influenza in the Elderly Serious complications from influenza –Secondary infections –Exacerbations of chronic diseases –Increased hospitalization and death Influenza vaccination –Reduced hospitalizations and death CDC. MMWR Recomm Rep. 2010;59(RR8):1-62.
High-Dose Inactivated Influenza Vaccine for Adults ≥ 65 Years, Influenza Season Rationale Higher antigen content –Standard dose TIV 45 μg total virus hemagglutinin antigen per dose –High-dose TIV 180 μg total virus hemagglutinin antigen per dose –Higher immune response; clinical ramifications unknown ACIP: no preference for any specific inactivated trivalent influenza vaccine for use in adults ≥ 65 years CDC. MMWR Wkly Rep. 2010;59(16):
Risk Factors for Invasive Pneumococcal Disease Extremes of age Comorbidities Certain ethnic groups Immune deficiencies Lynch J, Zhanel G. Semin Respir Crit Care Med. 2009;30(2):
S. Pneumoniae ABCs Data < ≥ 65 Cases Per 100,000 Population Deaths per 100,000 Population Age (years) Cases Deaths CDC ABC Surveillance report. Accessed Nov 2010.
Invasive Pneumococcal Disease Among Adults ≥ 65 Years, 1998/99–2007 Pilishvili T, et al. J Infect Dis. 2010;201: Cases/100,000 population Year PCV7 introduced Serotype group PCV7 type Non-PCV7 type 19A *92% reduction in PCV7 serotypes, 2007 vs baseline *
Pneumococcal Polysaccharide Vaccine (PPSV23) for Adults Vaccine contains 23 polysaccharide serotypes from S. pneumoniae Single dose recommended for: –All ≥ 65 years –Asthmatics and smokers age 19 to 64 years –19 to 64 years: chronic cardiovascular disease, chronic lung disease, diabetes, alcoholism, chronic liver disease, CSF leaks, asplenia, cochlear implants –Immunocompromised persons CDC. MMWR Morb Mortal Wkly Rep. 2010;59(34):
Revaccination with PPSV23 19 to 64 years: one-time revaccination after 5 years –Chronic renal failure or nephrotic syndrome –Functional or anatomic asplenia –Persons with immunocompromising conditions ≥ 65 years: one-time revaccination if vaccinated ≥ 5 yrs previously and < 65 years at time of primary vaccination ACIP. Accessed Nov 2010.
Pneumococcal Polysaccharide Vaccine Coverage –Adults ≥ 65 Years, 1997–March 2010 CDC/NCHS. Accessed Nov 2010.
Effectiveness of Pneumococcal Polysaccharide Vaccine in Older Adults: The VSD Cohort Study 3-year cohort study of 47,365 members of Group Health Coop (Seattle) PPV was associated with lower rates of bacteremia: –HR 0.56 (95% CI 0.33 to 0.93) PPV was not associated with lower rates of pneumonia –HR 1.07 (95% CI 0.99 to 1.14) HR = hazard ratio. Jackson LA, et al. N Engl J Med. 2003;348:
Effectiveness of PPSV23 in Adults 2008 Meta-analysis 22 studies; 15 randomized controlled trials (RCTs), N = 48,656 patients; 7 non-RCTs, N = 62,294 patients Results from RCTs –Invasive pneumococcal disease (IPD) Strong evidence of protection (74%); OR 0.26 (95% CI 0.15–0.46); P < No statistical heterogeneity –All-cause pneumonia Inconclusive efficacy (29%); OR 0.71 (95% CI 0.52–0.97); P = Substantial statistical heterogeneity –All-cause mortality No evidence of protection; OR 0.87 (95% CI 0.69–1.10); P = 0.25 –Adults with chronic illness Evidence is less clear Results from non-RCTs –IPD Evidence of protection (52%); OR 0.48 (95% CI 0.37–0.61); P < Moberley S, et al. Cochrane Database Syst Rev. 2008;(1):CD
PPSV23 and Prevention of Pneumonia in Elderly Patients Cohort studies suggest protection against IPD Some cohort studies suggest protection against pneumonia, while others do not No randomized trials have demonstrated efficacy against pneumonia in the elderly
Investigation of Pneumococcal Conjugate Vaccine for Adults Hak E, et al. Netherlands J Med. 2008;66(9): NCT Accessed November Randomized, placebo-controlled clinical trial 13-valent pneumococcal conjugate vaccine – Serotypes 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F conjugated to CRM ,000 adults ≥ 65 years – No prior vaccination with pneumococcal vaccine Primary/Secondary endpoints: –Cases of 1 st episode vaccine-serotype specific pneumococcal community-acquired pneumonia –Cases of vaccine-serotype invasive pneumococcal disease, safety
Hepatitis A Vaccine International Travel For healthy persons 40 years of age or younger –2 doses 6 months apart prior to departure –The first dose of Hepatitis A vaccine should be administered as soon as travel is considered –1 dose of single-antigen vaccine administered at any time before departure Consider both HAV and Ig for –Persons age > 40 with chronic illness traveling in less than 2 weeks and only receiving one dose of HAV –Persons at risk of severe disease from hepatitis A virus planning to travel in 2 weeks or sooner CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41):
Hepatitis A: Families of International Adoptees Hep A vaccination –All previously unvaccinated persons who anticipate close personal contact with an international adoptee from countries of high or intermediate endemicity during the first 60 days following arrival in the US 1 st dose of Hep A vaccine –As soon as adoption is planned –Ideally at least two weeks prior to the arrival of the adoptee CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
Hepatitis A Postexposure Prophylaxis For healthy persons 12 months through 40 years of age who have not previously received HepA vaccine Immunoglobulin and/or single-antigen hepatitis A vaccine Efficacy of Ig or HepA when administered > 2 weeks postexposure is unknown CDC. MMWR Morb Mortal Wkly Rep. 2007;56(41): CDC. MMWR Morb Mortal Wkly Rep. 2009;58(36):
FACT: Hepatitis B virus infects over 40,000 Americans annually CDC. Accessed March 2010.
Hepatitis B Vaccine Adult Schedule *Approved Twinrix schedule **A 4-dose schedule of Engerix-B is licensed for all age groups CDC. MMWR Recomm Rep. 2006;55(RR16): dose schedules for adults age ≥ 20 years –0, 1, and 6 months* –0, 1, and 4 months –0, 2, and 4 months –0, 1, 2, and 12 months** 2-dose schedule for adolescents age 11 to 15 years – 0 and 4-6 mos using adult 10 ug formulation, Recombivax-HB Behavioral, occupational, and medical indications; persons seeking protection from Hep B infection
MMR Evidence of Immunity for Health Care Personnel: Mumps, Measles, & Rubella Born in 1957 or later –Laboratory confirmation of disease or immunity Or –Appropriate vaccination 2 doses of MMR, 4 weeks apart Born before 1957 –Recommend 2 doses of MMR, 4 weeks apart to those unvaccinated without laboratory confirmation of disease or immunity Stronger recommendation if there is an outbreak ACIP. Accessed Nov 2010.
Identify and Address Barriers Patient Issues for Vaccination Awareness –Disease –Vaccine –Personal risk Provider recommendation Misconceptions/fears –About vaccine –About health care system Access and ability to pay
Main Reason for Not Being Vaccinated: NIS, Adult 2007 Adapted from Euler GL. Accessed Nov N = 2,181Sample size→N = 539N = 843N = 221
Cost Is Important, But…. Perceived cost as a significant barrier to patients being vaccinated Johnson DR, et al. Am J Med. 2008;121:S28-S35. Percent
Opportunities for Improvement Abound Nichol KL. Arch Intern Med. 2001;161:
Improving Vaccination Rates – Provider Issues Know the facts Recommend vaccinations to your patients Get organized and use systems approaches –Ensure offering and administration of vaccine Automatic processes that empower nurses are effective Address convenience, efficiency, durability Evaluate and provide feedback Consider new paradigms –New venues –Extend vaccination season Practice what we preach (get vaccinated!) Nichol KL. Cleve Clin J Med. 2006;73:
Shots Immunization App - Free For iPhone/iPod, iPad, Android, Blackberry, and PC Select vaccine name for information on High risk indications Adverse reactions Contraindications Catch-up Administration Risk communication Epidemiology Available at iTunes Store Content includes Childhood, Adolescent, and Adult Immunization Schedules for the US
Receive updates from the CDC via
updates from the Immunization Action Coalition -
Provider Recommendation Can Overcome Negative Attitudes Among Patients Vaccination Rates Among High Risk Patients With Negative Attitudes Nichol KL, et al. J Gen Intern Med. 1996;11:
Standing Orders Are Among the Most Effective Strategies Nonphysicians offer and administer vaccinations Established with physician approved policies and protocols Locations: –Clinics and hospitals CDC. Accessed Nov McKibbin LJ, et al. MMWR Recomm Rep. 2000;49 (RR1):15-26.
Success of Standing Orders as Part of a Multifaceted Program Education Standing Orders Nichol KL. Am J Med. 1998;105: Influenza Vaccination Rates for Elderly Patients in General Medicine Clinics
Patient and Provider Reminders Vaccinations Due or Past Due Patient/parent – Telephone, letter/postcard Provider –Computerized record reminders –Chart reminders Jacobson V, Szilagyi P. Cochrane Database Syst Rev. 2005;(3):CD
Tailored Interventions for Inner-City Health Centers to Improve Vaccination Rates Nowalk M, et al. J Am Geriatr Soc. 2008;56: InfluenzaPneumococcal (≥ 65) ** **P < vs Tailored Interventions Standing orders Provider and patient education Walk-in influenza clinics Electronic prompts Patient reminders
Provider Assessment and Performance Feedback Retrospectively assess the delivery of vaccine(s) Incorporates principles of continuous improvement AFIX –Assessment –Feedback –Incentives –eXchange Comprehensive Clinic Assessment Software Application (CoCASA) Immunization Information System (IIS) CDC. Accessed Nov The Community Guide. Accessed Nov 2010.
Expanding Access Consider new paradigms –New venues, walk-in clinics –Extended hours for vaccinations –Extend vaccination season Nichol KL. Cleve Clin J Med. 2006;73:
Where Flu Shots Are Received (Often Not the Doctor's Office) Singleton J, et al. Am J Infect Control. 2005;33:
Vaccinations in Nontraditional Settings Potential advantages –Cost –Access/convenience –Increased public awareness and demand –New providers and new strategies –For flu, pneumo, ??? other vaccines CDC. MMWR Recomm Rep. 2000;49 (RR1):1-13.
Targeting Hospitalized Patients Makes Sense Hospitalization is a marker for increased risk Hospitalized patients may be less likely to be immunized –Providers often miss opportunities to immunize Organized programs work in the inpatient setting
The Community Guide. Accessed Nov Briss PA, et al. Am J Prev Med. 2000;18(suppl 1): Evidence-based Methods for Improving Immunization Rates Reducing client out-of-pocket costs Client reminder and recall systems Vaccination requirements for college attendance Provider reminder systems when used alone Standing orders when used alone Provider assessment and feedback
Summary Critical patient issues for increasing adult vaccination rates –Knowledge / awareness –Provider recommendations Critical provider issues for increasing adult vaccination rates –Stay current with the immunization schedule, recommendations –Identify and address barriers –Educate patients –Recommend vaccines to patients –Implement organizational and systems strategies –Ensure health care workers are vaccinated –Consider new paradigms
Resources for Providers Immunization Schedules ACIP recommendations & provisional recommendations The Immunization Action Coalition: vaccine information for the public and health professionals The Guide to Community Preventive Services. Vaccine recommendations Assessment, Feedback, Incentives, and Exchange (AFIX) National Foundation for Infectious Diseases Centers for Medicare & Medicaid Services
Resources for Patients and Parents Guide to evaluating information on the web CDC Vaccine Information Statements (VISs) Vaccine Safety National Network for Immunization Information (NNII) Allied Vaccine Group Immunization Action Coalition (IAC) Vaccine Education Center at CHOP TCH Center for Vaccine Awareness and Research
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Dr Celin Gelgec
Melbourne Psychologist
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Dr Celin Gelgec is a Psychologist in Camberwell, VIC .
Dr Celin Gelgec has a special interest in Academic Performance, Anger Management, Anxiety & Phobias, Asperger's Syndrome, Assertiveness Training, Attention Deficit Hyperactivity Disorder (ADHD), Behaviour Problems, Bipolar Disorder, Carer Support, DBT, Depression, Family Therapy, Gender Dysphoria, Grief & Loss, Intellectual Assessment, Learning Difficulties, Lectures Seminars Workshops, Mindfulness-Based Cognitive Therapy, Obsessive-Compulsive Disorder (OCD), Panic Disorder, Psychosis, School Issues, Self-Esteem & Self Development and Stress Management.
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