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Pedram Argani, M.D.

Associate Director, Surgical Pathology
Professor of Pathology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0010788/pedram-argani

The average nursing home patient was 80 years old heart attack now love generic microzide 12.5 mg with visa, whereas the average day rehab patient was 74 years old heart attack lyrics sum 41 cheap microzide 12.5 mg. Day rehab patients were more likely to be white (90 percent) than nursing facility patients (87 percent) pulse pressure practice buy discount microzide, and 10 percent of nursing facility patients were black as compared with 3 percent of day rehab patients heart attack in dogs buy microzide 25 mg overnight delivery. The average allowed charges for the episode were $3 heart attack information order cheap microzide,647 for the nursing population and $4 prehypertension and anxiety order cheap microzide line,339 for the day rehab population. Average allowed charges per therapy day were highest for day rehab patients ($187) and lower for nursing facility patients ($102). Episode allowed th charges varied 139-fold, from $184 at the first percentile to $25,530 at the 99 percentile for nursing facility patients and 47-fold for day rehab from $391 at the first percentile to $18,293 at th the 99 percentile. For nursing facility patients, annual allowed charges were driven mostly by th variation in therapy days (207 at the 99 percentile to 2 at the first percentile), rather than by variation in allowed charges per therapy day ($259 at the 99th percentile to $39 at the first percentile). Day rehab patients used fewer therapy days at the extreme (98) and had higher th overall charges per therapy day at the 99 percentile ($330). The average nursing facility patient received 33 distinct days of therapy during the course of an episode with a median value of 20 therapy days. Day rehab patients received an average of 24 therapy days and a median value of 19 therapy days. Total calendar days averaged 60 with a median of 36 days for nursing facility patients and an average of 68 days with a median of 52 days for day rehab patients. The average number of therapy days per week is higher for nursing facility patients (4. The payment variables add substantial explanatory power to demographics for all three therapy disciplines. But even with the payment factors, only a small proportion of variation in episode therapy expenditures is explained. The additional factors in the comprehensive model add a significant amount of explanatory power to the payment model, but items such as pain and facility type are probably not appropriate for a payment model. Many of the Rasch function subscales predict that higher function is associated with lower therapy expenditures, all other factors equal. Their regression coefficients indicate that a decline from highest ability (score = 100) to lowest ability (score = 0) is associated with a $477 and $248 increase in expenditures, respectively. However, the opposite direction was found for self-reported life skills, with episode expenditures decreasing as patients became more impaired. The episode-based payment model R values increase from 9 to 32 percent, and the 2 comprehensive model values increase from 14 to 33 percent. The sizable increase in R may be due to provider practice patterns, unmeasured case-mix characteristics, or some other unobserved factors that are correlated with the provider. There is a very wide range between the minimum and maximum mean expenditures for those patient panel sizes up to 25 patients. Patient panel sizes of 50 or 100 have less variability but still exhibit wide ranges of variation. Patient panel sizes of 500 and 1,000 have the lowest levels of variation and are likely the types of practices that could accept the unsystematic risk of episode-based payments. The basic payment model includes demographic variables, primary diagnosis groups, Rasch clinician-observed mobility and self-care categorical variables, and indicators for diet modification, severe memory impairment, and verbal ability. The primary diagnosis groups are insignificant aside from stroke, which negatively predicts episode expenditures. The Rasch self-care items were positive and significant; the lower the functional score, the higher the predicted episode expenditures. When the additional payment variables are added to the model, the explanatory power increases from 11 to 32 percent (adjusted 21 percent). In this model, none of the Rasch function scales are significant, possibly because of issues of collinearity. Episode expenditures were not affected by prior hospitalization in the past 2 months. Secondary diagnoses of osteoporosis or hypertension are important predictors of expenditures as was also found in the annual models. Mental functions and motor functions are important functional predictors of expenditures, and shoulder/arm/elbow and knee are important positive predictors based on the body structure being treated. General/no specific body location and body structures not reported are both significant. The addition of these variables increases the explanatory power of the model to 43 percent (adjusted 30 percent). Of the additional variables added to the model, having a memory difficulty is positive and significant, and having trouble expressing ideas is a negative and significant predictor of episode expenditures. Unlike the annual model, prior function on self-care being limited was not significant. A primary diagnosis model was used because diagnosis is usually the first stage in case-mix classification of individuals. The grouping of the primary diagnosis categories is on statistical grounds only and might require adjustment for clinical face validity. Then, we examined subgroups within the 12 diagnosis groups defined by clinician-observed mobility. This indicates that beneficiary mobility and perhaps frailty is important in defining case-mix. For payment, it may be preferable to measure mobility using clinician assessment or patient self-report and not on patient utilization of medical services or devices. When a smaller set of payment case-mix variables are employed, timing of surgery followed by clinician-observed mobility and self-reported participation are most important. This process resulted in 17 final case-mix groups: 7 based on diagnosis alone and 10 based on 5 diagnosis groups split into higher and lower mobility subgroups. This method could be expanded with more variables and more splits, but, as is true of all the case-mix analyses, it would be limited by available sample sizes. We found that patient functional status and other variables do not explain more than a modest amount of variation in outpatient therapy expenditures. It appears that substantial variation in outpatient therapy expenditures is unrelated to patient need for therapy as defined by these variables. It is possible that clinical-need factors that we did not measure could explain more of the variation in expenditures, but we measured a wide range of patient-reported, clinician-observed, and administrative data and produced a number of diagnostic, functional, clinical, and utilization variables. The case-mix measurement could also benefit from enhancements to the assessment items to resolve issues such as ceiling effects and nonspecific but statistically significant results in the nursing facility models. Although the measured case-mix factors do not explain much therapy expenditure variation, case-mix adjustment of Medicare therapy caps or episode-based payments may nevertheless be desirable. We identify a number of characteristics that do predict some degree of expenditure variation, including diagnosis, functional status, and utilization. Case-mix groups defined by these factors predict expenditure differences at least on the order of three to one, which seems to indicate some group-level differences in expenditures. Case-mix adjustment of therapy expenditure caps or episode-based payments could be approached using only administrative data or by also incorporating patient self-report and clinician-assessment data. The former does not include systematic information on patient functional status and other characteristics, whereas the latter requires a potentially expensive and burdensome primary data collection system. Even with case-mix adjustment, however, the large amount of unexplained variation in therapy expenditures will require additional strategies in reimbursement. A budget-neutral, equal discipline-specific cap would be slightly lower than the current cap, whereas a combined-disciplines cap would be higher. Discipline-specific caps are most generous for beneficiaries needing a large amount of multiple disciplines of therapy, whereas a combined cap is most generous for beneficiaries needing only one discipline. Our budget-neutral analysis indicated that a combined cap would apply to a smaller portion of beneficiaries, but affected beneficiaries would exceed the cap by a larger amount, on average. We tested a wide range of administrative, clinician assessment, and patient self-report data as predictors of beneficiary annual therapy expenditures (among beneficiaries with some use of outpatient therapy). These variables included demographics, diagnoses (from claims and assessments), motor and cognitive functional status (from clinician assessments and patient self-report), hospitalizations by diagnosis-related groups, inpatient utilization of therapy, reasons for therapy (body structure, body function, activity limitations), pain (patient self-report), and surgical history. Both ordinary least squares models predicting mean expenditures and quantile regressions predicting the expenditure cap were estimated. We estimated comprehensive models in an attempt to isolate the true marginal effect of predictors on expenditures, holding as many other factors constant as possible. These models included payment models that eliminated variables from the comprehensive model thought to be unsuitable for payment; basic models that included only the key predictors diagnosis and functional status; and, to address redundancy among the predictors, stepwise regressions that added variables to the model one by one based on their incremental predictive power. One conclusion from these models is that systematic differences in annual therapy expenditures by some of these characteristics were observed. The differences in average (or quantile) therapy expenditures associated with selected beneficiary characteristics could be used to adjust the annual therapy expenditure cap. Some of the factors predicting therapy expenditures are available from existing administrative data, whereas clinician assessment and 55 patient self-report data would have to be obtained from a costly new and ongoing data collection effort from outpatient therapy providers and/or patients. A second conclusion is that the amount of variation in individual beneficiary annual therapy expenditures explained by the measured factors is small. This means that either (1) therapy expenditures are closely related to need for therapy, but available data and models are not able to estimate individual beneficiary therapy needs effectively; or (2) that individual 26 beneficiary therapy expenditures are not closely related to the amount of therapy needed. The weak ability to accurately predict the current dollar volume of therapy utilization in relation to characteristics we measured implies that even with a risk-adjusted cap, there will continue to be substantial demand for exceptions to the cap. This suggests that it will continue to be difficult for Medicare to impose a hard cap (without exceptions) on therapy expenditures, but risk adjustment will be able to modestly improve the targeting of therapy manual review. Further work to improve the measurement scales developed in this project, such as lessening or eliminating ceiling effects, could improve the ability to explain expenditures, although large gains do not seem likely. Current Policy versus Discipline-Specific versus a Combined-Discipline Cap We also examined how the therapy cap is imposed by therapy discipline. Using existing claims data, we simulated versions of the two alternatives that are budget neutral with respect to current policy, assuming no behavioral response on the part of beneficiaries or providers to cap changes (see Section 4. Equal, budget-neutral discipline-specific caps are each slightly lower than either of the two current policy caps, and a slightly higher percentage of beneficiaries are above at least one cap. Discipline-specific caps are most favorable to the minority of beneficiaries using multiple (especially all three) therapy disciplines because these beneficiaries can max out each of the three caps separately and achieve higher total therapy spending under the cap than with the other two policy alternatives. A single combined cap is higher than the current policy caps, and a significantly lower percentage of beneficiaries would exceed the single combined cap. A combined cap is most favorable to beneficiaries using only a single therapy discipline. Discipline-specific caps match more closely with the actual pattern of therapy expenditures by users of one discipline, two disciplines, or all three disciplines than current policy or a combined cap. A combined cap would target for review a smaller number of high outpatient therapy users across all disciplines. Such an issue should be considered for future research toward an alternative payment system. We found a high degree of variability of Medicare episode-based payments, driven primarily by the length of the episodes. In payment, the variability of episode length will need to be dealt with, most likely by renewable fixed-length episodes or possibly by an outlier policy. The unit of episode-based payment for outpatient therapy could be, for example, renewable 30-, 60-, or 90-day episodes. We analyzed 30-, 60-, and 90-day initial fixed-length episodes for physical therapy beginning in 2010 for community residents. Case-Mix Adjustment of Episode-Based Payments We examined predicting episode expenditures using clinician assessment and patient report information, combined with data from Medicare administrative enrollment and claims files. Predictors tested included demographics, diagnoses, functional status, reasons for therapy (body structure, body function, and activity limitations), patient self-report of pain, and surgical history. As found for annual expenditures, we also found that some factors predicted systematic average differences in therapy episode expenditures. But, as a group, the predictors accounted for only a small portion of the overall variation in expenditures. But the available case-mix variables are weak predictors of therapy expenditures in individual episodes. Weak case-mix adjustment creates financial risk for providers and allows greater scope for providers to enhance their profitability by selectively enrolling healthier patients. In mixed payment, therapy providers are paid partly on an episode lump-sum basis and partly on a fee-for-service basis for each additional therapy service provided. For example, the episode lump-sum payment might be $150 and payment for each service could be 70 percent of the current fee schedule amount. We conclude that the Centers for Medicare & Medicaid Services could consider mixed payment for outpatient therapy as a means of addressing the weak case-mix adjustment that is possible. Several of the lessons focused on design of the data collection instrument, whereas other areas focused on ways to improve the items included in the data collection instrument.

The cremasteric reflex: is tested by pinching or stocking the skin of the medical aspect of the thigh blood pressure normal low pulse cheap 12.5 mg microzide. Contraction of the cremasteric muscle occurs young squage heart attack order microzide 25 mg, resulting in elevation of the testis on the same side blood pressure chart urdu microzide 12.5 mg cheap. Sucking reflex when the centre of the lip is touched with a tongue blade there is a sucking movement of lips blood pressure medication increased urination 12.5mg microzide amex. Rooting reflex when the corner of the lips are touched with the tongue blade the lips move towards the blade blood pressure log printable purchase microzide overnight delivery. Grasp reflex touching of the palm between the index finger and the thumb will stimulate forced grasp prehypertension bp range buy microzide american express. Palmomental reflex scratching of the palm diagonally results in the contraction of ipsilateral mentalis muscle. If the reaction is positive, a pursing movement of the lips occurs after each tap. Touch and pressure sensation test Light-tough sensation examined with tipped cotton applicators. The examiner touches the applicator with a light brushing motion to similar areas on two sides of the body simultaneously or just one side and ask the patient to describe the sensation perceived as left, right, or both sides. In lesions of the cortex the peripheral sensations like pain, temperature, pressure, touch, and vibration are not affected. Neck stiffness involuntary rigidity of the neck due to pain arising from meningeal irritation. This will stretch the nerve root and pain will be elicited at the inflamed meanings. Barbara Bates-A Guide to Physical Examination and History Taking, 6 Edition, 1995, 2. Weinstein A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy (Biology) in the University of Michigan 2009 Doctoral Committee: Professor Emeritus Richard D. As we sat eating our lunch of dry salami, crackers and gouda cheese my grandfather handed me a magnifying glass and pointed me to the center of a flower. As I looked at all the levels of intricate structure, the two of them told me about Darwin, and how all the complexity that I saw was a consequence of a simple thing called selection. My maternal grandparents, Harry and Sophie Rubin, had a great deal to do with cultivating the traits on which I have leaned most heavily. His intellectual influence is evident throughout the work presented here, and much that is correct within it was built and refined with his invaluable insight and guidance. Larry Clark at the Monell Center in Philadelphia was the first teacher I had that understood the Darwinian landscape at a deep level. His willingness to take a young undergraduate seriously in his graduate Chemical Ecology seminar had lasting effects. That experience opened my eyes to dozens of important things about the evolutionary nature of humans, islands and the subtle dynamics at the frontier of evolutionary knowledge. As recognized as he is for his achievements as a biologist, I believe that Dick has yet to get his full due. He has been everywhere, on the map and off, and his powers of observation and analytical capacity have made for invaluable surveys of that landscape. It collected refugees from all over the Biology department, and was a great place to refine ideas and test out new heretical formulations. Among the many people in that sphere that helped shape my thinking about selection, a number stand out. Andrew Richards, David Marshall, John Cooley, Laura Howard, Deborah Ciszek and David Lahti have each been influential. Chapter 2 of this dissertation was co authored with Deborah Ciszek, and Chapter 4 with David Lahti, and the only reason their names are not on those chapters is that putting their names there violates an apparently inviolable University policy. Second, he has encouraged me to think on much longer timescales than are typical in biology, even amongst evolutionists. The second thing he did was bring the philosophy of rigorous scientific thinking up to the explicit layer. All of the people I mention here are rigorous thinkers, but Arnold introduced me, and many others, to the inner workings of that machine. Heather Heying, to whom I am now married, has helped shape every facet of my work since we joined forces in 1989. We have talked in detail about every Darwinian concept in this thesis, and well beyond. Having her excellent evolutionary mind to generate, shape and refine ideas with has been immensely useful. Without our many thousands of hours of discussion about selection, I cant say where any of this work would be. I can, however, say with confidence that the thesis never would have been iv completed, and I would not have gotten a professorship, absent her many talents and extraordinary patience. Elisabeth Kalko and the late Charles Handley both invested heavily in me and my work. Others that have played an important and positive role include Jennifer Ast, Antonia Gorog, Gary Paoli, Pia Malaney, Nat Kurnick, Jae Choe, Arnold Marglin, Beverly Rathcke, George Estabrook, John Vandermeer, Jerry Urquhart, Chris Picone, Tom DiBenedetto, Dyan Haspel, Allen Herre, Randy Nesse, Cecile Bockholdt, Mike Hemann, Alec Lindsay, Paul Fine, Lissy Coley, Tom Kursar, Egbert Leigh, Steve Hubbell, Scott Peacor, Bill Rice, Austin Burt, Paula Schofield, Jack Longino, Nalini Nadkarni and many insightful undergraduates at the Evergreen State College. Finally, I wish to thank my committee, Robyn Burnham, Richard Alexander, Gerald Smith, Beverly Strassmann and Elizabeth Tibbetts for putting up with much that was non-standard. Their coordinated efforts and insight made this thesis considerably better than it otherwise have been. Increased predictive power can be gained by treating trade-offs as emergent phenomena governed by laws that are also emergent. The law-like nature of trade-offs becomes evident when we subdivide examples by type. Only design trade-offs are law-like, although the other two types may be transformed into design limitations given strong selective pressures. Between every two fitness-enhancing characteristics of an organism or mechanism, a design trade-off must logically exist, preventing simultaneous optimization. Trade-offs may be obscured by insufficient selective time, noisy or fluctuating selective environments, and weak selection pressures. The interrelation between these phenomena on the one hand, and niche-partitioning, competitive exclusion, character displacement and phenotypic plasticity on the other is also considered. Chapter Two describes a senescence-causing trade-off between cancer prevention and tissue-repair capacity in vertebrates. Chapter Three relates the latitudinal diversity gradient to a gradient of design constraints that is a consequence of environmental fluctuation positively correlated with latitude on all relevant time scales. A natural reconciliation between niche assembly and community drift is proposed, and the effects of mate choice on diversity patterns is viii considered. The potential importance of trade-offs as an organizing principle has been discussed, and previous attempts have been made to sketch the landscape. What follows is an attempt to increase the utility of the trade-off concept by subdividing the concept into natural types. One of the reasons that trade-offs are incompletely known within biology is that even the simplest biological organisms are unimaginably complex. Because we are always working with a crude and incomplete understanding of the adaptations that comprise a given organism, the natural tendency of evolution to modulate and balance competing concerns may be obscured. Additionally, as Stearns (1992) observes, trade-offs may be hidden by the way in which we study. Clearly an individual plant must allocate each unit of resource in one direction or the other, so there must logically be a trade-off. But you would not get that impression if you measured the masses of roots and shoots of individuals sampled as you moved from high altitude to low, because plants of a given species will tend to be larger in all regards at lower altitudes, so root mass and shoot mass will be positively, rather than negatively, correlated. In order to see the trade-off, we must control for variables that either encourage or tax the plant as a whole. And it is quite common to hear agreement among them regarding principles, even laws, that have equal reason to be expected in biology. It is possible that there is some threshold of complexity above which these engineering principles cease being applicable, but that constitutes special pleading unless evidence of such thresholds emerges between the level of the most complex machines, and the simplest organisms. Until then, we are justified in cautiously peering into fields where the complexity is simple relative to the noisy biotic systems we primarily wish to untangle (Csete and Doyle, 2002). The other advantage of learning from engineered machines about the constraints that shape the adaptive landscape (what engineers sometimes call with design space) is that, unlike biological organisms, one can have a very complete understanding of exactly what each feature of a machine is intended to accomplish. And without complete knowledge of the advantage provided by a trait, it is difficult to do a cost/benefit analysis, which is at the core of understanding how any product of adaptation trades-off against any other. Trade-offs can usefully be divided into three types, probabilistic trade-offs, allocation trade-offs, and those trade-offs arising from inherent design-constraints. And dividing trade-offs in this way allows us to see that each has unique properties that must influence how they interact with adaptive evolutionary forces. Suppose, for example that a female frog prefers males that are unusually large, and at the same time, males that are unusually blue. There will, for obvious reasons, be few individuals in the remote right tail of the distribution for size, and there will be few individuals in extreme blue tail of the color distribution. As a consequence, she is likely to have a very difficult time finding individuals in both tails and, as with any trade off, she will have to prioritize the two considerations. That being said, if size and color are not at odds for some functional reason, then selection by females could produce, over time, large, intensely blue, males, thus eliminating the initial trade-off. If on the other hand, there is a significant fictional relationship between size and color such that being extreme in one regard has costs with respect to the other, then the probabilistic trade-off will be converted into either an allocation trade-off, or a design constraint trade-off depending on the functional nature of the relationship. The likelihood that the camera with the best light-metering will be the camera with the sharpest lens will initially be low, unless there is demand for a camera with both an unusually sharp lens and an unusually powerful light-meter, in which case, there being no obstacle to the production of such a camera, one might well be built. The second kind of trade-off, the type arising from the allocation of a limited resource, is illustrated by the root/shoot example above. This is the type on which Stearns (1992) review of the topic is primarily concerned. Allocation trade-offs arise in any instance where a resource must be divided amongst competing concerns. A family could spend twenty percent of its budget on food, ten percent on housing, investing the remainder in lottery tickets and that would qualify as a three way trade-off, even though the budget makes no financial sense. Likewise, an individual songbird could spend all its time searching for mates out of season, thus failing to forage sufficiently to maintain 3 homeostasis and the trade-off would be just as real. Of course, in general, the division of resources exhibited by organisms will quickly honed by selection to reflect an adaptive division of the resource. The reproductively optimizing force of selection will tend to convert such trade-offs into something that behaves like a design-constraint trade-off (described below), with one important difference: allocation trade-offs can be eliminated, at least in the short term, with supplemental resources. Consider the plight of a photographer trying to capture a picture of a moving object while maintaining a large depth of field, such that things at various distances from the camera are in sharp focus. The amount of light needed to get the right exposure is a simple sum affected by two parameters, the time the shutter is open, and the size of the aperture in the lens. If the variables were continuous rather than discrete, then there would be an infinite set of combinations of lens openings and shutter-speeds that would yield the right exposure. Those combinations with large apertures and fast shutter-speeds would freeze motion, at the cost of a narrow depth of field (only a narrow band of objects at a given distance away would be in focus). While, slow shutter speeds with small aperture openings will give a large depth of field, at the cost of moving objects being blurred. But the trade-off between depth of field and the freezing of motion evaporates if we supply large quantities of extra photons (as with a flash), allowing us to produce the same exposure with the lens opening small and the shutter set to a brief period. These trade-offs occur simply because the same form cannot be optimized for two different tasks simultaneously. Unlike the other two types, trade-offs that derive from design constraints are emergent phenomena, unobservable until revealed by selection of sufficient strength and duration to bump species up against them. The most important aspect of design constraint trade-offs is that they are insensitive to resource supplementation, and thus produce hard limits on what selection can and can not do. There are two important sub 4 categories within design-constraint trade-offs: the degree of hardness is not universal. Some design-constraint trade-offs are local optima that can be exceeded once an with innovation arises that allows circumvention. Design-constraints are likely to be the richest form of trade-off in terms of untapped explanatory power, because they exist inherently at the frontier where the biota meets its limitation. But design-constraint trade-offs are also the most easily misunderstood because, unlike allocation trade-offs that exist irrespective of selection, and unlike probabilistic trade-offs that are destroyed by selection, design constraints are invisible until the particular quadrant of the adaptive landscape in which they exist is explored by selection.

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Sleep enuresis arrhythmia and palpitation buy 25mg microzide overnight delivery, or bed wetting hypertension during pregnancy generic 25mg microzide with amex, is diagnosed in the absence of urologic blood pressure is highest in the buy genuine microzide online, medical pulse pressure healthy range buy microzide with visa, or psychiatric conditions in children after 5 years of age blood pressure zona plus buy 25mg microzide otc. In studying sleep in the younger age groups blood pressure chart in spanish purchase microzide 25 mg amex, one should consider the age related differences in sleep stages and their implications. Adolescents, on the other hand, are more likely to be sleep deprived due to increasing workloads from school, sports, and social activities and events. The disruption of regularly sleep schedules and decrease in total amount of sleep predispose them to circadian rhythm dyssomnias. Sleep enuresis Disturbed sleep related to neurologic disorders can be due to diverse causes such as headaches, seizures, mental retardation, and cerebral degenerative disorders. The severity of the sleep problem is correlated to the extent of the neurologic conditions. Psychiatric problems can also lead to night time wakings, nightmares, or difficulty going to sleep. In older children, generalized anxiety disorder and major depression can play a role also. Thus, in assessing sleep disorders, the physician must distinguish between primary causes and sleep disturbances related to other medical or psychiatric disorders. Describe at least two causes of obstructive sleep apnea and two causes of non-obstructive sleep apnea Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects, 2nd edition. The baby has been well until 3 days prior when he developed a mild upper respiratory tract infection. The etiology is unknown, however a number of risk factors have been identified which include: prone sleep position, sleeping on a soft surface, co-sleeping, maternal smoking, overheating, lack of adequate prenatal care, young maternal age, prematurity and/or low birth weight, and male sex. By 43 weeks postconceptional age, the relative risk of having an extreme event was no longer significant in the preterm versus the full term group. A leading hypothesis maintains that many of these infants have an immature or abnormal arousal response. The arcuate nucleus is thought to be involved with the hypercapnic ventilatory response, chemosensitivity, and blood pressure regulation (2). Infants possessing this abnormality may be uniquely prone to central and cardiorespiratory depression resulting from hyperthermia, hypercarbia and hypoxemia during sleep. This theory supports the notion of placing an infant in the supine (or non-prone) position during sleep, as prone positioning increases the likelihood of the nose and mouth becoming buried in the sleep surface. This association was strongly demonstrated in population based, case-control studies conducted in England, New Zealand and Australia. In 1994 the "Back to Sleep" campaign was initiated to inform the public about the risks associated with prone sleeping. It has been demonstrated that non-prone positioning during sleep is beneficial to preterm/low birth weight infants as well as term infants (5). Another modifiable risk factor is the use of soft sleep surfaces and loose bedding (2). Pillows, quilts, comforters, sheepskins and porous mattresses pose additional risks particularly when placed under the infant. Bed sharing may pose an additional risk factor; the mechanisms of which include the presence of loose bedding, the possibility of the parent rolling onto the child, entrapment, and rolling of the infant to the prone position. In addition, 12 out of 41 siblings of these patients had previously died suddenly and unexpectedly. As in any infant death, guilt is often the prevailing response with the parent questioning what they could or should have done to prevent such a tragedy. The most appropriate professional response under these circumstances is to demonstrate compassion, empathy and support. It should be recognized that necessary medical questioning is likely to cause additional stress. Parental stress and feelings of guilt or paranoia have been further exacerbated by the professional and public awareness of infanticide as a contributing cause to sudden infant death. Parental anxiety and stress may be further heightened by naive and uninformed, yet well-intentioned family members. A crib that conforms to recognized safety standards is a desirable sleeping environment for infants. Infants should not be put to sleep on waterbeds, sofas, soft mattresses, or other soft surfaces. Prone positioning is acceptable when the infant is awake and being observed so that issues related to development and positional plagiocephaly (head asymmetry and deformity) may be addressed. Devices to maintain sleep position or to reduce the risk of rebreathing are not recommended. Home monitors are available to detect cardiorespiratory arrest and may be of value for monitoring selected infants who have extreme cardiorespiratory instability. Avoidance of maternal smoking, overheating, and certain forms of bed sharing should be included as important secondary messages. Sudden Infant Death Syndrome has been nearly eradicated due to changes in infant positioning. Birth Weight and Gestational Age-Specific Sudden Infant Death Syndrome Mortality: United States, 1991 Versus 1995. His parents think he has abdominal pain as he is "gassy" and pulls his legs up as if he is trying to stool. He passes a lot of gas from his rectum and his parents can hear his stomach gurgling a lot. They have tried feeding, a pacifier, rocking, burping, changing the diaper, and inserting a rectal suppository but nothing has relieved the crying. Further questioning reveals this is the fourth day in a row that this has happened on a daily basis, usually in the evening, but the baby usually cries for about 2 to 3 hours. He has been feeding well with good weight gain and no fussiness until 4 days ago (age 16 days of age). No apnea, no vomiting, no fever, no constipation, no seizure activity, no trauma or history of shaking or abuse. Diagnostic impression by the physician: Unexplained recurrent crying with normal physical examination. Colic is one of the most commonly made diagnoses during the first 4 months of life with a reported incidence of 10% to 35% of all infants. The word "colic" is derived from the Greek word "kolikos", which refers to the large intestine. Colic has also been called the three month colic, infant colic syndrome, or paroxysmal fussing in infants. The classic definition of infantile colic was described by Wessel (1) in 1954 as, crying lasting more than 3 hours per day, 3 days per week, and continuing more than 3 weeks in infants less than 3 months of age. During these paroxysms, the legs are often flexed, the infant may be described as gassy, and parents often think the infant has abdominal pain. In addition, crying is not relieved by normal parental interventions (feeding, burping, changing diapers, etc. In 1962, Brazelton (2) published characteristics of the median daily crying at various ages: At 2 weeks of age: 1 hour and 45 minutes. The four clinical signs of colic are: 1) paroxysmal onset, 2) distinctive high-pitched pain cry, 3) physical signs of hypertonia and 4) inconsolability (3). Colic presents as intermittent and unexplained crying during the first three months of life by babies that are otherwise healthy. The "infant colic syndrome" (paroxysmal fussing) basically involves cyclic discrete periods of intractable crying, usually on a daily basis, with onset at 1-4 weeks of age (may be as early as the first week of age) and dramatic spontaneous improvement by 3-4 months of age. In addition to infant irritability, colic is characterized by recurrent episodes, excessive restlessness or activity, or diminished consolability. Colic is distinguished in that the crying is paroxysmal, intense and different in type from normal fussing and crying. The defining elements of colic, according to Carey (4) are: full force crying for at least 3 hours per day, for 4 or more days per week, in infants who are less than 4 months old and are otherwise healthy. The cry reaches a screaming level, is often high pitched and coupled with facial grimacing indicating that the infant is in severe pain. There is increased motor activity, which may include flexion of the elbows, clenched fists, and generalized hypertonicity of the musculature, with the knees drawn up or legs stiff and extended. There is no clear understanding of the etiology, pathophysiology and treatment of colic; however, proposed models for the etiology of colic fall into 3 broad categories: intrinsic or biological factors in the infant, extrinsic factors in the psychosocial environment and an interaction or systems approach. Crying is a non-specific response in an infant, which may be a major symptom of an underlying pathologic process. The etiologies of intractable crying in infancy range from a benign phase of psychomotor development to a life threatening illness. The etiology is initially obscure and an accurate diagnosis is dependent on a knowledgeable and organized approach. A careful history and physical exam with selected laboratory studies usually establishes a diagnosis. Since most of these patients initially present to the emergency department, the emphasis is on the evaluation of the infant or young child with intractable crying, and one must exclude serious underlying illness. Look for "red flags" in the history and physical, which suggest the possibility of significant underlying pathology (see Tables 1 and 2). The presence of any of these "red flags" should prompt a more extensive evaluation and aggressive management, often including specialty consultation and hospitalization. Robert Bolte (6) has described "Red Flags" of non-colic causes of extreme fussiness, which may be signs or symptoms of life threatening illness, obtained by further history or physical examination. Do not make a diagnosis of colic on patients with any of these historical or physical examination "red flags" until other causes listed under "differential diagnosis" (Table 3) are ruled out. Page 332 Table 1 Historical "Red Flags" Associated with Intractable Crying in Infancy (6) 1. Premature rupture of membranes (>24 hours), perinatal maternal fever/infection, neonatal jaundice. Significant decrease in level of activity, cyanotic/apneic "spell", or seizure-like episode. History suggestive of physical abuse (injury not consistent with reported history, inappropriate delay, non-maternal caretaker). Antibiotic pre-treatment ("partially treated" sepsis/meningitis), particularly in the young infant. Table 2 Physical Examination "Red Flags" Associated with Intractable Crying in Infancy (6) 1. Drugs and Toxins 1) neonatal narcotic withdrawal 2) neonatal barbiturate, ethanol, hydantoin withdrawal 3) irritability related to smoking mothers who breastfeed 4) reaction to pertussis immunization 5) theophylline, antihistamine, decongestant, cyclic antidepressant, amphetamine, cocaine toxicity A thorough history and a meticulous physical exam are the cornerstones of accurate diagnosis. Poole (5) described 56 afebrile infants who presented with unexplained excessive crying to the emergency department. The history provided clues to the final diagnosis in 20% of the cases, while the physical exam revealed the final diagnosis in 41% of the cases and provided clues to the final diagnosis in another 11%. Special emphasis should be given to the examination of the skin, palpation of the abdomen, eye examination (with funduscopic and eversion of the eyelids), evaluation of anterior fontanelle fullness, inspection of the tympanic membranes, oropharynx, and gums, palpation of extremities and clavicles, and performance of an anal rectal exam which may be done with a cotton tip swab. If colic is determined to be the likely diagnosis, there have been a number of studies with varying results regarding treatment: 1. His behavior modification approach resulted in a 65-70% decrease of crying time (3. Taubman also described a "bad" approach (ignoring the baby) which assumes colic that results from over stimulation, therefore generally "ignoring" the baby (letting them cry) would be the logical treatment. The apparent effectiveness of simethicone (seen within 1-4 days in 54-67% of treated infants) probably represents a high-grade placebo effect. Simethicone converts gas foam into non-foam gas, but the gas remains in the bowel lumen. Empathy and describing the natural history of colic to parents results in improvement by 3-4 months. Increased carrying time, automatic rocker swings, driving around the neighborhood (with baby in a car seat) and nap-time swaddling are benign measures that may be helpful. Empiric formula changes are generally not useful, but this is a benign measure and it is often suggested. Mothers who are breast and bottle feeding should be encouraged to breast feed as much as possible and minimize formula feeding. Infants who are exclusively formula fed can be changed to a protein hydrolysate formula (Nutramigen, Pregestimil, Alimentum), as a trial to see if there is a beneficial response. In attempting to discover why your infant is crying consider these possibilities: a. If the crying continues for more than 5 minutes with one response, then try another. When infant crying continues despite all efforts to stop it, including feeding, do the following: 1. If still crying, pick the baby up for a minute or so to calm him/her then return him/her to the crib. Crying may simply be a normal response to stress such as hunger, discomfort, or over or under-stimulation, or may represent the "infant colic syndrome" (paradoxical fussiness). Close follow-up is crucial if the etiology of the irritability and excessive crying is still somewhat obscure at discharge. Do not discharge an irritable infant if "extreme fussiness" has not resolved, particularly if a "red flag" is present. Red flags suggest that this intractable crying infant may not be due to the classic "infantile colic syndrome". Clinical Trial of the Treatment of Colic by Modification of Parent-Infant Interaction. New Strategies for the Treatment of Colic: Modifying the Parent/Infant Interaction. The pain is located in the upper mid abdomen and is associated with anorexia, nausea and four episodes of green vomitus. She has moderate abdominal distention with hyperactive bowel sounds, peristaltic rushes and borborygmi with generalized mild tenderness.

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If there is no major improvement of symptoms within one week after the initiation of intravenous cyclosporine blood pressure medication ending in pine microzide 12.5mg, the patient is usually referred for surgery wireless blood pressure monitor discount microzide online visa. Surgical Therapy Surgery in ulcerative colitis should be reserved for those patients with refractory disease blood pressure medication in the morning or at night buy microzide american express, complications associated with the medical therapy blood pressure chart age 35 cheap microzide 25 mg line, or complications of colitis hypertension genetics buy discount microzide on line. Colectomy may be used in pediatric patients for amelioration of growth retardation in prepubescent children affected by ulcerative colitis blood pressure testing purchase microzide american express. Current surgical alternatives include total proctocolectomy (Figure 16A) with Brooke ileostomy (Figure 16B), the intra-abdominal Koch pouch (Figure 16C), and restorative proctocolectomy with ileal pouch-anal anastomosis (Figure 16D). Surgical options for the treatment of ulcerative colitis; A, proctocolectomy; B, Brooke ileostomy; C, Koch pouch ileostomy; D, restorative proctocolectomy. Elective colectomy cures ulcerative colitis and has a very low mortality rate (less than 1%). The procedure should almost always be a total colectomy (Figure 17A) with ileostomy or one of two internal ileal pouch alternatives. The patient attaches a double-faced adhesive ring to the skin and then to an opaque sack (which can be emptied) that collects the 750-1000 ml of material that the ileum produces daily (Figure 17C). Ostomy societies can be very helpful in adjusting to the inconvenience and psychological issues of an ileostomy. An internal reservoir is created from reshaped ileum with a nickel-sized nipple valve opening onto the lower abdominal wall. The patient catheterizes the pouch through a nipple valve to remove ileal contents. The surgery involves creation of a new rectum from the small bowel and attaching the pouch of ileum to the anal canal (Figure 19). The pouch-anal anastomosis may be performed using a hand-sewn or stapled technique (Figure 20). In patients with persistent disease activity or the development of dysplasia or cancer, a mucosectomy (stripping) may be performed before the anastomosis. Those who do not advocate anal stripping believe that preservation of a few centimeters of rectal mucosa produces better functional results (Figure 21). In the patient with fulminant colitis, the colon may be removed first, leaving the creation of the pouch, restoration, and the removal of the rectum for a time when the patient has recovered from the colitis and is in better nutritional condition. This is a three-stage procedure, as a temporary ileostomy is made above the pelvic pouch to allow healing. In patients with more chronic and stable disease, the procedure may be performed in two stages (with a temporary ileostomy). Select patients are candidates for a restorative proctocolectomy performed in a single step. After a temporary protective ileostomy is closed, patients can defecate through their anus. Although pouchitis is a complication in 25% of patients, the ileoanal pouch is an acceptable and successful alternative to standard ileostomy. Overview the complications of ulcerative colitis can be divided into those that affect the colon and those that are extracolonic. Toxic Megacolon Overview the most feared complication of ulcerative colitis is the development of toxic megacolon. It occurs as a result of extension of the inflammation beyond the submucosa into the muscularis, causing loss of contractility and ultimately resulting in a dilated colon. Dilation of the colon is associated with a worsening of the clinical condition and development of fever and prostration. Diagnosis this diagnosis is based on radiographic evidence of colonic distention in addition to at least three of the four following conditions: fever higher than 38. At least one sign of toxicity must also be present (dehydration, electrolyte disturbance, hypotension, or mental changes). There may be rebound tenderness, abdominal distention, and hypoactive or absent bowel sounds. However, perforation can also present in severe ulcerative colitis even in the absence of toxic megacolon. Steroid therapy has been suggested to be a risk factor for colonic perforation, but this is controversial. Radiography X-rays of the abdomen reveal colonic dilation, usually maximal in the transverse colon, which tends to exceed 6 cm in diameter. Medical Therapy the goal of medical therapy is to reduce the likelihood of perforation and to return the colon to normal motor activity. A nasogastric tube is placed in the stomach for suction and decompression of the upper gastrointestinal tract. Broad-spectrum antibiotic coverage is instituted in anticipation of peritonitis resulting from perforation. Intravenous steroids are usually administered in doses equivalent to more than 40 mg of prednisone per day. Surgical Therapy Colectomy occurs in about 25% of patients and is required in almost 50% of patients with pancolitis. Colectomy with creation of an ileostomy is the standard procedure, although single-stage proctocolectomy is done occasionally. If surgical therapy is performed before there is colonic perforation, the mortality is approximately 2%. In cases in which there has been bowel perforation, however, the mortality risk increases to 44%. However, some degree of narrowing may be seen in approximately 12% of surgical specimens. Histologically, strictures present with hypertrophy and thickening of the muscularis mucosa without evidence of fibrosis. Strictures have been associated with malignancy, and biopsy of the strictures is warranted. In fact, in patients with long-standing history of ulcerative colitis, a stricture should be considered potentially malignant. Primary Sclerosing Cholangitis Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by fibrosing inflammation of extra and intrahepatic bile ducts. Patients may have symptoms of fatigue, pruritis, abdominal pain, fever, or jaundice. We encourage you to review this educational material with your health care professional. The foundation does not provide medical or other health care opinions or services. Researchers believe that several factors, such as a family predisposition and a faulty immune system, play a role in their development. The scope has the following tests and diagnostic procedures may be other tools that may be used for additional purposes, performed. The presence of infammation in the body A capsule endoscopy may also be performed. The capsule is expelled Tests may be performed to help health care providers during a bowel movement, usually within a day. If the person is experiencing more serious or altered levels of specifc compounds or chemicals within signs and symptoms or is not responding to treatment, the body, such as serotonin. For example, many women Complications often report more symptoms when they are menstruating. Anti-diarrheal agents, such as loperamide, diphenoxylate and atropine, are used to treat diarrhea. Biologic therapies, including infiximab, adalimumab, Antispasmodics, such as belladonna alkaloids/ certolizumab pegol, golimumab, vedolizumab and phenobarbital, hyoscyamine, dicyclomine, propantheline natalizumab, are antibodies grown in the laboratory and peppermint oil, are used to treat abdominal cramps that stop certain proteins in the body from causing and associated diarrhea. Antidepressants, such as fuoxetine, citalopram, sertraline, Antibiotics, such as metronidazole and ciprofoxacin, desipramine, amitriptyline, venlafaxine and duloxetine, are are used when infection occurs, either from the used to relieve gut pain and treat psychological distress disease itself or from post-surgical procedures. Probiotics, dietary supplements that contain certain benefcial bacteria, may help to balance the intestinal track. Fiber supplements can ease the movement of bowel contents, preventing constipation. Eat fve way toward reducing symptoms and promoting adequate small meals a day, every three or four hours, rather than nutrition. Dietary recommenda foods may cause diarrhea and gas if fat absorption is tions must be individualized, depending on the disease incomplete. If there is food eaten that guarantees a healthy diet, but daily intake narrowing of the bowel, these foods may cause cramp needs to include an adequate amount of calories and nutri ing. For a listing of sample foods and beverages pletely digested by the small intestine, these foods may to potentially try and avoid, see chart below. Stay well hydrated to avoid food (such as beans, cabbage and broccoli), spicy food, complications. They are available in the form of dietary supple ated during the time of a f are. Writing down when, what, There is no strong evidence to suggest that the use of pro and how much you eat can help you determine which, if any, foods affect your symptoms. Make sure to write down any unusual symptoms you may experience after eating, and include the time they began. Those interested Date & Time Food Amount Symptoms & Time of Occurrence in using probiotics should discuss this with their health care provider. Probiotics are live bacteria that are similar to benef cial (often called good or friendly) bacteria that normally Anxiety and Depression reside in the intestines. Such activities can include hobbies, satisfying social interactions or yoga and meditation. Physical activity plays a key role in reducing and preventing the effects of stress. Well-nourished bodies are better prepared to cope with stress, so be mindful of what you eat. Relaxation techniques and mind/body exercises, such as yoga, tai chi and meditation may help, particularly when used with other forms of treatment. Other stress management options include relaxation train ing such as meditation, guided imagery or biofeedback. By organizing this list into stress that is controllable/modif able and stress that is not. A stress journal may help identify the regular stressors in life and the ways to deal with them. Over time, patterns and common themes will emerge as well as strategies to successfully cope with them. Expressing what you are going through can be very helpful, even if there is nothing you can do to change the stressful situation. How long does the treatment take to Yes, it is possible to be diagnosed with both conditions. A careful medical history and physical examination by a gastroenterologist or other physician are essential to rule out more serious disorders. Tests may include blood tests, stool tests, visual inspection of the inside of the colon with fexible sigmoidoscopy or colonoscopy and x-ray studies. Due to rapid advances and new fndings, there may be changes to this information over time. This information should not replace the recommendations and advice of your doctor. In addition, it is important to learn how to make healthy food choices, replace nutritional defciencies and maintain a well-balanced nutrient-rich diet. On going infammation leads to symptoms such as abdominal pain and cramping, diarrhea, rectal bleeding, weight loss and fatigue. Incompletely digested food that travels through the colon may cause diarrhea and abdominal pain. In a person with ulcerative colitis, the small intestine works normally, but the in famed colon does not absorb water properly, 3 resulting in diarrhea, increased urgency to have a bowel movement and increased frequency of bowel movements. Severe diarrhea can cause dehydration, rob bing the body of fuids, nutrients and electro lytes (sodium, potassium, magnesium and phosphorus). This can make it difcult to consume enough calories and obtain sufcient nutrients. Chronic blood loss can eventually lead to anemia, which if left un checked, may cause fatigue.

They should offer services outside normal working hours and remove any financial barriers to testing and related services arrhythmia electrolyte imbalance microzide 25mg low price. In the case of low or concentrated epidemics blood pressure chart philippines purchase genuine microzide online, the programmatic focus should be on increasing access and uptake among most-at-risk populations keeping blood pressure chart purchase discount microzide on-line. This opportunity should be given in private blood pressure regulation discount generic microzide uk, in the presence of a health provider high blood pressure quiz discount microzide 25 mg otc. Post-test counselling should be tailored to the test result and blood pressure medication to treat acne buy cheap microzide 25mg on line, in the case of a positive result, should be more extensive. If viral testing is not available, presumptive clinical diagnosis in accordance with nationally defined algorithms will be required. Globally, more than 81 million units of whole blood are collected annually and at least seven million donors are deferred from blood donation. About one million donated units are excluded annually because they contain transfusion-transmissible infections. The blood transfusion service is often the first point of contact of the general public with the health system. It is uniquely suited to promote healthy living and to advise millions of blood donors on lifestyle issues that affect their health. Counselling of blood donors is necessary before (pre-donation counselling) and after (post-donation counselling) blood is collected, and should be preceded by pre-donation information and discussion. Effective pre-donation discussion and counselling are vital activities of the blood transfusion service, and are needed to encourage appropriate donor self deferral. It is also important in promoting health maintenance and regular donation by healthy donors. Donors need to be informed of the test result since it has an impact on their health and prevents the use of their donated blood. These services also have responsibilities to promote low-risk behaviour that reduces the risk of the spread of infection. Effective blood donor counselling can make significant contributions to national initiatives that aim to prevent future transmission of infection and promote healthy lifestyles. It can also lead to family testing and counselling and advice on follow-up and referral. Many countries still have no clear policy on blood donor counselling in the context of blood donation, and need guidance and support in setting up blood donor counselling services. Include blood donor deferral, confirmatory testing, notification, counselling and referral in the national blood policy. Selection of test kits and the order in which they are used are critically important for the good performance of the testing algorithm. If the initial test result is positive, the specimen is tested with a second test using different antigens and/or platforms. In low prevalence settings where false positive results are more likely, a third test is usually recommended. Parallel testing is more costly because of the number of assays and the labour required (particularly in low prevalence settings), but it may reduce the time needed to obtain a final test result. Ongoing quality assurance is required to monitor and evaluate the performance of each test within the national algorithm, and to ensure ongoing performance of the testing technology and algorithm. They do not require specialized equipment, allow a quick turn-around, usually have internal controls and can be operated by trained non-laboratory personnel, including lay service providers. Prevention programmes for prophylaxis and safe delivery usually require a combination of several interventions. Other concerns include preventing illness, receiving care for opportunistic infections and accessing antiretroviral treatment. Interventions to address their need to engage in sexual activity without fear of transmitting the virus to their sexual partners are highlighted below (see section 1. Recommendations for preventing illness and other aspects of care and treatment are outlined in section 1. Interventions should be tailored to the burden of disease and the nature of the epidemic in specific settings, as well as to the capacity and level of health services in those settings (see Chapter 4). Social marketing combines marketing strategies that increase the demand and supply of condoms at subsidized cost. These programmes should ensure that quality condoms are accessible to those who need them when they need them, and that people have the knowledge and skills to use them correctly and consistently. Male and female condoms should be made available universally, either free or at low cost, and should be promoted in ways that help overcome social and personal obstacles to their use. For some high risk populations, such as male sex workers and men who have sex with men, providing water-based lubricant is absolutely essential. Condoms should be stored and distributed according to international norms and standards. The male latex condom: Specification and guidelines for condom procurement. Treatment for each syndrome should be directed against the main organisms responsible for the syndrome within that geographical setting. Global strategy for the prevention and control of sexually transmitted infections, 2006 2015: Breaking the chain of transmission English: whqlibdoc. Guidelines for the management of sexually transmitted infections English. Periodic presumptive treatment for sexually transmitted infections: Experience from the field and recommendations for research. However, it is critically important to sustain interventions for behaviour and to provide prevention tools over long periods of time. Summary of recommendations Individual and small group dialogue between providers and clients in health settings serves as an important opportunity for providing information and counselling on safer sex and risk reduction. Those identified as being at ongoing risk may require more intensive counselling and support to reduce risky behaviour, including a reduction in number of partners. Counselling on delay of sexual debut and reduction of number of sexual partners, including visits to sex workers and reduction of concurrent partnership, is recommended to prevent sexual transmission among heterosexual partners. However, the benefit of this counselling for men having sex with men has not been established. Specific measures may be needed to support and counsel discordant couples and individuals in multiple concurrent partnerships, as well as for men having sex with men. Community-based behavioural interventions complement facility-level provider-client interactions. Surgery should be done in an appropriate clinical setting by trained health providers. Men who undergo circumcision should abstain from sexual activity for at least six weeks, or until surgical wounds are completely healed. There should be broad community engagement to introduce or expand access to safe male circumcision services. Such engagement also serves as a means of communicating accurate information about the intervention to both men and women. Male circumcision: Global trends and determinants of prevalence, safety and acceptability whqlibdoc. Male circumcision quality assurance: A guide to enhancing the safety and quality of services. In many countries, sex workers and men who have sex with men are criminalized and stigmatized, increasing high-risk behaviours and discouraging them from accessing health services. Where these barriers to implementing priority interventions exist, there is a need to actively create a supportive policy, legal and social environment that facilitates equitable access to prevention, treatment and care. The interventions listed below are often best delivered through community-based organizations doing outreach, or at health facilities. Interventions can be tailored for brothel or other entertainment establishments, or for more informal street-based and home-based settings. There is solid public health evidence demonstrating the effectiveness of comprehensive condom use programmes targeting sex workers or entertainment establishment workers, but most countries still have structural barriers that must be addressed to facilitate equitable access to services. Programme planning must include formative assessments to determine the needs and vulnerabilities of sex workers, and sex workers should be proactively involved in the design and delivery of programmes. Guidelines for the management of sexually transmitted infections in female sex workers. Unprotected anal sex between men is increasingly being reported in sub-Saharan Africa as well. Importantly, this approach also ensures their right to access appropriate and 19 effective prevention and care services of the highest possible quality, delivered free from discrimination. Prevention services for adults can be modified so that they are also appropriate for young people, but there should also be youth-specific prevention in settings where young people are more likely to access them. These may include schools, universities, youth clubs, popular youth hang-outs, workplaces, and pharmacies. The health sector should support community outreach to young people by providing guidance and linkages between services in the health sector and other sectors. Therefore, services targeting those groups should also be designed or modified to be youth-friendly, or else supplemented with services specifically geared to young members of those most-at-risk groups. This requires data to be disaggregated by age and sex, analysed, and used to guide policies and programming. The health sector should play a stewardship and advocacy role for young people (see section 2. Sex workers are among highly mobile populations, and labour migrants and truckers constitute a large portion of their clientele. All migrant and mobile populations are difficult to reach with behaviour change communications and other prevention interventions. This is due, in part, to the fact that their movement places them in situations where they are ethnic minorities and face cultural and language barriers. Summary of recommendations Access to health services should be based on the principle of equity, ensuring equal access according to need without discrimination that could lead to the exclusion of displaced, migrant or mobile people. Displaced, migrant and mobile populations should have access to services and levels of care equivalent to those provided to surrounding populations. Universal access to antiretroviral treatment for those who need it is now considered a minimum standard of care; displaced, mobile and migrant populations should receive this treatment as a human right. Whether comprehensive services are provided on-site or through referral, providers should follow clear and consistent protocols for management. The necessary supplies, materials and referral information should be made available to deal confidentially, sensitively and effectively with people who have experienced sexual violence. Despite overwhelming public health evidence demonstrating the effectiveness of harm reduction interventions, many decision-makers remain reluctant to implement or scale up these interventions because of their controversial nature. Intense advocacy, citing public health evidence, is often required to initiate and sustain harm reduction programmes. There is also a need for appropriate models of service delivery, health systems strengthening, and strategic information to guide harm reduction programmes. For example, procuring and distributing opioid agonist medicines, such as methadone, may require special measures and procedures. Summary of recommendations Stand-alone interventions are known to have little impact, so policy-makers should insist on a comprehensive package of interventions. All key interventions should be scaled up, at the necessary intensity, until they cover all drug users. The full range of injecting equipment should be covered, including needles, syringes, sterile mixing water, alcohol swabs, and containers for mixing, dispensing and transporting drugs. Decontamination methods for cleaning used injection equipment, such as bleach programmes, are not recommended as a first line of intervention and should be used only if sterile injecting equipment cannot be obtained. Psychosocial treatment of drug dependence has limited effectiveness in managing drug dependence, with high relapse rates. Unlike the case of opioid users, there are no effective substitution therapies for people with amphetamine-type stimulant, cocaine, hallucinogen or hypnosedative dependence. Though not very effective, psychosocial treatment remains the only option for non-opioid users today. Pregnant women already receiving cotrimoxazole should continue prophylaxis throughout pregnancy and postpartum. Health service support is also needed beyond six months to ensure optimal feeding of infants when exclusive breastfeeding alone is no longer adequate. All breastfeeding should stop once a nutritionally adequate and safe diet without breast milk can be provided. Complementary feeding: Report of the global consultation, and summary of guiding principles for complementary feeding of the breastfed child whqlibdoc. However, experts acknowledge that there is substantial uncertainty around this estimate. Comprehensive infection control strategies and procedures can dramatically reduce the risk of transmission associated with health care. Standard precautions minimize the spread of infection associated with health care and avoid direct and indirect contact with blood, body fluids, secretions and non-intact skin.

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