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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

Make use of educational all children aged 6 months to medicine cards cheap indinavir 400 mg fast delivery 4 years; opportunities all persons aged fi50 years; Provide fact sheets medications voltaren indinavir 400mg mastercard, brochures medicine 101 order indinavir 400 mg online, and other fu adults and children who have chronic pul­ information to medications with sulfur order cheap indinavir line Veterans and family sitting in monary (including asthma), cardiovascular clinic waiting areas. Written information should (except isolated hypertension), renal, he­ be direct and straightforward, using appropriate patic, neurologic, hematologic, or metabolic language and terminology, and at appropriate disorders (including diabetes mellitus); reading levels (see Section 11). For example, residents of nursing homes and other long­ this can include fu vaccine administration sites, term care facilities; dates, and times; fu facts vs. Vaccine acceptance may vary by individual, family, Most people who receive the fu shot have no community, or other demographic. Some people may get a low­ attitudes on vaccination and demographics of grade fever and aches lasting 1-2 days after patients can guide the development of strategies to getting the shot—mild in comparison to the improve vaccine acceptance. The injection may cause some discomfort, soreness, redness, or swelling Some individuals may consider getting the vaccine where the shot was given, which resolves in a if they were aware that: day or two. Re-emphasize that one cannot get the vaccine was effective in preventing infuenza. Inform providers about: Seasonal infuenza causes illness, hospitaliza­ How to respond effectively to patient questions tion, and deaths each year in the United States. High-risk patients – use of clinical reminders and health factors to identify these the vaccine was safe. Partici pants described what they do to keep healthy, including how important they believed it was for them to get vaccinated against the fu during the past fu season. Infection control behaviors and attitudes were then discussed, including why participants did or did not decide to get vaccinated, and barriers to getting vaccinated. Most vaccinated Veterans indicated that they made it a point to get the fu shot annually. The most com­ mon reasons for getting the fu shot were: Bad experiences getting the fu in the past Weakened immune systems or aging Habit (often began in the military when fu shots were required) Don’t want to spread the fu to others Doctor recommendation Most non-vaccinated Veterans said they routinely did not get the fu shot. The most common reasons for not getting vaccinated included: Fear of getting sick from the vaccine Vaccine not perceived as effective (doesn’t protect against all types of fu) Never got the fu Bad experiences with vaccines Don’t want to have the infuenza virus put in their bodies Belief that the immune system is strong enough to fght off the fu (don’t feel at risk for fu) Therefore, there should be continuous and ongoing vaccine education updates emphasizing the seri­ ousness of infuenza and addressing misconceptions about infuenza and the vaccine. Flu Coordinators, Infection Control Professionals/Preventionists, and other health care personnel should determine why patients elect not to get vaccinated and develop strategies that address those concerns. Targeted messaging is needed to provide information and eliminate fears surrounding vaccination and infuenza. The partner may be able section in the mailing for Veterans to provide to give vaccinations to family members and information if vaccinated at another location. Educational Other Communication Tools materials such as seasonal fu brochures or posters Ask reason for patient’s refusal of fu shot; dis­ should be widely distributed and available for cuss and dispel “fu shot myths” (see Section 7). To avoid spread­ ing fu and other germs, don’t go to work and Display posters in elevators and restrooms. Encourage those Addressing Concerns of Veteran Patients around you (friends, children, work colleagues) (or residents in long-term care facilities) to practice hand hygiene, especially after touching “Why should I get my fu shotfi Clean hands after infuenza every year: sneezing and coughing or making contact with Infuenza vaccine is the still the best way to your own secretions. Keep tissues in con­ have any symptoms, but still be able to transmit venient places. It’s not just a disease Vaccine effcacy for reducing illness has generally that affects the elderly. However, even when can spread it to other patients, putting them at the viruses are not well matched, the vaccine can risk for severe illness and complications from the protect many people and prevent fu- related com­ infuenza virus. All pregnant women are at risk from infuenza provider about when and where to receive your and its complications. It is important that wom­ vaccination, or watch for the reminder you will get en who are pregnant get the infuenza vaccine to in the mail with the vaccination dates and times protect themselves and their babies. You may be a candi­ toms than are seen with injections of placebos date for the nasal spray that delivers live attenuat­ among healthy working adults. This is an option for mon side effects of infuenza vaccination include healthy people up through age 49, especially when soreness, redness, or swelling at the injection site; there is a shortage of inactivated infuenza vaccine. The most common side effects from the nasal infuenza vaccine are a “I don’t need the vaccine. Neurological reactions (Guillian Barre Antiviral medications do not eliminate fu symp­ Syndrome) are also rare (1 in 1 million). Like all medication, “I got the infuenza vaccine before and I still antivirals may have side effects. Consider that infuenza has similar symptoms to other conditions, such as the common cold. Sometimes it may be diffcult to know if you have 196 “I’m not in a high-risk group. To protect friends, your co-workers, your family, and all those yourself, your friends, and with whom you come in contact. Any of these indicate a healthy normal response that may result in some mild discomfort, but this is different from actually getting infuenza. Checklist of a Successful Infuenza Vaccination Campaign fi Identify a facility champion as the Flu Coordinator. This person may want to work with the occupational health staff to combine resources and efforts to establish a facility-wide fu vaccination campaign for Veterans and staff. Increase vaccination events and locations where vaccination is available, and take the vaccine to clinics via mobile carts. While fu prevention primarily focuses on expected to model they have cleaned their hands vaccination and respiratory hygiene, hand hygiene effective hand hy­ prior to touching them. Ignaz Semmelweis in 1847 before affect patients in any type of setting where they scientists had discovered bacteria and the role receive care and can also appear after discharge. Although microbials, massive additional costs for health both performed approximately 3500 deliveries per systems, high costs for patients and their family, year, 600-800 mothers died each year on wards and unnecessary deaths. Infections from infuenza overseen by physicians and medical students, and can result in prolonged illness, extended hospi­ 60 mothers died per year on wards overseen by tal stays, and even death. This Directive incorporates the Joint Commission’s National Patient Safety Goal 15. Physician Ward Midwife Ward • If hands are visibly dirty or soiled, or have been exposed to Clostridium diffcile, health care workers must wash their hands with soap and water Role of Hands in Transmission In the remaining cases, alcohol-based hand rub may be used of Infuenza Virus • Before and after contact with a patient Evidence for the importance of hand hygiene has continued since Dr. A systematic review • After contact with inanimate surfaces and ob­ found that hand cleansing cut the risk of respirato­ jects in the vicinity of the patient ry infection by 16%. Specifcally, hands play a role in the transmission of the infuenza virus when droplets carrying infuenza virus contaminate animate and inanimate objects. It has been shown that a cough or sneeze from an infected person can spread the virus to surfaces 5-6 feet away. A non-infected person touching a contaminated surface can spread the virus to him or herself by then touching his or her eyes, nose, or mouth. Therefore, it is essential to follow hand hygiene guidelines to prevent the transmission of the infuenza virus. Following effective Approach: Hand hygiene is one part of a compre­ hand hygiene practices has long been recognized hensive, measurable program to improve safety by as the most important way to reduce the transmis­ reducing the risk of infuenza and other infectious sion of pathogens in health care settings. In 2004, the Joint Commission added a come to work while ill) is a proven disease pre­ National Patient Safety Goal requiring that accred­ vention strategy. Linking hand hygiene, respiratory ited health care organizations comply with hand etiquette, and vaccination programs will strength­ hygiene guidelines. Methods for measuring hand Fully integrated programs include designated hygiene performance may include use of auto­ leads to address specifc methodologies that ad­ mated systems, direct observation, product use vance a culture of safety. Comprehensive survey of hand hygiene measure­ Within the toolkit, you’ll fnd a myriad of resourc­ ment and improvement practices in the Veterans es. You’ll fnd educational materials Top 5 Hand Hygiene Improvement such as posters, brochures, and links to videos. Interventions Visit the reference folder to read the latest in re­ search and literature on hand hygiene and related topics. A host of monitoring and evaluation sys­ tems are outlined, as well as guidance on promo­ tion of effective hand hygiene policy and practice. The survey covered three content areas of hand hygiene: 1) methods of measuring health care worker hand hygiene compliance, 2) interven­ tions to improve hand hygiene compliance, and 3) Hand Hygiene Resources site-specifc targets for hand hygiene compliance.

Syndromes

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For this edition symptoms 0f parkinson disease discount indinavir 400mg on-line, the Plan has been revised to symptoms ulcer purchase indinavir from india refect new developments in pandemic infuenza preparedness and to medications similar to gabapentin purchase indinavir australia ensure consistencies with best practices medications and breastfeeding buy cheap indinavir 400 mg on line. The enhanced Plan includes a number of technical updates, revisions and additions. Two new annexes, Public Health Measures and Surveillance have been added and several others have been updated. This Plan has a national scope and is intended to provide planning guidance and a record of nationally agreed upon approaches to many of the components necessary for a comprehensive response. Operational details regarding implementation of the response have not been addressed in this plan as it would be more appropriate for that level of detail to be included in each jurisdiction’s plan. These goals will be realized only through the coordinated efforts of all levels of government in planning and preparation. The objectives of the Canadian Pandemic Infuenza Plan for the Health Sector are: To assist and facilitate appropriate planning and response at all levels of government by fi developing, through a federal, provincial and territorial (F/P/T) collaborative process, a national Plan that is acceptable and applicable to stakeholders and that clearly identifes roles and responsibilities; fi developing a Plan that is suffciently fexible to account for the unknown epidemiology of a pandemic and the needs of different stakeholders; fi recommending planning considerations for the appropriate prevention, care and treatment during a pandemic; and fi recommending planning considerations for appropriate communications, resource management and preventive measures to minimize societal disruption from a health sector perspective. To provide a Plan that is reviewed on an annual basis to ensure the incorporation of new developments and to ensure consistencies with best practices. To provide an evaluated Plan that is suffciently clear and comprehensive to ensure operational viability. The frst detailed draft of a plan, then referred to as the Canadian Contingency Plan for Pandemic Infuenza, was completed in 1988; there have been several drafts since then. The latest plan, frst published in February 2004, now referred to as the Canadian Pandemic Infuenza Plan for the Health Sector (the Plan), targets a wide range of people in the health sector who will be involved in planning and responding to an infuenza pandemic; these include health emergency responders, health planners, health care workers, public health laboratories, as well as those involved in the manufacture, registration and supply of pharmaceuticals. However, the primary audiences are the P/T Ministries of Health because the provision of health care and essential services is the jurisdiction of the provinces and territories. Given that an infuenza pandemic is the public health event that is the most likely to have a major national impact, a specifc plan to address this national public health emergency is needed. The Canadian Pandemic Infuenza Plan for the Health Sector is one of several national emergency response plans. The Plan is however focused on the health sector response and therefore is not Introduction 3 designed to address other important issues such as business continuity during a pandemic. As a national plan this document is intended to provide guidance and support planning at the P/T, regional, local and facility level. Each level of government and each health care institution should develop their own pandemic plans that use the overall approach in the Plan but contain more operational details relevant to the specifc site or jurisdiction. The Introduction Section and the Background Section are followed by the Preparedness Section and the Response Section; a Recovery Section is being developed for a later edition of the Plan. The Introduction and the Background Sections provide the conceptual and historical basis for the Plan and highlight overarching principles, such as roles and responsibilities. The Preparedness and Response Sections and pending Recovery Section refect the general principles of emergency response of the Plan. Under this framework, the types of preparedness and response activities needed for comprehensive pandemic planning can be summarized as follows: fi Prevention activities include planning actions to ensure that all existing or known or unavoidable risks are contained. The annual vaccine infrastructure is the building block used to develop the pandemic vaccine response. Implementation of these activities would involve a series of escalating and potentially varying (but harmonized) responses as the pandemic unfolds across the country. Implementation also involves documenting activities and outcomes to determine if a more extensive response is required or if adjustments to the planned response are necessary. These activities involve the organization of post- event activities to ensure restoration of “normal” Interpandemic services and service levels. Dismantling alternative care sites, phasing out alternate care workers, and commencing new services that may be required to address the impacts are examples of these types of activities. Activities would continue until the declaration of the end of the pandemic in Canada and the Interpandemic status is restored. The content of this comprehensive pandemic infuenza plan for the health sector has been organized into components. These components which include; surveillance, vaccine programs, the use of antivirals, health services, public health measures and communications, are frst identifed in the Preparedness Section. In that section, each component is addressed in terms of current status as well as planning principles and assumptions. Checklists of potential planning activities are also included as an annex (Annex A, Planning Checklists). This section is the result of work that began after the frst national meeting on F/P/T and local planning, which was held in January 2000; it is based on the deliberations of a number of pandemic infuenza working groups, as well as the input of other stakeholder groups and organizations. The purpose of this section is to provide information and guidelines that can be used in the development of plans for F/P/T and local management of an infuenza pandemic. The Response Section addresses high-level operational activities for an effective national health sector response, including essential F/P/T coordination. The national working groups and subcommittees addressed specifc issues in the Plan and developed the guidelines and reference documents annexed in the Plan. The original working groups included: Surveillance, Vaccines, Antiviral Drugs, Public Health Measures, Communications and Health Services, with the latter divided into Infection Control, Clinical Care, Non-traditional Sites and Workers, and Resource Management. Each annex was created to address specifc issues related to the overall goals of pandemic planning: frstly to minimize serious illness and overall deaths and secondly to minimize societal disruption among Canadians. The annexes published with the 2004 edition of the Plan were written based on the data available and prevailing beliefs and approaches to pandemic planning at that time. The annexes have been or are in the process of being updated to refect current thinking and advancements in science and planning activities, and some new annexes have also been added to this edition to make the Plan more comprehensive. The Working Agreement is an iterative document that allows for roles and responsibility components to be adapted or added as they are developed. The F/P/T roles and responsibilities, including joint responsibilities as outlined in the Working Agreement 2001, are captured in the current Plan. In general, the roles and responsibilities of the respective jurisdictions are as follows: fi the federal government, through Public Safety and Emergency Preparedness Canada, is responsible for the nationwide coordination of the pandemic infuenza response, including surveillance, international liaison and coordination of the vaccine response. The Ministers of Health may also be involved in planning simulation exercises once plans (national, federal and P/T) are in place. Development of cost estimates and options for decision makers will also be a joint F/P/T responsibility. Introduction 5 fi the P/T governments are responsible for mobilizing their contingency plans and resources. Health emergency response commences at the local level and moves up the line to P/T levels and then to the federal level of government. It is likely that the local public health authorities, through existing or enhanced surveillance, may be the frst ones to detect infuenza in their communities. It is essential that the lines of communication in communities and up the line to the P/T and federal levels are clear and established in advance of a pandemic. It is co-chaired by two public health experts who represent the federal and P/T governments. A pandemic can occur at any time with the potential to cause serious illness, death, and extensive social and economic disruption throughout the world. Experts agree that future infuenza pandemics are inevitable, but the timing and severity of the next pandemic cannot be predicted. Because there may be little warning, contingency planning is required to minimize the potentially devastating effects of an infuenza pandemic. In nature there are 16 different haemagglutinins and 9 different neuraminidases, which are two important surface glycoproteins of the infuenza A virus. Although all 16 of the H types can infect birds, to date only H1, H2 and H3 have been associated with widespread human disease and H5, H7 and H9 have demonstrated the ability to cause human disease. It is important to recognize that as birds are the natural reservoir for these infuenza viruses, occasionally people who have close contact with infected birds will become infected with novel viruses. Not all novel viruses however will evolve into pandemic viruses; nevertheless the pandemic potential of any new virus must be considered. The following conditions are necessary for an infuenza pandemic to occur: fi a new infuenza A virus arising from a major genetic change, i. Historic evidence suggests that pandemics have occurred three to four times per century. In the last century there were three infuenza pandemics (“Spanish fu” during 1918-1919, “Asian fu” during 1957-1958, and “Hong Kong fu” during 1968-1969); these pandemics were separated by intervals of 11 to 44 years. The worst, during 1918-1919, killed an estimated 30,000 to 50,000 people in Canada and 20 to 50 million people worldwide.

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A: studies in pregnant women show no risk; B: animal studies show no risk but human studies are not adequate or animal toxicity has been shown but human studies show no risk; C: animal studies show toxicity symptoms of appendicitis purchase cheapest indinavir and indinavir, human studies are inadequate but benefit of use may exceed risk; D: evidence of human risk but benefits may outweigh risks; X: fetal abnormalities in M-2 humans treatment xdr tb order indinavir 400 mg on-line, risk outweighs benefit treatment 2nd degree heart block generic indinavir 400mg free shipping. Pregnancy risk categories for representative therapeutics are included in Table 1 medicine park lodging discount indinavir on line. Animal studies indicate that tetracyclines can retard skeletal development in the fetus; embryotoxicity has also been described in animals treated early in pregnancy. There are few adequate studies of fluoroquinolones in pregnant women; existing published data, albeit sparse, do not demonstrate a substantial teratogenic risk associated with ciprofloxacin use during pregnancy. In cases for which either ciprofloxacin or doxycycline are recommended for initial empiric prophylaxis. While most vaccinations are to be avoided during pregnancy, killed vaccines are generally considered to be of low risk. Generally, it is best to manage these individuals on a case-by-case basis and in concert with immunologists and/or infectious disease specialists. Antimicrobials in Special Populations Pregnancy Class of Drug category Drug name breast milk Pediatric Oral Dose Pediatric parenteral dose Aminoglycosides C Gentamicin (+) small 3 7. Neonatal doses may be different Note: (2) Pediatric antibiotic doses included in this table represent generic doses for severe disease. Mesa Hills Drive John Lawrence Bailey Building El Paso, Texas 79912-5533 700 East Charleston Boulevard elpaso. These guidelines provide general recommendations for appropriate antibiotic use in specific infectious diseases and are not a substitute for clinical judgment. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in • Cultures: prefer tissue specimens post-debridement and Canada: Foot Care. Onset with persistent symptoms or signs compatible with acute rhinosinusitis, lasting for greater than or equal to 10 days without any evidence of clinical improvement 2. Clinical pearls • Within the first 3 days of therapy, as many as 2/3 of patients will satisfy all clinical stability criteria. The majority of the remaining 1/3 of patients will satisfy all criteria by day 7 of therapy. Clinical features favouring “atypical” bacteria (Mycoplasma or Chlamydophila): gradual onset and presentation, absence of septic shock, non-lobar pneumonia, family cluster, cough persisting more than 5 days without acute clinical deterioration, absence of sputum production, and normal or minimally elevated white-cell count. However, it should be noted that preliminary data suggests patients with influenza pneumonia may not benefit, and could be harmed by adding corticosteroids. If Pseudomonas is isolated, step-down to monotherapy (according to susceptibility data). Consider empiric • Always obtain a culture for: pregnant women; patients with sign and symptoms of pyelonephritis; premenopausal adult females with recurrent cystitis; urological antibiotics* procedure; patients with complicated urinary tract infections. Target peak levels are 10 to 15 mg/L, while target trough levels are less than 2 mg/L. Use as dosing weight is less than ideal body weight dry weight is less than 20% above ideal body weight dry weight is more than 20% above ideal body weight adjusted weight Adjusted weight = 0. For obese pregnant and post-partum patients, use maximum 500 mg dose prior to levels. Use is less than ideal body weight actual body weight is less than 20% above ideal body weight ideal body weight is more than 20% above ideal body weight dosing weight = 0. Use is less than 20% above ideal body weight actual body weight is more than 20% above ideal body weight dosing weight = 0. Recommendations for renal dose adjustment are made according to estimated creatinine clearance (CrCl) calculated using the Cockroft-Gault equation, which is used in practice. Recommendations for renal dose adjustment in the table below are for modifications of the maintenance doses; no adjustments are required for loading doses where applicable. In critically ill patients (ex: sepsis), antimicrobial pharmacokinetics can be significantly altered and unstable potentially resulting in sub-optimal dosing. A pharmacy consultation could be considered to optimize antimicrobial doses in this patient population. Oral Suspension Treatment of invasive fungal infections: 400 mg q12h or 200 mg four times daily for patients unable to tolerate a meal or nutritional supplement Therapeutic drug monitoring may be 6 mg/kg q12h x 2 Accumulation & resultant toxicity of the diluent can occur if CrCl less than 50 mL/min. Obesity: defined as an actual body weight greater than 20% above patient’s calculated ideal body weight. These rashes are usually not allergic and are not a contraindication to the use of a different beta-lactam • the frequently cited risk of 8 to 10% cross-reactivity between penicillins and cephalosporins is an overestimate based on studies from the 1970’s that are now considered flawed • Expect new intolerances. Carbapenems would be a reasonable option when antibiotics are required in patients with type-1 immediate hypersensitivity reaction to penicillins • Patients with reported Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, immune hepatitis, hemolytic anemia, serum sickness or interstitial nephritis secondary to beta-lactam use should avoid beta-lactams and not receive beta-lactam skin testing, re-challenging or desensitization • Penicillin skin tests can be used to predict penicillin sensitivity and have a 97-99% negative predictive value • Any patient with possibility of type-1 immediate hypersensitivity to a beta-lactam should be referred for allergy confirmation 1,2,3,4 Management of the Beta-Lactam Allergy (Figure 1 & Figure 2) 1. Complete a thorough investigation of the patient’s allergies, including, but not limited to: the specific drug the patient received, a detailed description of the reaction, temporal relationship of the onset of the reaction with respect to when the drug was given, concomitant drugs received when the reaction occurred, the time elapsed since the reaction occurred and tolerability of any structurally related compounds. Due to similarities in their beta-lactam ring structure it has been widely accepted that penicillins, cephalosporins and 5,9,10,11 carbapenems have significant cross-reactivity with other classes of beta-lactams. Therefore, it has been commonly recommended that patients with a severe 9 allergic reaction to one class of beta-lactam antibiotic should not receive any beta-lactam antibiotic. Another study showed that patients with an “allergy” label (to any antimicrobial) in their medical record were more likely to have longer hospital stays, to be admitted to an intensive care unit, to receive more than one antibiotic 36 during their hospitalisation, and to die during hospitalisation. Recent data shows that the rate of allergic cross-reactivity between penicillins and other beta-lactams is much lower than previous 4,5,9,11 estimates. Immunologic reactions to medications are generally classified according to the Coombs and Gell 5,9 classification of hypersensitivity reactions (see table 2). The onset and presentation of the reaction can be used to help classify the reaction and determine whether or not a beta-lactam antibiotic may be 5,9 used (table 2). Type-1, immediate hypersensitivity reactions, are immunoglobulin (Ig) E-mediated reactions and are the only true allergic reactions where the potential risk of cross-reactivity between 5,9 beta-lactams should be considered. Penicillins 20,21,22 Penicillin is the most frequently reported drug allergy and is reported in 5-10% of the population. Studies have shown that between 80 and 95% or more of those patients reporting a penicillin allergy 52 do not in fact have true hypersensitivity reactions and the vast majority of these patients can tolerate 1,10,21,22,23,24,25 beta-lactams. The use of penicillins can be associated with a nonimmediate, nonpruritic, nonurticarial rash in up to 5,26 10% of patients that is unlikely to be IgE-mediated and most often idiopathic or T-cell mediated. While inconvenient, these reactions have not been associated with anaphylaxis and pose no risk of 26 cross reactivity with other beta-lactams. An example is the nonpruritic maculopapular rash commonly seen after the administration of ampicillin or amoxicillin to children suffering from infectious 27 mononucleosis secondary to the Epstein-Barr virus. Cross-reactivity between penicillins (figure 2) may be due to shared common antigenic determinants based on similarities in their core ring structure that is common to all penicillins and/or the side chains that distinguish different penicillins from one another; therefore, cross-reactivity cannot be based on side chain similarities alone. Available literature suggests that the skin test using both major and minor antigenic determinants are roughly 50-60% predictive of penicillin hypersensitivity with a 97-99% negative 4 predictive value. The time passed since the reaction is useful because 50-80% of penicillin allergic patients lose their sensitivity after 5 and 10 years 2,29,30 respectively. Early analysis of cephalosporin use in penicillin allergic patients was complicated by the uncritical 5,9,11 evaluation of “allergic reaction”. This, accompanied with possible penicillin contamination in early cephalosporin 5,9 production, resulted in overestimations of cross-sensitivity. The American Academy of Pediatrics states that the likelihood of a penicillin allergic 53 patient reacting to a cephalosporin with a different side chain is similar to that of a non-penicillin 5 allergic patient. Meanwhile the risk of cross-reactivity may be up to 40% between 3,33 penicillins and cephalosporins with the similar R-group side chains. The authors go on to say: “Warnings against the administration of cephalosporins to patients with unconfirmed penicillin allergy should be removed from electronic medical record systems. The public would be better served by warnings that the use of cephalosporins, particularly third- or higher generation parenteral cephalosporins, is associated with an increased risk of C difficile infection within 38 90 days. A prospective study evaluating the possibility of using alternative cephalosporins in patients with confirmed cephalosporin allergy demonstrated that cephalosporin allergies are not a class effect, and that patients with confirmed cephalosporin allergy can safely receive cephalosporins with dissimilar 37 side chains. Carbapenems Early studies evaluating the risk of cross-reactivity between penicillin and carbapenems found rates upwards of 47%. However, these studies had poor definitions of allergy and variable methods for 9 determining allergy status. Overall, for patients with a history of proven, suspected or possible IgE-mediated reaction to a penicillin; 4.

Hence treatment integrity purchase 400mg indinavir overnight delivery, it seems possible that a change in tractability might occur during the primary school years medicine zanaflex cheap indinavir 400 mg with visa. So symptoms syphilis buy indinavir amex, there was no sign of changing treatment responsiveness during the pre-school years medications known to cause pancreatitis order 400mg indinavir fast delivery. However, it seems to be a different story with the retrospective follow-up of children previously 13 treated with the Lidcombe Program when they were 6–10 years old. One of the children in that report, Participant 4, did not to respond to the treatment, apparently because of compliance issues. In other words, there is evidence that increasing age during the school years is associated with decreasing treatment effect sizes at follow-up. For those 11 children, around half of the treatment effect at follow-up can be accounted for by age at the time of 2 treatment (r =. So, to summarise, verbal response contingent stimulation is suitable and efficacious for pre-schoolers but speech restructuring is usually suitable for adults, and there is reason to believe that responsiveness to verbal response contingent stimulation decreases with age during the school years. A treatment selection model That reasoning can be incorporated into a treatment selection model for school-age children. The model would, with increasing age, have verbal response contingent stimulation becoming progressively less suitable during that time of life, and speech restructuring becoming progressively more suitable. The model suggests verbal response contingent stimulation as a first intervention of choice for school-age children, because it is a simple treatment and does not require a novel speech pattern. The last treatment of choice for school-age children would be the more complicated speech restructuring technique with its associated disadvantages, supplemented with video self-modelling. Considering the clinical importance of the school-age time of life for stuttering, with its apparent changing clinical tractability, it is lamentable that there are no randomised clinical trials to provide guidance for clinicians. The gravity of the situation prompted the editor of an international speech- language pathology journal dealing with school-age children to issue a call to rectify the situation 62 63 urgently, and more than 100 researchers and clinicians endorsed that call. However, some adaptations to the clinical process are necessary when using the Lidcombe Program with school-age children. The language used to present verbal contingencies will be different, as perhaps will the activities for presenting verbal contingencies during practice sessions. One group of Australian, American, and Canadians who use the treatment with school-age children 64 comment as follows: Although school-age children’s interests are often captured by the latest fad toys, we still find that more traditional games, toys, books, magazines, comics and catalogs continue to be useful as stimulus materials. They also recommend that during clinic visits there is open discussion with the child about the types, frequency and wording of verbal contingencies that will be used. They remark that school-age children generally prefer that verbal contingencies not be used in the presence of their peers. They also state that, because reading aloud in class is a routine part of school life, it is often useful to include reading aloud without stuttering as a therapy task. Additionally, they say, token rewards are more likely to be useful with this age group, although tick charts may be sufficiently motivating in many cases. A common source of trouble with adapting the Lidcombe Program to this age group is the limited 64 access parents have to children compared with pre-school age children. The authors of the article suggest that in some cases when it is appropriate an older sibling, grandparent, or relative may be able to contribute to the treatment, providing that such a person attends all clinic visits. The classroom There are several sources of anecdotal and research evidence that implicate fear of speaking in the 65,66,67,68 classroom as a potential issue for stuttering primary school children. A common clinical picture of a school-age stuttering child is one who is quiet and withdrawn, and reluctant to participate in classroom activities, and is constantly anxious about being called on to speak in class. As expressed in 69 an early report: In school, he generally sits in the rear of the class, rarely initiates discussion or answers questions spontaneously, and he avoids most situations which might provoke the slightest fear of stuttering. Even though he may be intellectually superior to most of his classmates, he minimizes his own potentialities, capacities, and gifts by remaining silent and not risking the possibility of a stuttering effect. Accordingly, teachers can be critical personnel in the lives of children who stutter, particularly during the school years. If a stuttering child is anxious in the classroom and feels that it is a dangerous and threatening place, a teacher can make the classroom feel much safer. Participants who were interviewed as young 70 adults made it clear that the importance of the classroom experience extends into adolescence. That paper contained sensible advice to teachers to not suggest to children any techniques for controlling stuttering. Instead, the teacher can confidentially discuss with a child how help might be offered in the classroom, and together they can formulate a strategy for handling the matter. The 70 interview study mentioned previously indicated that such a constructive, individualised approach rarely occurred for the participants. It might be expected that anxiety about reading aloud in class can worsen for children who stutter when the class takes turns to speak. Apprehension about speaking, and quite often physiological signs of anxiety, can build steadily. Such anxiety about an impending classroom speech has featured in 67 interviews of adults recounting school experiences, with this one being particularly informative: If I thought there was a teacher that would randomly pick kids to read or would go down the row and everybody gets a turn, I’d have my mother talk to them and once again explain my situation, so that I did not have to read in class because any time they started that my ears would get hot, I’d start getting nervous, I couldn’t sit still, I just started to sweat, and the only thing I could think about was counting down the time until I had to read. For example, if the child wishes to speak toward the start of the order and has a name towards the end of the alphabet, the sequence of children speaking could occur from the back of the alphabet. Or, the teacher could call on children randomly, with the exception of the child concerned, who is called on at an agreed time. Or if the child is sitting towards the back or the front of the class, the speaking could be done in order of seating position. That review pointed out that many recommendations have been made to call on students to speak early during the class to reduce anxiety. The review points out that there is no direct empirical evidence about the merits of that approach. However, some laboratory experiments of wait-time to speaking with stuttering participants suggest that it is justified. Based on those experiments, the review presents the caveat that the student 72 “should not be the initial speaker, or should not read in the earliest position” (p. A report showed that an anti-bullying school program, involving 4 hours of teaching with manuals and videos, could positively influence peer 74 attitudes and bullying for school-age students who stutter. Another report suggested that a 45-minute presentation about stuttering improved attitudes about stuttering, although participants were 75 adolescent students. Positive results were reported with a 9-year-old boy who included a classroom presentation about 76 stuttering in his treatment, and by speech-language pathologists who gave a classroom presentation 77 as part of treatment for a 10-year-old girl. Some modern resources Some modern suggestions about how teachers might help children who stutter in the classroom are 78,79,80 available. A video production by the Michael Palin Centre in London promotes teacher 81 78 awareness of stuttering, and is available at their website. This video is a useful resource for clinicians who have contact with teachers of children who stutter. Clinicians may also direct parents to it so they can show it to the teacher of their stuttering school-age child. There is reason to consider speech restructuring for adolescents and school-age children, supplemented with video self-modelling. For adolescents, webcam speech restructuring has been shown to be a viable and useful clinical method. For school-age children, there is reason to consider application of a suitably adapted version of the Lidcombe Program. There are some indications that self-imposed time-out may be useful with some adolescents and school-age children. For school-age children, there are indications that syllable- timed speech could be clinically useful. There is an encouraging nonrandomised trial showing that there are benefits from a hybrid treatment of syllable-timed speech and parent verbal contingencies. It seems clear that, for adolescents and school-age children, stuttering reduction is not necessarily associated with anxiety reduction as measured with situation avoidance. Clinical trial data suggest that verbal response contingent stimulation is progressively less suitable during the school years, with speech restructuring becoming progressively more suitable. Teachers are critical personnel in the lives of stuttering school-age children, and there are good reasons to include them in management plans. Two- to six- year controlled-trial stuttering outcomes for children and adolescents.

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