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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Lisa M. Filippone, MD
Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation [published correction appears in Pediatrics fungus gnats bti buy mentax 15 gm. A new transcutaneous bilirubinometer antifungal washing powder uk discount 15gm mentax with mastercard, BiliCheck fungus gnats diatomaceous earth effective mentax 15gm, used in the neonatal intensive care unit and the maternity ward antifungal vaginal cream purchase 15 gm mentax mastercard. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy-term and near-term newborns fungus gnats killer generic 15gm mentax with visa. Evaluation of transcutaneous jaundice meter following hospital discharge in term and near-term neonates antifungal b&q discount mentax 15 gm amex. Technical Report- Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Screening and early postnatal management strategies to prevent hazardous hyperbilirubinemia in newborns of 35 or more weeks of gestation. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 76 Appendix 18 Figure 1: Nomogram for Designation of Risk. The serum bilirubin level was obtained before discharge, and the zone in which the value fell predicted the likelihood of a subsequent bilirubin level exceeding the 95th percentile (high-risk zone) as shown in Appendix 1, Table 4. Reprinted with permission from the American Academy of Pediatrics8 Note: these guidelines are based on limited evidence and the levels shown are approximations. Infants are designated as "higher risk" because of the potential negative effects of the conditions listed on albumin binding of bilirubin, 45-47 the blood brain barrier,48 and the susceptibility of the brain cells to damage by bilirubin. Note that irradiance measured below the center of the light source is much greater than that measured at the periphery. Measurements should be made with a radiometer specified by the manufacturer of the phototherapy system. See Appendix 2 for additional information on measuring the dose of phototherapy, a description of intensive phototherapy, and of light sources used. If total serum bilirubin levels approach or exceed the exchange transfusion Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 77 Appendix 18 line (Fig 4), the sides of the bassinet, incubator, or warmer should be lined with aluminum foil or white material. Infants who receive phototherapy and have an elevated direct-reacting conjugated bilirubin level (cholestatic jaundice) may develop the bronze-baby syndrome. Reprinted with permission from the American Academy of Pediatrics8 Note that these suggested levels represent a consensus of most of the committee but are based on limited evidence, and the levels shown are approximations. Blood for exchange transfusion is modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant. Reprinted with permission from the American Academy of Pediatrics10 Provide lactation evaluation and support for all breastfeeding mothers. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 80 Appendix 18 Table 2: Phototherapy Devices Commonly Used in the United States and Their Performance Characteristics. For precision based device assessment, the spectral bandwidth (*), which is defined as the width of the emission spectrum in nm at 50% of peak light intensity, is the preferred method to distinguish and compare instead of the total range emission spectrum (data usually provided by manufacturers). Emission peak values are also used to characterize the quality of light emitted by a given light source. The devices have been found exceptionally stable during several years of use and agree closely after each annual calibration. The footprint of a device is that area which is occupied by a patient to receive phototherapy. The irradiance footprint has greater dimensions than the emission surface, which is measured at the point where the light exits a phototherapy device. The minimum and maximum values are shown to indicate the range of irradiances encountered with a device and can be used as an indication of the uniformity of the emitted light. Most devices conform to an international standard to deliver a minimum/maximum footprint light ratio of no lower than 0. All of the reported devices are marketed in the United States except the PortaBed, which is a non-licensed Stanford-developed research device and the Dutch Crigler-Najjar Association (used by Crigler-Najjar patients). Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 82 Appendix 19 Appendix 19. Fetal effects of illicit substances include teratogenesis, intrauterine growth retardation, prematurity, low birth weight, birth complications, and central nervous system damage. Exposed newborns are at risk for neonatal abstinence effects and developmental and behavioral abnormalities. Increasing rates of substance abuse during pregnancy translate into higher numbers of drugexposed infants. The unrecognized infants are discharged to their homes where mothers are likely to continue to use/abuse illegal substances. These infants continue to be exposed to illegal substances and the associated chaotic life style, health degradation, violence, child abuse and neglect, and family dysfunction. Treatment also has a positive effect on fetal outcome (fewer intensive care admissions due to greater gestational age and birth weight). A screening and intervention protocol developed by a panel of experts from across Iowa will help medical care providers to make objective decisions regarding their screening/testing/intervention practices for substance abuse in women during pregnancy and for their offspring. Screening for maternal substance abuse must begin with a thorough but non-judgmental and compassionate interview. Consent for Testing Specific consent should be sought from the pregnant woman to perform urine toxicology testing if any risk factor is recognized via risk assessment form. Urine testing history including testing offer dates, maternal responses (consented versus declined), test dates, results, and positive testing drug(s) should be documented in the chart. Any concerning result should be shared with the hospital social worker and the pediatric team. Maternal consent is not needed to test a newborn as long as one or more of the risk indicators related to maternal and infant history or presentation are present; if the risk factors equate to the conditions stated in Iowa law that is "if a health practitioner discovers in a child physical or behavioral symptoms of the effect of exposure to cocaine, heroin, amphetamine, methamphetamine, or other illegal drugs including marijuana, or combination or derivatives that were not prescribed by a health practitioner or if the health practitioner has determined through examination of the natural mother of the child that the child was exposed in-utero. Urine/meconium or umbilical cord testing with testing dates and results should be documented in the chart. Risk assessment in Prenatal Clinic, Labor & Delivery, and Neonatal Units this tool consists of two assessments; one to assess the risk status of the pregnant/delivering woman, the other of the infant. Prenatal clinic/delivery room risk assessment form: Prenatal clinic and labor and delivery staff will fill out this form. This risk assessment should take place at the first encounter with the pregnant woman and at delivery. At other encounters the staff should document that the pregnant woman continues to be abstinent. Neonatal risk assessment form: this form will be filled out by the newborn staff who will also review the above listed form and maternal drug testing results. Labor and delivery staff should share the maternal risk assessment and testing results with the medical team providing care to the newborn. If prenatal care and delivery take place at different hospitals, the delivery hospital should request maternal consent to obtain the prenatal records from where prenatal care was obtained. Each hospital is encouraged to either adopt these attached forms or develop a system to incorporate the risk assessment forms into the prenatal/neonatal records. Prenatal clinic/labor and delivery staff, hospital substance abuse management team, hospital social worker(s), psychiatry staff, and pediatric team should review these forms in their assessment of their client (infant and/or the mother). Test specimens Urine: 10 ml urine; if submission to the lab is to be delayed it should be kept refrigerated until testing. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 84 Appendix 19 Umbilical Cord: 6-8 inch segment; cord blood should be drained from the cord segment and discarded, rinse exterior with normal saline, place cord segment in specimen container; sample is shipped to testing laboratory without preservative at room temperature. Every institution should have a procedure for documentation according to their policies and procedures in handling all specimens obtained for the purpose of newborn toxicology testing. Institutional response to addiction in Prenatal Clinic/Labor & Delivery Unit Hospitals are recommended to establish an in-house team to respond to the needs of pregnant women using illicit drugs. This team may include staff from prenatal clinic, newborn unit, hospital social services, hospital/community chemical dependency unit/agency, and psychiatry department. Staff becoming aware of substance abuse or positive test results should have this team or the hospital social worker involved to improve the referral process for treatment at any time during pregnancy. Information on referral centers for substance abuse treatment can be found at, Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 85 Appendix 19 1. The National Survey on Drug Use and Health Report, Substance Use During Pregnancy: 2002 and 2003 Update. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. The relationship between parental substance abuse and child maltreatment: findings from the Ontario Health Supplement. Obstetrics Clinic and Labor and Delivery Unit Risk Factors Related to Current Pregnancy Maternal urine drug screen positive. Yes Unexplained discrepancy between delivery/prenatal care facilities (hospital hopping). Yes Untreated maternal depression or major psychiatric illness within the last 3 yearsYes Ever used illegal drugs during any pregnancy. Yes Risk Factors Related to Maternal Social History History of illicit drug use by mother or partner within the last 3 years. Yes History of illicit drug rehabilitation by mother or partner within the last 3 years. Yes History of child abuse, neglect, or court ordered placement of children outside of home. Yes Unexplained symptoms that may suggest drug withdrawal/intoxication: high pitched cry, irritability, hypertonia, lethargy, disorganized sleep, sneezing, hiccoughs, drooling, diarrhea, feeding problems, or respiratory distress. Yes Unexplained congenital malformations involving genitourinary tract, abdominal wall, or gastrointestinal systems. Yes Physician/Nurse Practitioner Signature No No No No No No No No No Date Staff should order meconium and urine screening tests for illicit drugs if the answer is Yes to one or more questions under the Risk Assessment Tool parts A or B. Women who were not screened prenatally, those who engage in behaviors that put them at high risk for infection and those with clinical hepatitis should be tested at the time of admission to the hospital for delivery. The case may be reported by phone (1-800-362-2763), by secure fax (515281-5698), or in writing. Vaccination of Infants at Birth Birth Dose: Only single-antigen hepatitis B vaccine should be used for the birth dose. The initial vaccine dose (birth dose) should not be counted as part of the vaccine series because of the potentially reduced immunogenicity of hepatitis B vaccine in these infants; three additional doses of vaccine (for a total of four doses) should be administered beginning when the infant reaches one month of age. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 90 Appendix 20 After the Birth Dose-Completion of Vaccine All infants should complete the hepatitis B vaccine series with either single-antigen vaccine or combination vaccine, according to the recommended vaccination schedule. Administration of four doses of hepatitis B vaccine to infants is permissible in certain situations (e. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 91 Appendix 21 Appendix 21. In the United States, perinatal asphyxia and resulting hypoxic ischemic encephalopathy occurs in 1 to3 per 1,000 births. The clinical criteria for defining moderate and severe encephalopathy are described in Table 1. Brain injury occurs as the result of an intrapartum event that disrupts cerebral blood flow and leads to decreased oxygenation in the brain, most often in term or late preterm infants. Accumulating evidence supports the thinking that this is an evolving process of brain injury which begins with the initial hypoxic-ischemic insult, but then extends into the recovery period. After resuscitation where cerebral perfusion and oxygenation are restored, a secondary reperfusion injury occurs from 6 to 48 hours after the initial event. However, research has emerged with new treatment options that have great potential for improving outcomes. Brain cooling has a favorable effect on multiple pathways contributing to ischemic brain injury. Studies suggest that cooling the deep regions of the brain can provide some neuro protection for the newborn at risk for severe brain injury. The Neonatal Resuscitation Program, 6th Edition guidelines recommend that infants born at >36 weeks gestation with evolving moderate to severe hypoxic ischemic encephalopathy should be offered therapeutic hypothermia. The potential adverse effects of induced hypothermia include hypoglycemia, decreased myocardial contractility, ventilation-perfusion mismatch, increased blood viscosity, acid-base and electrolyte imbalances, and an increased risk for infection. The cooling process should continue for 72 hours followed by slow rewarming Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 92 Appendix 21 over at least 4 hours. Cooling centers must have the capability for multidisciplinary care and longitudinal follow-up. Cooling Techniques Induced hypothermia has been studied using two methods of treatment: selective head cooling and whole-body cooling. Both methods have been associated with a reduction in brain injury following a hypoxic-ischemic event. Although selective head cooling has been associated with fewer systemic effects of hypothermia, it has not been proven effective in cooling the deep regions of the brain where the greatest potential for neuro protection exists. Whole-body cooling involves lowering the core body temperature and is associated with more adverse systemic effects. But, this method provides more consistent regulation of the brain temperature and more effective cooling of the deep brain structures. There must be physiologic evidence of acute perinatal depression: a cord blood gas or first postnatal blood gas indicating severe acidemia, pH <7. Neurologic criteria for cooling include the presence of seizures or an abnormal neurological exam that is defined by the presence of signs in 3 of 6 categories from Table 1. The general guidelines for identifying potential candidates for induced hypothermia treatment are outlined in the attached algorithm (Figure 1), "Whole Body Cooling for Hypoxic Ischemic Encephalopathy. So, it is imperative that practitioners identify potential candidates for cooling soon after birth and initiate transfer to a cooling center. Guidelines for Perinatal Services, Eighth Edition, Appendices Updated August 2013 93 Appendix 21 Clinical trials supported by the Neonatal Research Network are ongoing at the University of Iowa, information is available at: neonatal. The risk of death or moderate/severe disability was increased with the duration and total time of elevated esophageal temperatures >38.
Vitamin D: the patterns achieve 30 to 45 percent of the Recommended Dietary Allowance for children younger than age 8 years and approximately 55 to 70 percent the Recommended Dietary Allowance for the rest of the population antifungal quiz purchase mentax 15gm overnight delivery. Vitamin E: the patterns generally provide less than 80 percent of the Recommended Dietary Allowance for Vitamin E jessica antifungal treatment 15 gm mentax overnight delivery, except for children younger than age 8 years antifungal rx safe 15gm mentax, where 82 to 94 percent of the Recommended Dietary Allowance is achieved fungus gnats remedy buy 15 gm mentax fast delivery. Choline: the patterns generally provide less than 85 percent of the Adequate Intake for choline fungus on mulch buy cheap mentax 15gm online. Folate: the patterns provide approximately 85 percent of Recommended Dietary Allowance for folate at the 1 antifungal soap target mentax 15 gm online,800 and 2,000 energy-levels during the first trimester for women who are pregnant. Current evidence supports supplementation or targeted efforts to increase iron intakes through dietary choices and fortification for women who are pregnant or who are planning to become pregnant. Careful choices of foods high in iron, including fortified foods, should be considered by females, especially during adolescence and pregnancy, to meet the increased iron Scientific Report of the 2020 Dietary Guidelines Advisory Committee 10 Part D. Some women may need an iron supplement and should consult with a health care provider. Dietary intakes of folate are generally low and folate status may be compromised in some groups of women. Efforts to encourage inclusion of fortified foods or dietary supplements among women with low intakes are warranted. The Patterns were developed for specific age groups (ages 2 to 3 years, ages 4 to 18 years, ages 19 to 30 years, ages 31 to 70 years, and ages 71 years and older) and life stages. The nutrient profiles for food groups and subgroups that were developed for specific age groups reflect variation in dietary intake within the population. The Committee reviewed the similarities and differences between nutrient profiles of specific age groups to consider how best to fulfill nutrient needs across all the life stages. The nutrient profiles specific to each age group were calculated as described above in Methodology. Notably, the nutrient-dense representative foods remained the same for each age group. A description of these nutrient profiles is available in the online Food Pattern Modeling Report. The online report provides the proportions of consumption for each item cluster within each food group or subgroup, the representative foods for each item cluster Scientific Report of the 2020 Dietary Guidelines Advisory Committee 11 Part D. The proportions of consumption of the item clusters were similar across age groups for many food groups and subgroups with variations of only a few percentages. Apple juice was reported as almost 42 percent of fruit juice consumption among those ages 4 to 18 years, while only 17 percent among those ages 19 to 70 years and 14 percent for those ages 71 years and older. Conversely, orange juice contributed 62 percent to fruit juice consumption for those ages 71 years and older, 53 percent for ages 19 to 70 years, and 36 percent for ages 4 to 18 years. The proportion of broccoli in the dark green vegetable subgroup was highest among ages 4 to 18 years at nearly 48 percent of the subgroup, and lowest among those ages 71 years and older at 25 percent of the dark green vegetable subgroup. For those ages 71 years and older, only about 5 percent of the proportion of all starchy vegetable consumption were french fries, compared to 19 percent of starchy vegetables for ages 4 to 18 years. Whole grain bread accounted for 25 percent of whole grains among ages 4 to 18 years and 41 percent for those ages 71 years and older. More than 54 percent of the proportion of nuts and seeds profile among ages 4 to 18 years was from peanut butter and decreased to 23 percent of nuts and seeds for those ages 71 and older. Thus, modifications were made in the nutrient profiles to accommodate these observed changes in food choice based on life stage. For detailed results, including a summary of the nutrients provided by the patterns in comparison to nutrient goals, levels of all nutrients provided by each pattern, and a comparison of the nutrients in all patterns to all nutrient goals, see the online Food Pattern Scientific Report of the 2020 Dietary Guidelines Advisory Committee 12 Part D. Each age-sex group was assigned an intake pattern at a specific energy level that should meet their energy needs to maintain current body weight, assuming an average height and weight and physical activity within the healthy weight range. Within the online Food Pattern Modeling report, the specific nutrient goals for each pattern and the age-sex group(s) for which the pattern was assigned is listed. For this evaluation, the pattern selected was at an energy level appropriate for sedentary (less active) individuals within the age-sex group. If this pattern met nutrient goals for adequacy, patterns at higher energy levels (for more physically active individuals) also would meet those goals. All foods are assumed to be in nutrient-dense forms, lean or lower-fat, and prepared with minimal added fats, sugars, refined starches, or sodium. The sum of energy from the food groups in nutrient-dense form and oils was considered "essential calories," and any remaining energy calculated by subtracting essential energy from the energy goal for the pattern were considered remaining energy for other uses. Compared with the 2015 food pattern modeling exercise, the available remaining energy for other uses for the 2020 Patterns is slightly less because of updates to the nutrient profiles identified above. Further details on how the remaining energy for other uses were applied and analyzed is discussed in Chapter 12 (see Healthy U. If amounts of some of the more common nutrients were to be reduced, it would result in not meeting recommendations for several key nutrients. The nutrients for which adequacy goals are not met in almost all patterns are vitamin D, vitamin E, and choline. Unlike when the 2015 Scientific Report of the 2020 Dietary Guidelines Advisory Committee 14 Part D. Saturated fat ranges from 7 percent to 8 percent of energy, with most patterns providing 7percent of energy from saturated fat including the solid fats available as "remaining calories for other uses. Scientific Report of the 2020 Dietary Guidelines Advisory Committee 16 Women Who Are Pregnant or Lactating Part D. Estimated energy needs and the total anticipated nutrient composition of the patterns for women who are pregnant or lactating are described in the online Food Pattern Modeling report. The Food Patterns at energy levels estimated for women who are pregnant or lactating meet or exceed nutrient needs for most nutrients, as shown in Table D14. The iron requirement for women consuming a vegetarian diet with nonheme iron sources is approximately twice that of women consuming a non-vegetarian diet. Careful choices of foods high in iron should be considered during pregnancy to meet a larger proportion of iron from dietary sources. Some women may need an iron supplement and should consult with their health care provider. Iron needs are in general lower during lactation than during non-pregnant or pregnant women if menstruation has not resumed, which varies based on exclusivity of breast-feeding. Dietary supplements used by women who are pregnant or lactating contribute towards most of these nutrients, except choline that is not present in high amounts in prenatal supplements. The development of these patterns is described in detail in Appendix E-3-7 of the 2015 report. The online Food Pattern Modeling report provides food groups and comparison to goals for all age-groups and energy levels Scientific Report of the 2020 Dietary Guidelines Advisory Committee 20 Part D. Cream, sour cream, and cream cheese are not included due to their low calcium content. Legumes (beans and peas) can be considered part of this group as well as the vegetable group, but should be counted in 1 group only. If all food choices to meet food group recommendations are in nutrientdense forms, a small number of kcals remain within the overall energy limit of the Pattern. The number of these kcals depends on the overall energy limit in the Pattern and the amounts of food from each food group required to meet nutritional goals. Healthy Vegetarian Pattern Although vegetarian dietary patterns are associated with positive health outcomes, their description in the literature often focuses on foods that are not consumed, rather than on the foods that represent the pattern. In previous analyses, more than 90 percent of self-identified vegetarians consumed dairy products on the Scientific Report of the 2020 Dietary Guidelines Advisory Committee 23 Part D. Nutrient adequacy of the Healthy Vegetarian Patterns aims to meet the same nutrient standards met by the Healthy U. The updated Healthy Vegetarian Pattern generally meets nutrient needs. Bioavailability of iron from non-heme sources found in vegetarian diets is lower than that from heme sources. The Committee did not specifically address the iron bioavailability for any of the Patterns, as absorption rates are known to differ based on intake of calcium, zinc, and phytates in the diet. The Healthy Vegetarian Pattern contains some differences in food group amounts compared to the Healthy U. The major difference is the lack of meat, poultry, or seafood subgroups in the Healthy Vegetarian Pattern. Using the 2,000 kcal level as reference, the Healthy Vegetarian Pattern is higher in soy products (particularly tofu and other processed soy products), legumes, nuts and seeds, and whole grains compared to the Healthy U. The 2,000 kcal Healthy Vegetarian Pattern provides less protein (12 g), less fat (1 g), less dietary cholesterol (96 mg), more carbohydrate (19 g), and more dietary fiber (5 g), than the 2,000 kcal Healthy U. For micronutrients, the Healthy Vegetarian Pattern provides less potassium, vitamin A, vitamin D, sodium, and choline than the Healthy U. Amounts of fiber, magnesium, and folate are higher in the Healthy Vegetarian Pattern, primarily due to the increased quantity of legumes and nuts and seeds. Calcium also is slightly higher in the Healthy Vegetarian Pattern due to the higher quantity of processed soy products, including tofu, which often contains a calcium salt, as well as the calcium from dairy and other food groups. The 2,000-kcal Healthy Vegetarian Pattern meets goals and recommendations for most nutrients, although some gaps remain. The major difference between the 2 patterns is that the Healthy Mediterranean-Style Pattern contains more fruits and seafood and less dairy. Although the development of the pattern was focused on health outcomes vs nutrient adequacy, the adequacy of the Healthy MediterraneanStyle pattern has been compared to the same nutrient standards as the Healthy U. The food group and subgroup amounts for this Pattern are described in the online Food Pattern Modeling report. The Healthy Mediterranean-Style Pattern provides calcium, vitamin A, and sodium in lower amounts than the Healthy U. This reflects the lower amount of dairy in the Healthy Mediterranean-Style Pattern for adults: 2 cup-equivalents (cup-eq) compared to 3 cup-eq in the Healthy U. Regardless of energy level, the Dairy Food group (inclusive of calcium-fortified soy beverages) is 2 cup-eq for children ages 2 to 3 years, 2. Using the 2,000-kcal level as reference, the Healthy Mediterranean-Style Pattern includes more fruits (2. The higher amount of protein foods comes directly Scientific Report of the 2020 Dietary Guidelines Advisory Committee 25 Part D. If Nutrient Needs Are Not Met, Is There Evidence to Support Supplementation and/or Consumption of Fortified Foods to Meet Nutrient Adequacy Fortified foods, such as ready-to-eat cereals, are included in food pattern modeling in proportion to their consumption in that age group. However, no special emphasis is placed on fortified foods within the food pattern modeling exercises. Women of reproductive age should carefully consider choices of foods high in iron, especially during pregnancy, so as to obtain a larger proportion of iron from dietary sources given the higher bioavailability. Prenatal dietary supplements provide iron in amounts sufficient to meet needs of most women during pregnancy, and should be discussed with a healthcare provider. During the periconceptual time period, folic acid has been shown to reduce the risk for the occurrence or reoccurrence of neural tube defects. Efforts to encourage inclusion of folic acid in the diet from fortified foods or dietary supplements among women with low intakes are warranted. Choline is not currently part of most dietary supplements that Americans typically consume,15 nor is it fortified in any products known to the Committee. More research is needed, particularly for women of reproductive age, around the health consequences of low levels of choline intake. Thus, the Committee did not consider evaluating whether fortification or supplementation is warranted. The growth in this field of research (and subsequent literature base) reinforces the conclusion that for now, the primary Healthy U. A general consensus has emerged from the Committee based on systematic review about the core components to encourage and those to limit. Therefore, the goal going forward is to help the public achieve these healthy dietary intakes more consistently over the lifespan. Furthermore, the recommended patterns provide the combinations of foods to meet nutrient recommendations while maintaining an appropriate energy intake based on life stage, sex, and physical activity level. However, this work demonstrates that careful choices must be made to consume nutrient-dense forms of foods, lower in foods with sodium, added sugars, and saturated fat within a given energy level. Similarly, the modeling exercises also demonstrates that choosing less nutrient-dense foods. Chapter 1), together with high rates of overweight and obesity suggesting excess energy intakes and or low physical activity. Some shifts that are needed are minor-primarily requiring a different type of food choice or food preparation. For example, choosing a more nutrient-dense snack option of nuts or seeds rather than potato chips or pretzels would provide similar amounts of energy based on serving size, but would help to increase intake of a broad range of nutrients. Baking rather than frying, or alternating food preparation techniques may be considered a small shift that would be beneficial over time. However, other changes or shifts in the diet are likely to require a concerted effort to include foods that may be underconsumed and/or displacing foods and beverages that are overconsumed. One example of this is increasing daily vegetable intake even if the taste of vegetables is not preferred by an individual. Opportunities for improving the dietary quality of Americans can be gleaned by analyzing intake patterns across life stages. As noted in Chapter 1, dietary quality is highest in the youngest populations, with notably lower quality in adolescents and early to middle-aged adults.
If the regimen must be stopped and another alternative for suppressing hepatitis B cannot be found fungus on nails purchase mentax 15gm overnight delivery, liver enzymes should be monitored and treatment re-instated as soon as possible fungi classification definition buy mentax 15gm free shipping. Providers are encouraged to seek regular updates on the subject and antifungal pet shampoo proven mentax 15gm, when in doubt fungus zucchini plants effective mentax 15gm, to discuss individual cases with experienced providers or consult a national or regional clinical support centre lung fungus x ray mentax 15gm generic. For occupational exposure antifungal remedies buy generic mentax 15gm, immediate care of the exposure site includes: wash the site with soap and water; encourage bleeding from the site but do not increase the tissue damage in any way (e. A non-judgemental attitude will contribute towards open conversation where clients will be free to share accurate information on risk (for risk assessment, Table 11. Have you had sexual contact where neither you nor your sexual partner was wearing a condom If yes, did you use syringes, needles or other drug preparation equipment that had already been used by another person Have you had sex while you or your partner was under the influence of alcohol or drugs During these days, safer sex practices should be encouraged (including abstinence and condoms). Programs should ensure that missed opportunities are minimized and every single encounter with infected Key populations is optimally used. These patients are best, comprehensively, managed by providers who have received specific training in the management of injection drug use. Peer-led, community based approaches are particularly useful in improving adherence and retention. Age Breast Development Pre-pubertal Breast bud stage with elevation of breast and papilla (thelarche); enlargement of areola Further enlargement of breast and areola; no separation of their contour Areola and papilla form a secondary mound above level of breast Mature stage: projection of papilla only, related to recession of areola Pubic Hair Pre-pubertal Sparse growth of long, slightly pigmented hair, straight or curled along labia Darker, coarser and more curled hair, spreading sparsely over junction of pubes Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs Adult in type and quantity, with horizontal (feminine) distribution 1. Age External Genitalia Pre-pubertal Enlargement of scrotum and testes; scrotum skin darkens and changes in texture Enlargement of penis (length at first); further growth of testes Increased size of penis with growth in breadth and development of glans; testes and scrotum larger, scrotum skin darker Adult genitalia Pubic Hair Pre-pubertal Sparse growth of long, slightly pigmented hair, straight or curled at the base of the penis Darker, coarser and more curled hair, spreading sparsely over junction of pubes Hair adult in type, but covering smaller area than in adult; no spread to medial surface of thighs Adult in type and quantity, with vertical (male) distribution 1. Address immediate reaction and concerns a child might have Find out from the parent/guardian if they have observed anything after disclosure, eg change in behavior. Monitor potassium daily - If creatinine level increases > 2 fold, omit dose of Ampho B, increase hydration to 1L 8 hourly. If you take less than the dose prescribed the treatment will be effective and will result in resistance and treatment failure. If you are late taking your dose, you can still take it up to 12 hours later, and then continue with your regular schedule (e. If you are more than 12 hours late you should skip the dose and just wait for your next one at 7pm). It does not have to be exactly 12 hours apart if your schedule does not allow; the most important thing is to take them twice per day every day (e. If you are late taking your dose, you can still take it up to 6 hours later, and then continue with your regular schedule (e. Be sure to tell your clinician and pharmacist the names of all the medications (including traditional/herbal) that you are taking, and any time you are given new medications. We have support groups based at the health facility, and there are also support groups in the community - Other reminders. Confirm patient phone number and consent to call if misses an appointment or any urgent lab results - If we cannot contact you by phone we will try to call your treatment buddy. Confirm treatment buddy name and phone number, and consent to call if needed - If we cannot reach you or your treatment buddy, we may try and visit you at home. If viral load is detectable, it is important to determine whether the treatment is failing due to drug resistance or poor adherence. For example, if the patient has chosen 9 pm, but is already asleep in bed by 9 pm, then that is not a good dosing time. Ask how s/he manages side effects and if it influences the way s/he takes the drugs. Ask the patient in a casual way (not in an accusing way) if they sometimes use substances; emphasize treatment planning in case they do "Taking alcohol or drugs sometimes makes it difficult for us to remember to take treatment. Tablet may be crushed and dispersed in water (5-15 ml) or onto a small amount of food and ingested immediately. Headache; fatigue; nausea; diarrhoea; skin rash; pancreatitis; peripheral neuropathy; hepatotoxicity/ hepatitis; lactic acidosis and severe hepatomegaly with steatosis (rare fatal cases have been reported). Lactic acidosis and severe hepatomegaly with steatosis (fatal cases have been reported); headache; diarrhoea; nausea; rash; skin discoloration. Skin rash (may be severe, requiring hospitalization, and life-threatening, including Stevens-Johnson syndrome, toxic epidermal necrolysis); hepatitis; fever, nausea, headache. Jaundice; headache; fever; depression; nausea; diarrhoea and vomiting; paraesthesia; spontaneous bleeding episodes in haemophiliacs. Exacerbation of liver disease; fat redistribution and lipid abnormalities; diarrhoea; abdominal discomfort; headache; nausea; paraesthesia; skin rash; spontaneous bleeding episodes in haemophiliacs. Monitor liver functions especially in patients at risk or with pre-existing liver disease. Fatigue Dietary restrictions Major side effects Comments Interacts with carbamazepine, phenobarbital and phenytoin, use alternative anticonvulsants. Administer at least 2 hours before or after taking supplements or antacids containing Mg, Al, Fe, Ca and Zn. Virologic consequences are uncertain; the potential for additive hepatotoxicity exists. Use of this combination is not recommended; however, if used, co administration should be done with careful monitoring. Dose: Adjust atorvastatin dose according to lipid responses, not to exceed the maximum recommended dose. Ketoconazole Limited data, minimal effect Dose: Use with caution; do not exceed 200 mg ketoconazole daily. Start with reduced dose of 25 mg every 48 hours and monitor for adverse effects Theophylline 47%, monitor theophylline levels. Co-administration not recommended unless benefit of fluticasone outweighs the risk. Health information systems: Does the facility have an established system to monitor patient outcomes specifically retention, lost to follow-up, mortalities and viral load suppression This publication has been produced with the financial and substantive assistance of the European Union. This document, as well as any data and any map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Until a lasting and equitable solution is found within the context of the United Nations, Turkey shall preserve its position concerning the "Cyprus issue". The information in this document relates to the area under the effective control of the Government of the Republic of Cyprus. All requests for public or commercial use and translation rights should be submitted to rights@oecd. At the same time, many lives could be saved by redoubling efforts to prevent unhealthy lifestyles. Policies to control tobacco and harmful consumption of alcohol or to halt obesity therefore need to be actively pursued. This edition of Health at a Glance: Europe also makes a strong case for promoting mental health and preventing mental illness. Promoting mental health and improving access to treatment for people with poor mental health should be a priority. Health systems have achieved remarkable progress in treating life-threatening diseases such as heart attacks, strokes and various cancers, yet wide disparities in survival rates persist not only between countries but also among hospitals and health care providers within each country. Health care needs to place people at the centre, which requires asking patients more systematically whether they are better, or worse, following different health care interventions. We must also measure how well the primary care sector is managing the growing number of people living with one or more chronic conditions. Poor Europeans are on average five times more likely to have problems accessing health care than richer ones, and policies must prioritise financial protection for disadvantaged groups. As health systems evolve, they must become more resilient and adapted to rapidly changing environments and needs. In this edition of Health at a Glance: Europe, we highlight the importance of reducing wasteful spending, and the potential gains for efficiency and sustainability of health systems. Evidence from various countries suggests that up to one-fifth of health spending is wasteful and could be reallocated to better use. This publication would not have been possible without the effort of national data correspondents from the 36 countries who have provided most of the data and the metadata presented in this report, and financial support provided by the European Union. Michael Mueller, James Cooper, David Morgan and Jens Wilkens prepared Chapter 5 on health expenditure and financing, with input by Sebastiano Lustig. Strategies to reduce wasteful spending: Turning the lens to hospitals and pharmaceuticals. StatLinks2 Look for the StatLinks2at the bottom of the tables or graphs in this book. To download the matching Excel spreadsheet, just type the link into your Internet browser, starting with the dx. Making the case for greater priority to improving mental health Mental health is critical to individual well-being, as well as for social and economic participation. The heavy individual, economic and social burdens of mental illness are not inevitable. Many European countries have in place policies and programmes to address mental illness at different ages. Reducing wasteful spending to make health systems more effective and resilient "Evidence from various countries suggests that up to one-fifth of health spending is wasteful and could be reallocated to better use" Wasteful spending occurs when patients receive unnecessary tests or treatments or when care could have been provided with fewer and less costly resources. Evidence from various countries suggests that as much as one-fifth of health spending is wasteful and could be reduced or eliminated without undermining quality of care. When it comes to hospitals, many admissions could be avoided with better management of chronic conditions in the community. Unnecessarily delayed discharges are also costly for hospitals, and many dischargeready patients occupy beds that could be used for patients with greater needs. When it comes to pharmaceuticals, minimising waste and optimising the value derived from medicine spending are also critical to achieving efficient and sustainable health systems. A mix of policy levers can support this goal, including: 1) ensuring value for money in the selection and coverage, procurement and pricing of pharmaceuticals through Health Technology Assessment; 2) exploiting the potential savings from generics and biosimilars; 3) encouraging rational prescribing; and 4) improving patient adherence. This slowdown appears to have been driven by a slowdown in the rate of reduction of deaths from circulatory diseases and periodical increases in mortality rates among elderly people due partly to bad flu seasons in some years. These gaps largely reflect differences in exposure to risk factors, but also indicate disparities in access to care. Alcohol control policies have reduced overall alcohol consumption in several countries, but heavy alcohol consumption among adolescents and adults remains an important public health issue. Inequality in obesity remains marked: 20% of adults with a lower education level are obese compared with 12% of those with a higher education. The quality of acute care for life-threatening conditions has improved in most countries over the past decade. Fewer people die following a hospital admission for acute myocardial infarction (a 30% reduction on average between 2005 and 2015) or stroke (a reduction of over 20% during this same period). However, wide disparities in the quality of acute care persist not only between countries but also between hospitals within each country. Remarkable progress has also been achieved in cancer management through the implementation of population-based screening programmes and the provision of more effective and timely care. Survival rates for various cancers have never been higher, yet there is still considerable room for further improvement in cancer management in many countries. Yet, low-income households are still five times more likely to report unmet care needs than high-income households, mainly for financial reasons.
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Ten-year clinical fungus gnats driving me crazy generic mentax 15 gm mastercard, developmental fungus clear order 15 gm mentax with amex, and intellectual follow-up of children with congenital cytomegalovirus infection without neurologic symptoms at one year of age fungus gnats prevention purchase 15gm mentax with mastercard. Human cytomegalovirus seroprevalence in three socioeconomically different urban areas during the first trimester: a population-based cohort study fungus gnats no plants cheap mentax 15gm fast delivery. Seroprevalence fungi definition simple buy mentax 15gm line, incidence of prenatal infections and reliability of maternal history of varicella zoster virus fungus gnats predators order mentax 15 gm free shipping, cytomegalovirus, herpes simplex virus and parvovirus B19 infection in South-Western Finland. National Institute of Allerg y and Infectious Diseases Collaborative Antiviral Study Group. Ganciclovir therapy for symptomatic congenital cytomegalovirus infection in infants: a two-regimen experience. Ganciclovir population pharmacokinetics in neonates following intravenous administration of ganciclovir and oral administration of a liquid valganciclovir formulation. Neuropathogenesis of congenital cytomegalovirus infection: disease mechanisms and prospects for intervention. Epidemiological impact and disease burden of congenital cytomegalovirus infection in Europe. A literature review was carried out of articles in PubMed, European Monitoring Centre for Drugs and Drug Addiction publications, and related documents in order to assess public health challenges and possible intervention strategies related to problem drug use and pregnancy in Europe. It revealed the following: Involving pregnant drug users in drug treatment is likely to decrease the chances of pre- and perinatal complications related to drug use and to increase access to prenatal care. Timely medical intervention can effectively prevent vertical transmission of human immunodeficiency virus, hepatitis B virus as well as certain other sexually transmitted diseases, and would allow newborns infected with hepatitis C virus during birth to receive immediate treatment. Pregnancy may be a unique opportunity to also help women with dual diagnosis (substance use combined with mental illness) and enrol them into special treatment and support programmes. Issues related to homelessness and intimate partner violence can also be addressed with appropriate interventions. Treatment and care for pregnant drug users should offer coordinated interventions in several areas: drug use, infectious diseases, mental health, personal and social welfare, and gynaecological/obstetric care. Furthermore, approximately 20% of drug users entering drug treatment and around 34% of opioid users are women (the great majority of whom are of childbearing age) [3], and every year, as many as 6. The issue of pregnancy and drug use is important to address because of the associated personal and public health challenges regarding both the mother and the unborn child, especially regarding infections that are common among drug-using populations. Methods A literature review of articles in PubMed published in or after 1990 was conducted using the keywords "pregnancy" and "drug use" / "substance abuse", and specific keywords for each area of interest (e. Articles discussing pregnancy and tobacco or alcohol use without the mention of other drugs were not considered. In addition, when articles were found that were especially relevant to this review, the "Related Articles for PubMed" links were also investigated. While our focus was on pregnant drug users in Europe, some non-European references were included when found relevant. In this paper, we use the terms "drug use" to refer to problem use of drugs other than alcohol or tobacco, and "pregnant drug users" to refer to pregnant women with problem use of drugs other than alcohol or tobacco. Pregnancy complications linked to drug use Continued drug use during pregnancy may lead to complications for the foetus, for the newborn, and later during childhood [6,7]. Complications for the foetus include spontaneous abortion, restricted foetal growth, incorrect maternal placentation, compromised foetal well-being and pre-term delivery. The newborn can be affected by low birth weight, postnatal growth deficiency, microcephaly, neurobehavioral problems and drug withdrawal syndrome [8,9]. Drug treatment Lack of appropriate obstetric and neonatal care has been associated with obstetric complications and with poor pregnancy outcomes among drug users [9-12]. Treatment of drug dependence of pregnant drug users therefore involves not only a stabilisation of their health and social situation as drug users, but also offers an opportunity for regular contact with health services, including standard pre-natal care [13]. Since the 1970s, methadone maintenance has been recommended for opioid dependence in pregnancy [14], although some studies have shown that buprenorphine may offer an advantage over methadone with regard to lower intensity of neonatal abstinence syndrome [1517]. However, the possibility of drugdrug interactions should be kept in mind, and dose adjustments of substitution treatment may be necessary in different stages of the pregnancy [19]. A recent systematic review of psychosocial interventions suggested that contingency management strategies are effective in improving retention of pregnant drug users in outpatient treatment, but failed to assess any effects on obstetrical and neonatal outcomes [20]. Evidence on the effects of home visits by nurses, counsellors or midwives to women with a drug problem is currently insufficient [21]. However, several decades of clinical management of pregnant drug users point to a need to consider the life circumstances of the individual women and apply a case management approach [9,10,13,14,17,19,22]. The prevalence of infectious diseases is also high among pregnant women who use illicit drugs [23]. The likelihood of transmission increases with the viral load, which is higher during active injecting drug use. In Europe, as many as 80% of clients enrolled in drug treatment report a mental health problem [2,49-52]. Psychiatric co-morbidity is complex because patients may suffer from more severe symptoms than people with only substance use or mental illness, they may not respond well to treatment, and, when in treatment, they may have higher rates of relapse and attrition [53,54]. While in the general population men report higher levels of drug use than women [55], women report higher rates of mental illnesses, especially depression and anxiety disorders [56]. However, levels of psychiatric co-morbidity among substance users seem to be similar in both sexes [57]. In a study in France, 22% of pregnant drug users in substitution treatment for opioid use reported moderate to severe psychiatric disorders, mostly depression, neuroticism and anxiety disorders [25]. Pregnant women suffering from psychiatric co-morbidity often report a history of emotional, physical and sexual abuse as well [57,58]. Pregnancy may be an opportunity of contact with care services for both conditions of co-morbidity. However, the fear of losing the custody of the child and the feeling of guilt about using drugs during pregnancy may often pose a barrier to seeking treatment [57]. Interventions among pregnant women with psychiatric co-morbidity should target the three problematic areas (mental health, drug related problems and pregnancy) in a coordinated and integrated way, taking into account the individual needs of these women [10,19,59]. Social and personal welfare Issues related to the social and personal welfare of pregnant drug users include, among other things, homelessness and intimate partner violence. Overall, about one in ten drug users entering treatment in Europe lives in unstable conditions or is homeless [3]. Homelessness and drug use in pregnant women are associated with problematic perinatal events [11,12], inadequate access to health care, social isolation, and psychosocial and physical problems [60]. Among female drug users, those who are homeless more often face difficulties obtaining public assistance, and are afflicted by greater social isolation, a lack of family and social networks, higher rates of emotional, physical and sexual abuse as well as undernutrition, and they are more likely to engage in survival sex [60]. Some homeless female drug users may be able to discontinue the E U R O S U R V E I L L A N C E Vol. Homeless pregnant drug users are less likely to seek drug treatment than domiciled pregnant drug users, and, when in treatment, they are less likely to maintain abstinence and are more likely to leave treatment prematurely [60]. When compared to women who have not experienced assault, pregnant women who have been assaulted were more likely to drink alcohol or use drugs [63,64]. In a perinatal substance abuse treatment clinic, many pregnant drug users reported being abused during their pregnancy: 41% reported emotional abuse, 20% physical abuse and 7% sexual abuse [65]. Abused pregnant drug users often report that emotional abuse is more disturbing than physical abuse, and many report being subject to both emotional and sexual abuse [64,65]. The abuser in most of the cases is the partner, ex-partner or someone closely related to the victim [65-67]. The risk of increasing drug or alcohol use increases after experiencing violence [63,65,67]. Intimate partner violence among pregnant drug users is responsible for health problems such as depression, post-traumatic stress disorder, chronic pain in different parts of the body (e. Clinics, including prenatal clinics and drug treatment centres, may be the most appropriate place for pregnant drug users to receive interventions in order to prevent recurring partner violence and abuse [62,68-70]. Conclusions Pregnant drug users are at a higher risk than pregnant women who do not use drugs of contracting blood-borne and sexually transmitted infections. In addition, they are also affected by a number of physical, mental and social health problems. Services geared towards the general population need to cater to pregnant drug users as well. Special services for problem drug users should use outreach methods to timely identify pregnant drug users not in contact with services and ensure referral and collaboration with pregnancy care givers, using integrated case management strategies. Treatment and care for pregnant drug users should offer coordinated, multidisciplinary interventions encompassing several areas: prevention, screening and treatment of infectious diseases; mental health; personal and social welfare; gynaecological/obstetric care; and drug use [20,21]. The aim of such treatment and care is to reduce risk through the integrated collaboration of obstetricians, addiction counsellors, social workers, general practitioners, and other health care specialists [71], and to link drug treatment with other interventions aimed to help pregnant drug users. In addition, to prevent parental neglect that may be the consequence of drug abuse, adequate parenting support services should be made available and easily accessible to pregnant drug users. High pregnancy rates and reproductive health indicators among female injection-drug users in Vancouver, Canada. Maternal and neonatal effects of substance abuse during pregnancy: our ten-year experience. Adverse perinatal outcomes associated with homelessness and substance use in pregnancy. Neonatal outcome following buprenorphine maintenance during conception and throughout pregnancy. Buprenorphine and methadone treatment of opiate dependence during pregnancy: comparison of fetal growth and neonatal outcomes in two consecutive case series. Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence. Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions. Home visits during pregnancy and after birth for women with an alcohol or drug problem. The impact of intensive case-managed intervention on substance-using pregnant and postpartum women. Prospective multicenter observational study of 260 infants born to 259 opiate-dependent mothers on methadone or high-dose buprenophine substitution. Transmission of hepatitis C virus to infants of human immunodeficiency virusnegative intravenous drug-using mothers: rate of infection and assessment of risk factors for transmission. Increased vertical transmission of human immunodeficiency virus from hepatitis C virus-coinfected mothers. Should hepatitis B vaccination be introduced into childhood immunisation programmes in northern Europe Treatment retention and birth outcomes of crack users enrolled in a substance abuse treatment program for pregnant women. Illicit drug use in patients with psychotic disorders compared with that in the general population: a cross-sectional study. The state of the drugs problem in the European Union and Norway, Selected Issue 3: on Co-morbidity. Prevalence of comorbid psychiatric illness and substance misuse in primary care in England and Wales. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. Characteristics of drug-abusing women with children in residential treatment: a preliminary evaluation of program retention and treatment completion. Comparing homeless and domiciled pregnant substance dependent women on psychosocial characteristics and treatment outcomes. Intimate partner violence and comorbid mental health conditions among urban male patients. Intimate partner violence screening and intervention: data from eleven Pennsylvania and California community hospital emergency departments. Intimate partner violence screening and brief intervention: experiences of women in two New Zealand Health Care Settings. Vertical (mother-to-infant) transmission of the infection occurs usually in perinatal period and is responsible for the majority of the disease burden in endemic areas. The risk of vertical transmission generally depends on the level of maternal infectivity during pregnancy, i. Between September 2008 and December 2008 a total of 749 pregnant women (mean age 28. The study was performed in accordance with the Helsinki Declaration and was reviewed and approved by the Hospital Ethics Committee. A significant proportion of young women from Asia and Africa who live and work in Greece are second generation immigrants and the majority of them were born in our country, in contrast to Albanian or Eastern European women. Importantly, vaccination-induced protection rates were relatively highest and comparable among Albanian and Greek women (40. Surveillance for hepatitis B virus infection in pregnant women in Greece show high rates of chronic infection among immigrants and low vaccination-induced protection rates: preliminary results of a single center study. Department of Medical Microbiolog y, Leiden University Medical Center, Leiden, the Netherlands the theme of this conference was "public health action towards awareness, prevention, and treatment". These children were a testimony of the severe disabilities that congenital infections can cause. More than 250 participants from all over the world attended the conference, which included about 50 oral presentations and 50 poster presentations. In this report the different topics of this conference will be briefly discussed, with a focus on disease burden and public health. Between 17 and 20 % of these congenitally infected children will have permanent disabilities [2]. In this group, administration of intravenous ganciclovir for six weeks protected against hearing deterioration.
After a weekend Old Firm fixture there is an increase in emergencies of between 15% and 20% in demand fungus gnats peroxide buy 15gm mentax overnight delivery. In almost all of these emergencies alcohol is a factor and often violence is involved fungi examples cheap 15gm mentax. The Service has agreed a process with the police to manage drunk and incapable people safely in the community and ensure that they are referred appropriately fungal nail salon cheap 15 gm mentax overnight delivery. In some cities and at particularly busy times fungus gnats larvae kill purchase mentax 15 gm without a prescription, such as the festive season fungus feet buy discount mentax 15 gm online, the Service works with local authorities and other agencies to provide create city centre triage and rest and recuperation areas to better manage the care of drunk and incapable patients and reduce the unnecessary visits to busy A&E departments fungus vs mold mentax 15 gm cheap. Local action plan for your service / practice / provider References/web links/dates Please describe how you will implement the alcohol conversation in your organisations below: 96 Version 5: Requests for amendments to linda. Fire professionals may come into contact with people who abusing alcohol and who are not accessing any other services. A preventative approach from the Fire professionals when educating local people about fire or managing an incident may help service users to reduce their intake. In 8% (2,483) of these fires where impairment due to suspected drug or alcohol use was recorded as a contributory factor. Impairment due to alcohol or drug resulted in 41 deaths and 1,208 injuries from 2,483 dwelling fires. Average fatality rate where alcohol or drug impairment suspected to be an influencing factor is three times more compared to where alcohol or drug impairment was not an influencing factor the rate of serious injuries is four times higher where drug or alcohol impairment was a contributory factor than where alcohol or drug impairment was not a factor. Male casualties outnumbered females by two to one in dwelling fires where impairment due to suspected alcohol or drug use was an influencing factor. More than half (56%) of casualties in accidental dwelling fires where impairment due to alcohol or drugs was a contributory factor were themselves not suspected to be under the influence of alcohol or drugs References/ web links. Professionals in Criminal Justice may come into contact with people who abusing alcohol and who are not accessing any other services. Alcohol has been seen nationally to have implications for criminal justice systems. A preventative approach from the criminal justice professionals when educating local people about fire or managing an incident may help service users to reduce their intake. Other reports have previously made calls for further attention and action to address alcohol-related offending needs. See here for relevant bulletins from Findings bank and here for further Offender Health publications and links on the Alcohol Learning Centre. This document was produced by the Home Office in 2009 to help commissioners of services. Arrest referral is a term generally used to describe the process of engaging in terms of a brief intervention with a detained person in a police custody suite and facilitating their referral into treatment or some other diversionary channel. Alcohol Arrest Referral schemes specifically look at individuals committing alcohol related offending and so are quite different from interventions designed to improve the health of an individual. Local action plan for your service / practice / provider References/web links/dates Please describe how you will implement the alcohol conversation in your organisations below: 101 Version 5: Requests for amendments to linda. Health visitors play a unique role in terms of their relationship with, and access to , families with very young children. They have ready access to the home environment and, unlike, say, social workers, do not just see people at times of crisis; unlike teachers they often see the whole family group, rather than just one member of it in isolation. It important that health visitors should be in a position to be able to: Identify families where parental alcohol misuse may be a problem Make a reasonable judgement of the extent to which parental drinking is, and is not, affecting good enough parenting Offer appropriate advice to parents misusing alcohol, which may include brief interventions as well as referral elsewhere. The aim of the health visiting service is to promote the health of the whole community and to help in promoting healthy lifestyles, addressing concerns about physical and mental well-being, with the key principles including: the search for health needs the stimulation of an awareness of health needs the facilitation of health-enhancing activities References/ web links. As professionals in their own right it is, under the legislation, up 103 Version 5: Requests for amendments to linda. Whilst being independent practitioners with broad responsibilities, national targets and pressures on services are focusing the work of health visitors towards key areas and government targets. These are focusing their work with individuals on a minimum number of child health development checks. In respect of working with individuals and families health visitors work within the frameworks and guidance set out in: Working Together to Safeguard Children Department of Health Framework for Assessment Health Visitor Practice Development Resource Pack the implications of the first two of these documents in relation to practice around parental alcohol misuse. Alcohol is a factor in many of the priority health issues that health visitors need to address, including mental health, coronary heart disease, stroke, accidents and some cancers. Problem drinking can also severely affect the well-being of families through its association with child abuse and neglect and domestic violence. Health visitors can raise the issue of alcohol intake in a nonstigmatising way, particularly as part of a family health plan. Local action plan for your service / practice / provider Please describe how you will implement the alcohol conversation in your organisations below: References/web links/dates 104 Version 5: Requests for amendments to linda. Nurses in general practice (termed practice nurses) and community nurses are an under-utilized resource for the detection and management of patients with alcohol misuse. A preventative approach from the practice/ community nurses across East Surrey when treating local people may help service users to reduce their intake. There is some evidence suggesting that patients with alcohol-related problems do consult their general practice. For example, Wallace and Haines (1984) reported that 4% of patients surveyed had a problem with alcohol. A report by McMenamin (1997) suggests that these figures may be higher, with 13% of men and 2. A more recent questionnaire survey of practice nurses showed that an average of 3. In recognition of this, there has been a massive increase in practice nurse numbers from less than 5000 in 1989 to over 10 000 in 1995 (Department of Health, 1995a). Given the potential for primary care to have a major role in the detection and treatment of alcohol misuse, it has been suggested that practice nurses may be an underutilized resource for the management of such patients (Deehan et al. Indeed, the first and often the only contact for individuals with potential alcohol-related problems may be the practice nurse-led clinics in general practice. Clearly, it is important to ensure that practice and community nurses are 106 References/ web links To be added Version 5: Requests for amendments to linda. The minimum training and competence requirements for practice nurses must include (a) an ability to take a careful alcohol history [which is often not done by doctors (Kitchens, 1994; Roche and Richard, 1994; Volk et al. Local action plan for your service / practice / provider Please describe how you will implement the alcohol conversation in your organisations below: References/web links/dates 107 Version 5: Requests for amendments to linda. Dental practitioners may come into contact with people who abusing alcohol and who are not accessing any other health or social care services. People who present at Dental surgeries may not identify that they have an alcohol issue and would not normally approach services for help due to reasons such as social class and stigma. However, a preventative approach from the dental practitioners may help service users to reduce their intake. The British Dental Health Foundation states that alcohol is one of the main causes of dental erosion and this may be further affected by vomiting due to alcohol. Consequently, bacterial overgrowth and increased penetration into gingival tissues can occur. Consumption of 10 or more drinks per week results in higher periodontitis risk compared to those who consume fewer than 10 drinks per week. Increasing alcohol consumption from five units to 20 units a week increases the risk of periodontal disease from 10 percent to 40 percent. Alcohol causes dehydration of the mouth, so bacteria are not washed away by saliva, and plaque formation occurs faster. There are studies on the detriment of alcohol on dental health and the higher incidence of dental caries experienced. Local action plan for your service / practice / provider References/web links/dates Please describe how you will implement the alcohol conversation in your organisations below: 109 Version 5: Requests for amendments to linda. Housing professionals may come into contact with people who abusing alcohol and who are not accessing any other services. People who present at for housing, re-housing or housing advice may not identify that they have an alcohol issue and would not normally approach services for help due to reasons such as social class and stigma. However, a preventative approach from the Housing professionals may help service users to reduce their intake. Local action plan for your service / practice / provider References/web links/dates Please describe how you will implement the alcohol conversation in your organisations below: 110 Version 5: Requests for amendments to linda. People may present to prison services who have an alcohol disorder and may not interact with statutory services. Professionals in Domestic abuse may come into contact with people who abusing alcohol and who are not accessing any other services. Alcohol has been seen nationally to have huge implications for domestic abuse service. A preventative approach from the domestic abuse health professionals when educating local people about domestic abuse may help service users to reduce their intake. In April 2011, the Government implemented section 9 of the Domestic Violence, Crime and Victims Act 2004. This means that local areas are expected to undertake a multi-agency review, following a domestic homicide, to assist all those involved in the review process, in identifying the lessons that can be learned with a view to preventing future homicides and violence. A review of cases found that In a number of cases the victim and/or the perpetrator had complex needs which could include domestic violence and abuse, sexual abuse, alcohol, substance misuse and mental health illness. In some cases the domestic violence and abuse was not always identified because agencies were focusing on addressing, for example, the mental health or substance misuse. In these cases there was often more silo working which meant an appropriate multi-agency intervention was not considered. There appeared to be a need to raise awareness and understanding of how best to engage and work with those with complex needs. The domestic homicide reviews suggests that Drug and alcohol services should review, amend and make robust use of their risk assessment frameworks, which involve assessment of risk in relation to violence and abuse. Occupational health departments within organisations have the opportunity to address both the prevention agenda and early implementation for people who may have an alcohol problem but who may not interact with statutory services. There is guidance from the health and safety executive regarding alcohol at work: While for many people, drinking alcohol is a positive part of life and does not cause any problems, the misuse of alcohol can lead to reduced productivity, taking time off work, and accidents at work. Some employers have decided to adopt alcohol screening as part of their alcohol policy. If you think you want to do the same, think very carefully about what you want screening to do, and what you will do with the information it generates. Screening by itself will never be the complete answer to problems caused by alcohol misuse. There are no precise figures on the number of workplace accidents where alcohol is a factor, but alcohol is known to affect judgement and physical coordination. There is previous data from the faculty of public health Local action plan for your service / practice / provider References/web links/dates Please describe how you will implement the alcohol conversation in your organisations below: 117 Version 5: Requests for amendments to linda. Education Professionals may come into contact with children and parents who abusing alcohol and who are not accessing any other services. A preventative approach from the educational professionals when educating local people (Adults and Children) about alcohol may help service users to reduce their intake. The vehicle for improving the quality of alcohol education in schools is the Healthy Schools Programme. It can help tackle public health issues such as substance misuse and support young people with the financial decisions they must make. Professionals in pharmacies may come into contact with people who abusing alcohol and who are not accessing any other services. A preventative approach from the pharmacy service professional when educating local people about pharmaceuticals may help service users to reduce their intake. Early detection and intervention are also effective and these are areas where community pharmacy has a potential role to play What should you do It recognised the significant role community pharmacies could pay in helping reduce health inequalities by delivering consistent and high quality health and wellbeing services, promoting health and providing proactive health advice and interventions. The National pharmacy Association website has information on the initiative and hints and tips. There is evidence of the effectiveness of community pharmacy based public health interventions such as smoking cessation and methadone maintenance for addictions. This suggests that similar benefits could be derived from their involvement with alcohol misuse. Although school nurses may have only infrequent contact with individual children, the contact that they do have may be at a time and in circumstances that give them a unique opportunity to address difficult issues. Unlike a teacher, they do not generally have the opportunity of spending every day getting to know a child and of forming ongoing relationship. Like many other professional groups, school nurses will tend to have a general view of alcohol related issues and even this may vary considerably depending on their nursing practice experience. The national aim is that school nurses should: Have information about the effects of parental alcohol misuse on children and what can be done to support these children, both individually and within the wider school context Have information that addresses key issues that arise within the context of schools and their educational role. They are unlikely to have received training about the effects on children of parental alcohol misuse or about resilience factors. Situations arising in schools Alcohol-related issues are most likely to arise either as a concern about children drinking or in dealing with a parent whose behaviour is difficult due to their alcohol misuse. Awareness of, or concern about, a child who may be affected by parental drinking problems is not an issue which is commonly considered by professional staff in schools, even though 1 in 4 adults drink at levels likely to be harmful and 1 in 20 will be alcohol dependent. However, the work undertaken in schools by School Nurses offers at least 3 possible scenarios that may yield opportunities for interventions on or about the effect of parental drinking. These are: Where a child has asked to see the school nurse about something and the school nurse suspects (or could do, with better information) that parental alcohol misuse is a factor Where the school nurse is the person to whom a child chooses to unburden him or herself (perhaps where the child asks to see the nurse at a drop-in, or has come to the nurse for another reason) Where a teacher or other professional asks for an opinion on a child they are generally concerned about.
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