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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Nevertheless chronic gastritis recovery time order macrobid 50 mg free shipping, the use of obesity when referring to children is widely used in publications (see Chapter 5 for further discussion on Body Mass Index screening) gastritis clear liquid diet buy macrobid 50mg overnight delivery. Efforts to treat overweight children and adolescents may lead to a cycle of weight loss attempts that further damages self esteem or contributes to the development of an eating disorder gastritis zinc discount 100 mg macrobid free shipping. Pregnant Adolescents Between 1991 and 2004 there were more than 80 acute gastritis symptoms nhs generic 100 mg macrobid amex,700 teen births in Massachusetts (National Campaign to Prevent Teen Pregnancy gastritis yogurt safe 50mg macrobid, 2006) and in 2000 gastritis symptoms lightheadedness purchase macrobid 50 mg, 12,150 girls in the state, ages 15-19, became pregnant (The Alan Guttmacher Institute, 2006 updated). The school nurse has a special role in caring for the pregnant teen, because she/he may be the first health care professional to learn of the pregnancy. All pregnant teens should also have their dietary habits assessed and be provided with special dietary counseling. Thereafter, the school nurse may work with the student to ensure that her nutritional and medical needs are met. Pregnancy at any age places great physical demands on a woman, and for a teenager there are recognized additional risks. Nutrient and calorie demands are greatest for girls who become pregnant soon after menarche (their first menstruation), because they are most likely to still be in a stage of rapid growth. The nutritional status of a pregnant adolescent is closely linked to the future health of her baby. Dieting, skipping meals, snacking, eating away from home, consuming fast foods, and trying unconventional diets are common eating behaviors. If good nutritional habits are not well established before pregnancy, it becomes difficult for them to catch up once pregnant. Lack of proper nutrition during pregnancy can lead to iron-deficiency anemia, poor weight gain, and compromised fetal development. An adequate amount of this nutrient reduces the risk of having a baby with birth defects of the spine and spinal cord. A pregnant teen generally needs to consume 300 calories beyond her typical intake, to support the growth and development of the baby and to sustain necessary changes in her own body. These calories should come from well-balanced meals, not foods that offer little nutrient value or are high in salt, sugar, or fat. The weightgain pattern should be monitored to ensure that energy intakes are sufficient to support a gain of about 0. Constipation can be a problem during pregnancy but can be avoided by eating foods rich in fiber. Adequate daily fiber intake can be ensured with several servings of whole grains, beans, fruits, and vegetables. Water is a better choice than soda or other high-calorie, low-nutrient beverages, which may cause excess weight gain without providing any additional benefits. With the exception of iron, adolescents should be able to obtain all their nutrient needs from a wellbalanced diet. Due to typically poor dietary habits, however, it is generally recommended that they take a prenatal multivitamin/mineral supplement. If dairy intake is insufficient, a calcium supplement may also be recommended, but it is important to note that iron and calcium supplements should not be taken together, because calcium will interfere with the absorption of iron. Teens should be cautioned against taking any vitamin supplements without consulting a doctor. For example, excess intake of vitamin A has been shown to increase the risks of certain birth defects. No amount of any of these substances is safe during pregnancy, and their abuse increases the risk of premature birth and other complications. Special attention must be paid to providing pregnant teens with the services and support necessary to prevent and treat dependencies on drugs, alcohol, and tobacco. Post delivery, teens will need additional support to remain drug- and tobacco-free. Common nutritional concerns associated with special health care needs include inadequate intake of calories and nutrients leading to malnutrition, poor growth and short stature, dental problems, anemia, and constipation. Many disabilities and illnesses are linked to a delay in the maturation of feeding skills, leading to an increased risk of inadequate dietary intake. Alternatively, overweight can result from conditions associated with limited physical mobility or exercise and/or side effects of certain drug therapies, such as chronic steroid use. Early assessment (see Exhibit 9-6) of nutritional status, followed by appropriate nutrition intervention and monitoring, can prevent or minimize these conditions. Federal law and the regulations for the National School Lunch Program and the School Breakfast Program require schools to make accommodations for children who are unable to eat the school meal as prepared because of a disability. School nurses can incorporate appropriate modifications or substitutions into the school lunches and/or breakfasts to accommodate their special dietary needs, ensure that nourishing meals are provided, and help to make mealtime a pleasant experience. Schools may, at their option, make substitutions for persons with special needs that do not meet the definition of disability under federal law. In these instances, the school must have a written statement signed by a recognized medical authority. First, it ensures that the nutrition integrity of the school meal will not be compromised by the substitution. More importantly, it ensures that decisions about specific food substitutes are made by persons who are highly qualified to prescribe them. Most children with special health care needs are under the care of a physician and dietitian who may be available to the family, child, school nurse, and food service personnel to discuss care and dietary guidelines. Note: the school nurse should document any dietary adjustments on the Individual Health Care Plan. Student Athletes Rigorous athletic training may demand caloric intake beyond what is necessary to support normal growth and the physical maturation associated with the pubertal growth spurt, but this does not necessitate the consumption of specialty sports nutrition products such as sports bars, gels, supplements, and protein powders. Adequate fluid intake during exercise is vital for effective energy metabolism, body cooling, and overall performance. The amount of additional energy needed by adolescent athletes depends on the intensity, duration, and specific type of exercise (see Chapter 10). After exercise, carbohydrate-rich foods should be consumed within 2 hours, to replenish muscle and liver glycogen stores. If healthy, balanced dietary habits are in place, protein supplements are unnecessary. High-protein foods typically consumed in a healthy diet include red meat, poultry, fish, cheese, milk, tofu, eggs, dried peas and beans, nuts, and peanut butter. Excessive protein consumption (including the use of protein or amino acid supplements) can lead to dehydration, renal stress, and excessive excretion of calcium, as well as unwarranted calorie consumption. Young athletes who participate in contact sports, weight lifting, heavy weight wrestling, and longdistance cold water swimming may attempt to enhance their sports performance by increasing their body weight. These students should be guided to increase their caloric intake in a manner consistent with healthy dietary recommendations, without adding foods that contribute significant amounts of saturated fat or cholesterol. When undernutrition is coupled with intensive training, significant risk to proper growth and development can occur (see also Chapter 10). Short-term effects may include chronic fatigue, hypoglycemia, and increased incidence of illness and heat exhaustion. Sports that encourage low body fat or a lean physique can place adolescents at increased risk for long-term conditions such as undernutrition and eating disorders. In young women, the long-term effects of limiting calories combined with intense athletic practice may include delayed menarche and amenorrhea (ceasing of menstrual period), which can impair skeletal growth and result in an increased risk of scoliosis, stress fractures, loss of potential stature, and osteoporosis later in life. These adolescent females should be referred to a primary care provider for dietary counseling. A change in the quality and quantity of the diet is a worthwhile first step for the amenorrheic athlete and should be initiated prior to the use of hormone therapy. An additional nutritional concern of student athletes is adequate consumption of dietary iron. The best sources of iron are lean red meats, iron-fortified cereals and other grains, and green, leafy vegetables. If insufficient iron is consumed, adolescents can develop "sports" anemia, characterized by depressed hemoglobin and a reduction in oxygen-carrying capacity. Iron deficiency anemia may occur in males during periods of rapid growth, but adolescent female athletes (especially black females) are at greater risk. If a transient iron deficiency goes unchecked, continued stress in a young, growing athlete can lead to a chronic form of anemia and may cause long-term health problems. Sixty health, nutrition, physical activity, and education organizations assisted with or supported the development of these policies, which are based on nutrition science, public health research, and best practices. Department of Agriculture, has developed the Wellness Solutions website -. The School Nutrition Association has also developed local wellness policy recommendations to assist schools. These recommendations, sample policies developed by school districts from around the country, and additional resources are available at. Items available on the site include: policy requirements, basic steps, sample policies, and links to additional resources from other agencies and organizations. Using this team-focused assessment - which involves teachers, parents/guardians, students, health professionals, and the community - will facilitate development of an action plan for improvement of student health and safety. The assessment includes nutrition-specific score cards for elementary and secondary (middle/high) school, which are available on the School Health Index site. The guidelines are reviewed and updated based on scientific research and food product availability. At young ages, children should be given the opportunity to learn healthy eating practices without being influenced by unhealthy food options. Some are fortified with unnecessary and potentially harmful additives that children do not need at any time. Examples for vending machines include dried fruit and for a la carte lines and school stores include fresh fruit, like pineapple slices or melon cubes, and fresh vegetables, like baby carrots. This 4g/oz of total carbohydrate includes lactose (natural milk sugar) and any added sugar. Milk and milk products are high in nutritional value and provide calcium, protein, and vitamin D for bone growth and development. Guidelines for Special Events Schools are encouraged to extend the nutrition standards to after-school events and fundraisers. In lieu of candy sales during school hours, students and faculty are encouraged to coordinate fundraisers with the school food service. The school food service director can assist those planning food-oriented fund-raising events, such as community suppers, pancake breakfasts, and bake sales. Such collaboration results in successful fundraising, positive public relations for the school food service, and a strong sense of school-community team work. Today, however, hunger is not the only food-related threat to the well-being and educational achievement of students. Chief among these problems is an epidemic of overweight and associated health conditions in the school-age population. Because healthy eating habits begin at an early age, schools are uniquely positioned to make a positive impact, so nutrition education is a critical strategy. In addition, schools, like their community partners, will need to address their nutritional environments, confronting such challenges as foods offered in vending machines, through a la carte menus, and at special events. Schools, families, students, communities, and health care providers will need to join forces to develop and implement policies and practices that can begin to curb this epidemic. Their mutual goal should be the growth of this generation of students into healthy adults. This portion of the site is devoted to body image, eating right, understanding eating disorders, fitness, and so forth. The program is designed to promote healthful eating and physical activity in schools, homes, and communities. Six interlinked components - classroom education, food services, physical education, staff wellness, family involvement, and a schoolwide promotional campaign - work together to create a supportive learning environment.
Preventing Unintentional Injuries While it may not be possible to prevent all injuries gastritis meal plan buy macrobid 50 mg on-line, the study of injury control has revealed ways to reduce the number and severity gastritis diet 8 month generic macrobid 100mg with visa. It is generally understood that the most effective injury-prevention efforts address multiple factors and use multiple approaches simultaneously gastritis diet зурхай buy macrobid 50 mg without prescription. Rather than concentrating exclusively on individual behavior gastritis sintomas purchase 100 mg macrobid with visa, effective injury-prevention efforts also make remedial changes in the environment gastritis diet japan buy 100 mg macrobid with amex, products gastritis diet скачать cheap macrobid 50 mg on line, social norms, legislation, and policy. Categories of Unintentional Injuries this section contains descriptions of the most common causes of injuries to children, with strategies for schools to be involved in prevention and intervention. Bicycle and Wheel-Related Sports Injuries Bicycles, which are ridden by nearly 28 million U. In 2003, nearly 285,600 children age 14 and under were treated in hospital emergency rooms for bicycle-related injuries (Safe Kids Worldwide, 2007). Nearly six million children and adolescents younger than 18 years old ride skateboards, of which 750,000 ride a skateboard weekly. Skateboarding injuries result in 50,000 visits to hospital emergency rooms annually, and 1,500 hospitalizations (Injury Free Coalition for Kids, 2003). Each year, some 153,000 injuries are attributable to in-line skating (Injury Free Coalition for Kids, 2003; Forjuoh, 2002; American Academy of Pediatrics, 1998). Education about bicycle and wheeled sport safety and the promotion of bike helmet use by children on all forms of wheeled recreation equipment is a major concern for injury professionals. They regard this as an area in which safety compliance could make a significant difference in injury occurrence. Work with the local police department, Kiwanis and other groups to organize bike rodeos. Invite local retailers to provide incentives to children observed wearing helmets. Initiate a bike helmet safety day with skilled adults to assess proper use of helmets and advise students accordingly. Work with local community providers and business to convey a consistent message of wheel safety. Teaching home fire prevention and fire safety behaviors to young children, as well as to older children with self-care and childcare responsibilities, can save lives. In-school lessons can be supplemented with take-home materials on smoke alarms, carbon monoxide detectors, home escape plans, and practice fire drills. Parents and caregivers can help children turn their understanding into useable knowledge by making and practicing individual home escape plans that take into account the needs of each family member and by conducting home fire drills after children have fallen asleep. Scald burn injury (caused by hot liquids or steam) is the most common type of burn-related injury among young children, while flame burns (caused by direct contact with fire) are more prevalent among older children. Scalds, while rarely fatal, are very common among preschoolers, via hot tap water, hot beverages, boiling water, and hot food. Burns may be caused by contact with cigarette lighters, home heating devices, and other hot appliances. In addition, many first-time jobs involve food preparation, which may entail a high risk of burns. A flyer from the Massachusetts Department of Fire Services about carbon monoxide safety is available at. Alcohol and lack of restraints are the 2 major factors resulting in deaths from motor vehicle accidents. Alcohol is a factor in 1 out of 4 vehicle occupant deaths among children 14 and younger. More than two-thirds of these fatally injured children were passengers in vehicles driven by alcohol-impaired drivers (Shults, 2004). One study found that in almost 40% of instances where children were not properly restrained, the drivers were also unbelted (Cody, 2002). A survey of more than 17,500 children found only 15% of children in safety seats were correctly harnessed into correctly installed seats (Taft, 1999). The presence of teen passengers increases the crash risk for unsupervised teen drivers; the risk increases with the number of teen passengers. This is not entirely a function of alcohol and/or drug use, although both are a factor in many teen motor vehicle accidents. Teens are actually less likely than adults to get behind the wheel after drinking, but when they do, their risk of crashing is far greater, even with low or moderate bloodalcohol levels (Zador, Krawchuck & Voas, 2000). At all levels of blood alcohol concentration, the risk of involvement in a motor vehicle crash is greater for teens than for older drivers (Insurance Institute for Highway Safety, 2000). In a survey of teen drivers by the National Sleep Foundation, over half said they had driven while drowsy at least once in the last year, and 15% at least once per week (Carskadon, Minell & Drake, 2006). It can, however, increase awareness of and reinforce sound community safety emergency planning. Each year, there are approximately 11 deaths and more than 1,300 nonfatal pedestrian injuries in the school-age population. According to the Harborview Injury Prevention and Research Center, the most common actions by children leading to pedestrian injuries involve dashing or darting into the street. Contributing to the vulnerability of younger school-age children is their inability to judge the speed and distance of oncoming cars, their small size, their narrow field of vision, poor impulse control, and difficulty judging the direction of sounds. According to Safe Kids Worldwide, auditory and visual acuity, depth perception, and proper scanning ability develop gradually and do not fully mature until at least age 10. Important Preventive Messages Pedestrian safety training for children should teach about traffic signs and signals and safe walking zones, while emphasizing that motorist compliance cannot be relied upon. Promote involvement of public safety and community agencies in creating safe walking policies and safe areas while enforcing pedestrian-related traffic laws. Consumer Product Safety Commission, concluded that each year emergency departments treat more than 200,000 children 14 and younger for playground-related injuries. Approximately 45% of those injuries are severe, including fractures, internal injuries, concussions, dislocations, and amputations. Injuries due to falls from playground equipment result in a higher proportion of severe injuries than either bicycle or motor vehicle crashes (Phelan, 2001). Because playgrounds pose a higher risk of injury than most other areas of the school, this topic is discussed in 2 chapters of this manual: Chapter 4 covers playground design considerations and equipment safety, and this chapter concentrates on issues related to safe play and supervision. Prevention Issues It is natural for children to take risks while playing on school playgrounds, however it is important that playgrounds not contain items that can cause injury in the natural course of play. Children, especially younger children, may not know the limits of their own physical development, making them especially prone to injury. Furthermore, most school populations include some children with cognitive and physical limitations that increase injury risk. The most critical areas to address are equipment height, surfaces, maintenance, supervision, and equipment spacing. Detailed information about the importance of shock absorbing surfaces and their maintenance can be found at. Ensure adequate adult supervision on playgrounds, using trained playground monitors. To prevent strangulation, do not allow children to wear upper outerwear with drawstrings while playing on playground equipment. Provide safe access and, when necessary, adapted play equipment and higher levels of supervision for children with disabilities. Require school personnel to track playground injuries, including the age of the child and the equipment involved. School Bus Safety School buses are associated with relatively few injuries and deaths. Sports Safety Sports, including activities such as cheerleading, are the most frequent cause of injuries for adolescents. Schools should provide training for activities advisors to ensure safe student participation. It can range from mild to severe and can disrupt the way the brain normally works. Even though the second blow may occur days or weeks after the first or may be no more powerful than a slap, it can cause a sudden swelling of the brain that quickly leads (within 2 or 3 minutes) to unconsciousness or cardiac arrest. Research suggests that, while use of improved sports equipment such as chest protectors and softer balls may provide some protection, such events are not completely preventable. However, according to the American Heart Association, the high rate of fatalities associated with Commotio Cordis is preventable. Other severe injuries associated with sports include spinal cord injury and eye trauma. Common Acute Sports Injuries Acute injuries are injuries that occur suddenly during activity. Note: Growth plate injuries can have potentially serious complications that impede proper development of limbs. Overuse or Chronic Injuries Overuse or chronic injuries are usually the result of repetitive training activities such as running, overhand throwing, or tennis serves. Heat-Related Illnesses and Sun Exposure Playing rigorous sports in hot weather requires close monitoring of both body and weather conditions. Children perspire less than adults and require a higher core body temperature to trigger sweating. Heat-related illnesses include dehydration, heat exhaustion (nausea, dizziness, weakness, headache, pale and moist skin, heavy perspiration, normal or low body temperature, weak pulse, dilated pupils, disorientation, fainting), and heat stroke (headache, dizziness, confusion, and hot, dry skin, possibly leading to vascular collapse, coma, and death). A further health concern is sun safety: Students and staff should take precautions to avoid excessive sun exposure. Work-Related Injuries Large numbers of teens work after school, during school vacations, and on weekends. Teens also work during school hours, in jobs secured through school in cooperative education, school-tocareer, internship, and career technical education programs. In addition, many younger teens also work, and national studies have found that 80% of adolescents have held jobs by the time they have completed high school. Work-related injuries constitute a significant proportion of injuries to adolescents. More than half of the injuries occurred in just 4 industries: restaurants (35%), grocery stores (14%), nursing homes (5%), and department stores (5%). For each of these industries, the Teens at Work Project has created fact sheets that may be used by industry, labor, educators, parents, and teens themselves in developing injury prevention strategies. Among working teens surveyed at one large Massachusetts high school, 26% reported having been verbally assaulted at work, 10% reported being sexually harassed, and 11% reported being physically assaulted on the job (Personal Communication with K. As adolescents begin to explore the world of work, they need to learn how to recognize the hazards existing in all types of jobs and how to say no to unsafe or restricted work. Guiding adolescents and parents toward choosing a safe and meaningful working experience that does not detract from school should be a goal of Massachusetts schools and communities. In addition, schools have a responsibility to ensure that students are provided safe and healthy work experiences when placing students in internships and job placements.
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Some of its side effects include pruritus gastritis loss of appetite purchase 50mg macrobid with amex, headache gastritis and esophagitis buy macrobid 100 mg free shipping, myalgia gastritis diet фацебоок purchase macrobid 100 mg overnight delivery, alopecia gastritis ka desi ilaj purchase macrobid 100 mg on line, and spotty depigmentation gastritis diet фиксики cheap 100mg macrobid with mastercard. It can cause exacerbations of psoriasis atrophic gastritis symptoms uk order macrobid 50 mg without a prescription, eczema, and dermatitis, and caution should be used if it is prescribed to people with these disorders. Mefloquine is effective for prophylaxis in most of the world except the border area between Thailand and Myanmar. It is considered safe to use in pregnancy and breast feeding although small amounts of drug are passed in breast milk. The most serious side effects are neuropsychiatric, such as bad dreams, paresthesias, hallucinations and even psychotic reactions. Other side effects include vertigo, seizures, hepatotoxicity, headache, confusion, gastrointestinal upset, pruritus and depression. As with chloroquine, prophylaxis should begin 1-2 weeks before arrival in a malariaendemic area and continue for 4 weeks after return. Atovaquone/proguanil is effective and safe for children but is not recommended for use in pregnant women or women breast-feeding infants lighter than 5 kg. Prophylaxis should begin 1-2 days before arrival in a malaria-endemic area and continue for 7 days after return (see Table 51-6). Doxycycline is efficacious, safe, and the most inexpensive choice for prophylaxis. Its use is contraindicated in pregnancy, breast-feeding, and in children younger than 8 years. Side effects include gastrointestinal upset, vaginal yeast infection, phototoxicity, hepatic toxicity, pseudomembranous colitis, and increased intracranial pressure. Prophylaxis should begin 1 day before arrival in a malaria-endemic area and continue for 4 weeks after return (see Table 51-6). It has also been used for prophylaxis of the primary infection in special circumstances. Of the 50 million travelers to the developing world each year, over 50% will have a travel-related health impairment and 10%20% will consult a physician, either while abroad or after returning home, due to a travel related illness. This section describes three common problems faced by the family physician-fever, diarrhea and eosinophilia-with the goal of assisting the physician make a final diagnosis and provide appropriate treatment to the returning traveler. Fever and eosinophilia, in particular, may occur as symptoms in a wide range of infectious and inflammatory conditions. Fever in a Returning Traveler Fever in a returning traveler requires a thorough history (including immunizations and any use of prophylactic medications, illness in companions, sexual activities, and any nonprescribed drug use) and physical examination. Often localized symptoms or signs (eg, respiratory symptoms, jaundice) help narrow the diagnosis. If the diagnosis is not immediately obvious, consideration must be given to diseases that are endemic in the area(s) visited. Stable patients may be safely observed for a few days, and most fevers will resolve spontaneously. Finding Rash Possible Associated Diseases Dengue, typhoid, rickettsial infections, syphilis, gonorrhea, brucellosis, hemorrhagic fever viruses, other viral illnesses including arboviruses Hepatitis, malaria, yellow fever, leptospirosis, relapsing fever Rickettsial infections, brucellosis. Selected causes of fever in a traveler returning from the tropics (not in order of frequency). Fever usually has an infectious cause, but occult malignancies and rheumatologic conditions should be considered in the differential diagnosis. If illness persists or the patient is unstable or seriously ill, laboratory investigation becomes the key to the diagnosis. Seriously ill patients must be hospitalized, and any patient suspected of having a highly contagious condition must be isolated. This is especially true of travelers returning from Africa with hemorrhagic fever. Differential diagnoses to consider in a traveler returning with fever are listed in Table 51-8. It is important to remember that "the common is still common," and, in fact, the most common causes of fever in returned travelers are routine illnesses such as upper and lower respiratory tract infections, sinusitis, urinary tract infections, and influenza. Thus, the conditions in Table 51-8 should be considered only if a more common cause is not readily apparent. Malaria is one of the more common and worrisome causes of fever in a returning traveler. Most cases of serious fever requiring hospitalization in travelers are due to malaria. Infections, particularly with P falciparum, frequently occur within 2 weeks of the mosquito bite, but may occur up to 5 years after exposure, especially if caused by P vivax or P ovale. In a seriously ill febrile traveler to a malarial area, for whom no cause can be found, it may be wise to include empiric treatment for malaria, even if the results of the blood smear are negative. Most acute bacterial infections can be treated successfully with ciprofloxacin or other antibiotics. Some travelers develop a transient lactase deficiency after any bacterial, viral, or parasitic infection. Some travelers, especially those not careful with their diet, may develop a small bowel bacterial overgrowth, which may require antibiotic treatment. Some causes of persistent diarrhea in a returning traveler are listed in Table 51-9. In addition to checking for ova and parasites, an evaluation for Giardia antigen and bacterial cultures should also be performed. If symptoms of rectal disease are present, anoscopic and sigmoidoscopic examination should be done with biopsies as needed. If the results of these tests are negative, the physician should consider an empiric trial of metronidazole for the treatment of a possible Giardia or other protozoan infection. Six months later, 18% still reported loose stools, 18% reported abdominal pain, and 9% had fecal urgency. Caumes E et al: Health problems in returning travelers consulting general practitioners. Eosinophilia in a Returned Traveler A high level of eosinophilia (>450 eosinophils/L) almost always indicates a parasitic infection. High levels of eosinophilia are characteristically found in helminthic infections, especially for those helminthes that have an extraintestinal migration phase and produce tissue infection. Strongyloides and lymphatic and tissue filariasis cause some of the highest levels, and infection in humans can persist for many years if not treated. Protozoans, such as Giardia and Plasmodium species, do not generally cause eosinophilia, with the exceptions noted in Table 51-10. Schistosomiasis has become a serious problem for people swimming or rafting in freshwater in Africa. Allergic disorders, such as allergic rhinitis or asthma, can also cause eosinophilia. Of the remaining 38 cases a definitive parasitological diagnosis could only be made in 9 (23. A therapeutic trial of albendazole was given to most of the cases without a specific diagnosis and about 90% reported a favorable response with resolution of symptoms and a significant decrease in the eosinophil count after 2 months. The workup for a traveler with eosinophilia must include multiple stool examinations, including stool concentration if schistosomiasis is suspected. Biopsy specimens of skin lesions (onchocerciasis) or swollen lymph nodes (filariasis) can be examined for definitive diagnosis. A therapeutic trial of albendazole is probably warranted as above if no diagnosis is found. There is information about vaccines, and the site also has safety information about cruise ships. Psychosocial Disorders 569 Depression in Diverse Populations & Older Adults Annelle B. The report cited the commonality of mental illness and the fact that undertreatment of mental illness is an enormous problem fueled by stigma and barriers to access. Several demographic groups were identified as being at particularly high risk for having unmet mental health needs: children and youth, older adults, and members of medically underserved ethnic and racial groups. Because these groups rely largely on the primary care setting for their mental health needs, the report strongly recommended an expanded role for primary care physicians and allied health practitioners in providing mental health services. Depression is the leading cause of disability (lost years of healthy life) in Western countries at ages 15-44 years old. In the United States, the point prevalence and lifetime prevalence of depression are 6. While depression may occur at any age, the typical age of onset of major depression is 27-35 years and the highest rate of depression exists in adults ages 40-59. Depression often coexists with other chronic medical illnesses, particularly in later life. Medical illness and disability -more common in the elderly-are risk factors for depression. Depression diminishes quality of life, leads to nonadherence with self-care (diet, exercise, taking medication as prescribed), increases use of other medical services, is a risk factor for suicide, and is associated with cognitive impairment in older adults. Additionally, major psychosocial risk factors for depression include bereavement, caregiver strain, social isolation, disability, role transitions, and severe medical problems. Depression is associated with abnormal functioning of the brain and often has a genetic basis. It often goes unrecognized and untreated and can therefore increase morbidity and mortality in populations such as the elderly and ethnically and racially diverse groups with high prevalence of chronic illness. However, depression is treatable and some interventions can significantly reduce its symptomatology and incidence. In order to prolong recovery and prevent recurrence, maintenance treatment beyond the acute treatment of the episode is usually medically appropriate, thus making the primary care setting an appropriate medical home for depression care. In addition, many people prefer to be treated in the general medical sector rather than being referred to specialty mental health care. Greenberg P et al: the economic burden of depression in the United States: how did it change between 1990 and 2000 Preventive interventions may include psychoeducation about the particular challenges being confronted, stresscoping techniques, the use of problem-solving therapies to help patients cope more effectively with increasing limitations, supporting general health and wellness (good nutrition/ exercise/relaxation), facilitating support of family/friends/ support groups, and protecting sleep quality through better sleep hygiene. Prevention strategies for addressing depression in the elderly have also been shown to be effective in the primary care setting. Over the past decade, it has become clear that antidepressant treatments can have a very favorable impact on the long-term course of depressive illness, particularly in preventing recurrences of disease. In addition, because symptoms and signs of depression are frequently masked by other medical conditions, health care providers treating individuals with chronic diseases may not recognize that the underlying cause of depressed mood, decreased energy, sleep changes, or appetite changes is depression. Therefore, a high index of suspicion of depression should be maintained when treating patients who present with symptoms and signs of chronic physical conditions, multiple somatic complaints, or chronic pain complaints. Screening should be utilized in these instances populations with consistent systems in place for diagnosis, treatment, and follow-up. The American Heart Association and the American Psychiatric Association specifically recommend screening for depression in patients with coronary heart disease. Depression and Other Chronic Illnesses Depression commonly co-occurs with chronic diseases, complicating treatment and worsening chronic disease outcome. Depression is an independent risk factor in the development of cardiovascular diseases (heart disease, stroke). Screening, diagnosis, and treatment of depression could have an impact on the course and management of chronic diseases Although approximately one-third of individuals with chronic medical conditions may experience symptoms of Table 52-2. Cancer Type Breast Colon Gynecological Lung Lymphomas Oropharyngeal Pancreatic Prevalence of Depression (%) 1. Impact of Health Disparities Overall, studies show that disparities exist between whites and racially and ethnically diverse groups in mental health status, in utilization of mental health services, in quality of care and outcome regardless of socioeconomic status in the four major underserved ethnic and racial groups: African Americans, American Indians, Asian Americans, and Hispanics. Risk of mental illness and poor mental health outcomes in diverse and underserved populations is increased due to nonfamilial factors associated with depression (eg, socioeconomic status, environmental factors, access to health care, and higher rates of health disorders). Despite increases in the rate of antidepressant medication use over the past 12 years among all racial and ethnic groups, this increase has been disproportionately higher in whites compared with non-Hispanic blacks. The increased risk of living in poverty with inadequate access to health care and inadequate treatment, more prevalent in populations of color, may multiply stress and contribute to persistent and recurring episodes of depression. For nonwhite populations, the chronic stress of discrimination and subsequent effects on immune regulation of living as a member of a marginalized racial and ethnic group can also contribute to depression. Because of the independent increased risk of chronic diseases and mental illness in diverse racial and ethnic populations, the impact of mental illness on chronic diseases is increased substantially. Applied Research Center and Northwest Federation of Community Organizations: Closing the Gap: Solutions to RaceBased Health Disparities, 2005. Only 20%-30% of patients with emotional or psychological issues report these to their primary care physicians, and the most common somatic symptom reported by more than half of patients with major depression was "feeling fatigued, weak, or tired all over. Initial assessment should include a focused psychiatric history and examination and, for older adults, a brief clinical cognitive examination. In addition, a medical history, physical examination, focused neurologic examination, and laboratory studies to rule out physical conditions with similar symptoms are preferred as part of the assessment. It is also important to assess other domains, particularly for older adults, including level of functioning or disability, loss or grief concerns, physical environment, and psychosocial situation. In more than 90% of patients diagnosed with a major depressive disorder (characterized by several major depressive episodes), two of these nine features are present: depressed mood or anhedonia (the loss of interest or pleasure) Clinical Findings the type and level of severity of depression runs along a spectrum, ranging from subclinical varieties to major depression. Major depression typically occurs in episodes, each with a clear beginning and end. After an initial episode, more than 50% will have additional episodes in their lifetime.
The newer long-acting dihydropyridine calcium channel blockers amlodipine and felodipine appear to be safe when used in the treatment of hypertension but do not improve heart failure outcomes gastritis youtube generic macrobid 100 mg with mastercard. Most antiarrhythmic drugs (except amiodarone and dofetilide) have an adverse impact on heart failure and survival because of their negative inotropic activity and proarrhythmic effects gastritis diet therapy discount macrobid 50 mg fast delivery. Phosphodiesterase inhibitors (cilostazol gastritis diet foods list buy discount macrobid 100 mg online, sildenafil gastritis symptoms right side safe 50 mg macrobid, vardenafil gastritis healing diet safe macrobid 100mg, and tadalafil) can cause hypotension and are potentially hazardous in patients with heart failure gastritis and coffee macrobid 50mg low cost. Thiazolidinediones and metformin, both used in treatment of diabetes, can be detrimental in patients with heart failure because they increase the risk of excessive fluid retention and lactic acidosis, respectively. Implantable devices-Nearly one-third of all heart failure deaths occur as a result of sudden cardiac death. Clinical trials have shown that cardiac resynchronization therapy with biventricular pacing can improve quality of life, functional class, exercise capacity, exercise distance, left ventricular ejection fraction, and survival in these patients. Subsequent retrospective subgroup analysis of the trial discovered some survival improvement at a serum digoxin concentration of 0. Because survival is clearly worse when the serum digoxin concentration is greater than 1. Digoxin should be used cautiously in elderly patients, who may have impaired renal function that adversely affects drug levels. Hydralazine and nitrates-The combination of hydralazine and isosorbide dinitrate (H-I) is a reasonable treatment in patients, particularly blacks, who have persistent heart failure symptoms with standard therapy. Anticoagulation-It is well established that patients with heart failure are at an increased risk of thrombosis from blood stasis in dilated hypokinetic cardiac chambers and peripheral blood vessels. Despite this known risk the yearly incidence of thromboembolic events in patients with stable heart failure is between 1% and 3%, even in those with lower left ventricular ejection fractions and evidence of intracardiac thrombi. Such low rates limit the detectable benefit of warfarin therapy, and retrospective data analysis of warfarin with heart failure show conflicting results, especially given the major risk of bleeding. Warfarin therapy is only indicated in heart failure patients with a history of a thromboembolic event or those with paroxysmal or chronic atrial fibrillation or flutter. Adverse therapies-Therapies that adversely affect the clinical status of patients with symptomatic heart failure should be avoided. Other than for control of hypertension, calcium channel blockers offer no morbidity or mortality benefit in heart failure. Elderly women, usually with a heavy prevalence of hypertension and diabetes mellitus, appear to be most at risk. When considering the diagnosis of diastolic heart failure, conditions that mimic heart failure-including obesity, lung disease, poorly controlled atrial fibrillation, and occult coronary ischemia- have to be ruled out. Management focuses on controlling systolic and diastolic blood pressure, ventricular rate, and volume status, and reducing myocardial ischemia, because these entities are known to exert effects on ventricular relaxation. Diuretics are used to control symptoms of pulmonary congestion and peripheral edema, but care must be taken to avoid overdiuresis, which can cause decreased volume status and preload, manifesting as worsening heart failure. These patients can have rapid recurrence of symptoms, leading to frequent hospitalizations and a significant or permanent reduction in their activities of daily living. Before classifying patients as being refractory or having end-stage heart failure, providers should verify an accurate diagnosis, identify and treat contributing conditions that could be hindering improvement, and maximize medical therapy. Control of fluid retention to improve symptoms is paramount in this stage, and referral to a program with expertise in refractory heart failure or referral for cardiac transplantation should be considered. Other specialized treatment strategies, such as mechanical circulatory support, continuous intravenous positive inotropic therapy, and other surgical management can be considered, but there is limited evidence in terms of morbidity and mortality to support the value of these therapies. Careful discussion of the prognosis Prognosis Despite favorable trends in survival and advances in treatment of heart failure and associated comorbidities, 50% of patients die within 5 years of diagnosis. For example, Asian populations tend to have total cholesterol values 20%-30% lower than populations living in Europe or the United States. It is important to recognize that unlike a serum sodium electrolyte value, there is no normal cholesterol value. Atherosclerosis is an inflammatory disease in which cells and mediators participate at every stage of atherogenesis from the earliest fatty streak to the most advanced fibrous lesion. Elevated glucose, increased blood pressure, and inhaled cigarette by-products can trigger inflammation. Ruptured or unstable plaques are responsible for clinical events such as myocardial infarction and stroke. Lipid lowering, whether by diet or medication, can therefore be thought of as an anti-inflammatory and plaque stabilizing therapy. Although the benefits of lowering cholesterol were assumed for many years, not until the past decades has enough evidence accumulated to show unequivocal benefits from using lifestyle and pharmacologic therapy to lower serum cholesterol. Evidence in support of using statin agents is particularly strong and has revolutionized the treatment of dyslipidemias. These guidelines emphasize 1 the opinions contained herein are those of the author. They do not represent the opinions or official policy of the Department of the Air Force, the Department of Defense, or the Uniformed Services University. Rarely, patients with familial forms of hyperlipidemia may present with yellow xanthomas on the skin or in tendon bodies, especially the patellar tendon, Achilles tendon, and the extensor tendons of the hands. There are a few associated conditions that can cause a secondary hyperlipidemia (Table 21-1). These conditions should be considered before lipid lowering therapy is begun or when the response to therapy is much less than predicted. In particular, poorly controlled diabetes and untreated hypothyroidism can lead to an elevation of serum lipids resistant to pharmacologic treatment. Identify the presence of coronary heart disease or equivalents (coronary artery disease, peripheral arterial disease, abdominal aortic aneurysm, diabetes mellitus). Assess level of risk: use Framingham risk tables if 2+ risk factors and no coronary heart disease (or equivalent) is present. It strongly recommends (rating A) routinely screening men 35 years and older and women 45 years of age and older for lipid disorders. They make no recommendation for or against screening in younger adults in the absence of known risk factors. Step 2 focuses on determining the presence of clinical atherosclerotic disease such as: coronary heart disease, peripheral arterial disease, or diabetes mellitus. Step 4 uses the Framingham coronary risk calculator to classify the patient into one of four risk categories: high-risk, having coronary artery disease or a 10-year risk of greater than 20%, moderately high risk, having a 10-year risk of 10%20%, moderate-risk, having greater than 2 risk factors, but a 10-year risk of less than 10%, or low-risk, having 0-1 risk factors. Pharmacotherapy Step 7 reviews the options for drug therapy if required (Table 21-4). Given their proven efficacy, and enhanced patient compliance over other classes of medications, statin agents are the drugs of first choice. In particular, patients with diabetes or those in the highest risk category derive special benefits from their use due to their innate anti-inflammatory effects. Myopathy and increased liver enzymes are the main potential side effects from statin agents. Monitoring of liver function tests at 12 weeks, 6 months, and annually thereafter can help identify patients with hepatic side effects and facilitate prompt discontinuation. It can be prevented by the prompt discontinuation of the agent when muscle pain and elevated muscle enzymes occur. Unexplained pain in large muscle groups should prompt investigation for myopathy, however routine monitoring of muscle enzymes is not supported by any evidence. Therefore, a side effect with one agent should not prevent a trial with another statin agent. Prior concerns about statins causing cataracts or cancer have been alleviated by the release of several meta-analyses. Saturated fat is limited to less than 7% of total calories, cholesterol intake to less than 200 mg/d. The cultural background of the patient will impact the choice of dietary recommendations. This reinforces the need for dosage titration and close monitoring of lipid effects during drug initiation. Statin agents can be combined with fibrates and nicotinic acid, but the potential for side effects is increased. When a statin is combined with a fibrate the use of fenofibrate is preferred over gemfibrozil due to a much lower rate of rhabdomyolysis. Yet, long-term patient compliance is difficult due to flushing, nausea, and abdominal discomfort. Additionally, nicotinic acid can cause an increase in blood glucose, which can limit its use in diabetic patients. The bile acid sequestrants cause gastrointestinal side effects and can lead to decreased absorption of other medications. However, recent trials have not demonstrated benefits in reducing cardiovascular outcomes. Of concern is that most patients do not undergo monitoring for potential hepatic or muscle side effects. Several other supplements such as ginseng, chromium, and myrrh all have putative cholesterol-lowering effects but little patient-oriented clinical outcome evidence supporting their use. Aggressive treatment of inactivity, obesity, hypertension, and the use of low-dose aspirin are encouraged in these patients. Triglycerides are classified as follows: <150 mg/dL 150-199 mg/dL 200-499 mg/dL >500 mg/dL Normal Borderline high High Very high C. Complementary and Alternative Therapies Several complementary or alternative therapies are employed for cholesterol reduction but, the evidence supporting their use is variable. Garlic has few side effects but several trials have shown that it changes lipids minimally. As such, it is effective at lowering lipid values, but carries the same side effect profile as statins. Treatment of Special Groups the treatment of dyslipidemias in special groups presents problems because less trial data is available. Women-Several statin trials included women although they accounted for only 15%-20% of the total enrolled patient population. Children-There are accumulating studies showing the safety of statins in adolescents. However, given concerns of interrupting cholesterol synthesis in the growing body, therapy is usually confined to the very high risk. Therapeutic lifestyle interventions are safe, and can have a profound impact on the long-term health of the child if they are followed. Cholesterol treatment studies have not enrolled patients younger than 35 years of age because the frequency of clinical endpoints would be reduced and the duration of the studies would need to increase. Indications for Referral Patients who do not respond to combination therapy or have untoward side effects on therapy should be considered for specialty consultation. Combinations of multiple agents or lipid plasmapheresis may sometimes be required. Some of these are diseases that have been clearly characterized (eg, cystitis and pyelonephritis), whereas others (eg, urethral and prostate infections) are not as well understood or described. Asymptomatic bacteriuria, uncomplicated cystitis, complicated cystitis, two urethral syndromes, four prostatitis syndromes, and pyelonephritis are discussed in this chapter. General recommendations about specific antibiotics are inappropriate, given that antibiotic resistance differs from location to location. It is the responsibility of the individual physician to be familiar with local antibiotic resistances, and to determine the best first-line therapies for his or her practice. Always keep in mind that antibiotic use breeds resistance, and try to keep first-line drugs as simple and narrow-spectrum as possible. General Considerations Asymptomatic bacteriuria is defined separately for men, women, and the type of specimen. By definition, the patient must be asymptomatic; that is, he or she should not be experiencing dysuria, suprapubic pain, fever, urgency, frequency, or incontinence. Screening for bacteriuria does not need to be done in young, healthy, nonpregnant women; elderly healthy or institutionalized men or women; diabetic women; persons with spinal cord injury; or catheterized patients while the catheter remains in place. Pregnant women are now the only group that should be routinely screened and treated for asymptomatic bacteriuria. In the United States, screening is usually done by urine culture because dipstick screening can miss patients without pyuria or with unusual organisms. Approximately one-third of all women have experienced at least one episode of cystitis by the age of 24 years, and nearly half will experience at least one episode during their lifetime. Risk factors among these women include changes in the perineal epithelium and vaginal microflora after menopause, incontinence, diabetes, and history of cystitis before menopause. Urethritis from sexually transmitted pathogens should always be considered in this age group, and prostatitis should always be ruled out in the older age group by a rectal examination. Any cystitis in a man is complicated, due to the presence of the prostate gland, and should be treated for 10-14 days to prevent a persistent prostatic infection. The usual first-line treatment in the absence of significant resistance or penicillin allergy is a 7-day course of amoxicillin. Nitrofurantoin or a cephalosporin is suggested for penicillinallergic pregnant patients, again for 7 days. Lin K, Fajardo K: Screening for asymptomatic bacteriuria in adults: evidence for the U. Young Women Considering the frequency and morbidity of cystitis among young women, it is hardly surprising that the lay press and medical literature contain a host of ideas about how to prevent recurrent cystitis. These range from the suggestion that cotton underwear is "healthier" to wiping habits, voiding habits, and choice of beverage. Unfortunately, the vast majority of these preventive measures do not hold up to scientific study (Table 22-1).