Free Scarlet Letter Essays: Puritanistic Elements -- Scarlet Letter es

Puritanistic Elements in The Scarlet Letterâ â Rigidity was the religion drilled by the individuals of provincial Boston, the setting for Hawthorne’s The Scarlet Letter.â It is a result of the convictions of the Puritan religion that Hester Prynne, the fundamental character in The Scarlet Letter, is segregated from the community.â Puritan beliefs are regularly raised in the book.â Although Hawthorne never totally expresses his situation on Puritanism, it appears to be evident that he approves of the religion. The story starts with Hester in prison for adultery.â She is introduced as a solid womanâ€she holds her head high and doesn't attempt to conceal the letter.â She confronts her discipline, and neither the onlookers nor her imply that she is being dealt with unfairly.â It appears to be unusual that everybody would concur upon Hester’s sentence, since everyone seldom concedes to anything.â Because Hawthorne never talks straightforwardly to the peruser about his own sentiments, it must be construed from the characters what he thinks.â Thus, since Hester’s discipline is excused by everybody, it must be accepted t...

Context Clues and Literacy ESL Reading Lesson

Setting Clues and Literacy ESL Reading Lesson One of the principle difficulties of any English perusing abilities class is that understudies will in general turn upward, or even demand looking into, each word they don't comprehend. While this craving to comprehend everything is absolutely commendable, it very well may be harming over the long haul. This is on the grounds that understudies will start to feel burnt out on perusing in the event that they are continually intruding on the procedure to discover another word in the word reference. Obviously, the utilization of tablets may make this somewhat less annoying. Nonetheless, understudies need to understand that perusing in English ought to resemble perusing in their own language. The utilization of relevant intimations can be perhaps the most ideal approaches to improve understudies understanding abilities. Understanding that a content can be comprehended from a general perspective by utilizing logical pieces of information can go far towards helping understudies adapt to progressively troublesome writings. Simultaneously, the utilization of relevant hints can likewise give a methods by which understudies can quickly build their current jargon base. This exercise gives various pointers helping understudies distinguish and use setting to further their potential benefit. A worksheet is likewise included which assists understudies with perceiving and build up the aptitude of logical comprehension. Setting Clues Reading Lesson Point: Increased mindfulness and utilization of relevant understanding signs Movement: Awareness raising concerning the utilization of relevant signs, trailed by worksheet rehearsing logical perusing Level: Intermediate - upper moderate Framework Compose this model sentence on the board: Tom concluded that he frantically required the glockum if he somehow happened to comprehend the problemAsk understudies what they do in the event that they are perusing an English book and don't comprehend a particular word.Ask understudies what they do on the off chance that they are perusing a book in their local language and don't comprehend a particular word.Ask understudies what glockum means.Once understudies have built up that they dont realize what a glockum is, request that they surmise at what it may be.Ask understudies what grammatical feature a glockum is (for example action word, thing, relational word etc.)Have understudies clarify how they showed up at their estimates, which pieces of information did they use?Explain the idea of perusing in lumps for example taking a gander at the content encompassing the obscure word for clues.Show them an article from a propelled level magazine (Wired, National Geographic, The Economist etc.) Ask understudies to recognize the plausible jargon territories that might be utilized in the model article.Explain the significance of actuating jargon by first rapidly looking at the content to be perused. This thought is significant as the cerebrum will concentrate on related ideas therefore setting up the understudy for what is to be perused. Point out that by utilizing these pieces of information (for example lumping, grammatical feature, legitimate finding, jargon enactment), understudies can show up at an a lot more full comprehension of troublesome writings - regardless of whether they don't see each wordHave understudies isolate into little gatherings and complete worksheet. Understanding Clues Derivation - What does the sentence concern? Which words does the obscure word appear to relate to?â Grammatical form - Which grammatical form is the obscure word? Is it an action word, thing, relational word, descriptor, time articulation or something different? Piecing - What do the words around the obscure word(s) mean? How could the obscure word(s) identify with those words? - This is essentially derivation on a progressively neighborhood level. Jargon Activation - When rapidly skimming through the content, what does the content appear to concern? Does the format (structure) of the content give any hints? Does the distribution or sort of book give any pieces of information to what the content may be about? Which words would you be able to think about that have a place with this jargon classification? Make coherent estimates about the importance of the obscure words in the accompanying passage. Jack immediately entered the didot and cleaned the different misturaes he had been utilizing to fix the wuipit. He had regularly imagined that this activity was very yullning. In any case, he needed to concede that this time things appeared to be somewhat simpler. At the point when he completed, he put on his redick and returned to the examination to unwind. He took out his preferred funnel and subsided into the delightful new pogtry. What a fabulous schnappy he had made when he had purchased the pogtry. Just 300 yagmas! What could a didot be? What grammatical form is misturaes? On the off chance that Jack utilized the misturaes to fix the wuipit what do you think the mistraes must be? What could yulling mean? - What grammatical form is frequently utilized with a consummation - ing ? Which equivalent word could be utilized for yulling ? fundifficultexpensive What sort of things do you put on? In view of the above inquiry, what sort of thing must a redick be? Is a pogtry utilized inside or outside? Which words let you realize that the pogtry was modest? What must yagmas be? ClothesCigarette typeType of cash

Starbucks Strategies for Profitability

Starbucks Strategies for Profitability 1. Presentation Significant target of this investigation is to reveal insight into the procedures and endeavors made by Starbuck to take care of its issues identified with gainfulness. So as to do a cautious investigation of interior activities is attempted to have a thought regarding the accomplishment of these activities to come back to a steady pace of productivity development by Starbucks. To have development in benefit Starbucks needs to create upper hand among the opponent firms. Starbucks should consider by and large patterns of industry, with the goal that since quite a while ago run gainfulness development can be guaranteed. Both the inside and outside elements confronted with the firm are broke down independently so as to have a dependable future position. 1.1. Positive Aspects related with Starbucks and Recommended Strategy Starbucks gives sound workplace to its representatives and have itemized and worker well disposed investment opportunity plans. Besides, the significant qualities of Starbucks lie in the alluring shop structure and agreeable shop condition. Starbucks plans to turn into a top espresso outlet at provincial level as well as at universal level. So the technique of globalization will help Starbucks to build its benefit. So as to effectively actualize this procedure execution focuses for supervisors should be set so they are given the motivating force to improve their presentation. 1.2. Goals of Starbucks Clean gracefully of espresso. Make promptly cheerful customers all the period. Give a fantastic work spot and handle pride and each other with deference. Acknowledge decent variety being a significant component in the way we do organization. Utilize the best necessities of value towards the purchasing. Lead decidedly to the towns and our condition, and notice that achievement is critical to our potential achievement. 2. Issues looked by the Firm 2.1. Inner Issues Restricted Product Range: Starbucks offers an item run included single source and roughly thirty items , Coffee machines, propelled sweets, espresso cups, espresso extras card, a put away worth card, espressos, frap-puccino caffeine items, espressos, alcohols, kind of frozen yogurts, sound, distributions, motion pictures, house Starbucks and blessings. Constrained Advantages gave to Employees: Many clashes among laborers have been seen since in different outlets of Starbucks everywhere throughout the world and the fundamental explanation was low-pay and broadened work hours. As the weight of work stays high the representatives feel exhausted and henceforth they think that its hard to keep working at Starbucks. 2.2. Deficient Growth of Alternatives Available At the point when the business was begun there were only 17 bistros however now the outlets are running in 39 countries everywhere throughout the world having very nearly 12,240 outlets. The overall pace of development related with bistros is excessively high when contrasted with that of Starbucks. This reality prompts make a serious nervousness for Starbucks and limits the development openings accessible to the firm. 2.3. Client Relationships The customers of Starbuck are not so much broadened and have a place with practically comparable gathering. Then again it not the situation with other worldwide espresso brands. Another thought is joined with the Starbucks association with their customers. Starbucks is viewed as amazing espresso brand when shopper contemplations are concerned. In the area of Beijing where Starbucks as of late shut an outlet because of ethnic contrasts among producers can likewise be viewed as a danger to the future development of a business. Some progressive enemy of free enterprise activists left the Starbucks turning out to be previous customers, yet furthermore Starbucks and particularly little individuals even not endorsed inside the company’s feel uncomfortable or shops. Due to Starbucks fast turn of events, the maker so dropped its one of a kind accommodation for clients and keeps on being commoditized. Significant Issue Faced by Firm Based on above conversation it is discovered that significant issue for Starbucks is restricted development openings which might be aftereffect of frail client connections. 3. Investigation of Financial Ratios Liquidity proportions: Tells us about the capacity of a firm to pay its momentary obligation commitments. The most usually utilized liquidity proportions are present proportion, fast proportion and income proportion. Current proportion (Cr) = Current Assets/Current Liabilities Current proportion shows that the amount of current resources a firm has so as to have the option to pay its transient obligation. For the year 2009 Cr =403.60/309.30 = 1.30 For the year 2010 Cr =476.10/318.50 = 1.49 End: The present proportion is 1.30 in the year 2009 which shows that the firm had current resources of $ 1.30 so as to pay risk of $1. In the year 2010 the firm had $ 1.49 to pay the risk of $1. The improvement in current proportion is demonstrating that the situation of firm as present advantages for money its obligation has been improved. Snappy proportion ( Qr)= (Current resources Inventory-Prepaid)/current Liabilities Snappy proportion shows that the amount of convertible resources a firm has so as to have the option to pay its momentary obligation. For the year 2009 Qr =403.60-119.20-44.30/309.30 = 240.3/309.30 = 0.77 For the year 2010 Qr = 476.10 115 †47.30/318.50 = 313.8/318.50 = 0.98 End: The present proportion was 0.77 in the year 2009 which shows that the firm had convertible resources of $ 0.77 so as to pay risk of $1. In the year 2010 the firm had $ 0.98 to pay the risk of $1. The improvement in snappy proportion is showing that the situation of firm as convertible advantages for money its obligation has been improved. Money proportion (Chr) = Cash/Current Liabilities Money proportion shows that the amount of money a firm has so as to have the option to pay its momentary obligation. For the year 2009 Chr = 54.50/309.30 = 0.17 For the year 2010 Chr = 76.70/318.50 = 0.24 End: The money proportion was 0.17 in the year 2009 which shows that the firm had money of $ 0.24 so as to pay obligation of $1. In the year 2010 the firm had $ 0.24 to pay the obligation of $1. The improvement in real money proportion is demonstrating that the firm has more money to take care of its obligation has been improved in 2010 when contrasted with 2009 which is a decent sign for Starbucks. Influence Ratios: These proportions educate us regarding money related structure of organization. The wellsprings of fiancã © of a business are appeared by influence proportions. It shows the segments of obligation financing, value financing and self financing of a firm. Obligation to value proportion = Total Debt/Total value. It shows the parts of obligation and value in firm’s capital structure. For the year 2009 (DEr) = 1827.80/ - 1033.60 = - 1.76 For the year 2010 (DEr) = 1783.10/ - 696.40 = - 2.56 End: negative estimation of value is demonstrating that the estimation of an advantage used to make sure about an advance is not exactly the exceptional equalization on the advance. The estimation of advantages is far beneath the extraordinary parity on the credit used to buy those benefits which is indication of conceivable monetary misery of the firm. Obligation to value proportion is more noteworthy than 1 demonstrating that the part of obligation is a lot higher than that of value in firm’s capital structure. The obligation segment has been diminished in 2010 when contrasted with 2009. Obligation to resource proportion (DAr)= Total resource/Total resources. It shows the amount of firm’s resources are financed through obligation for example parts of obligation and value in firm’s capital structure. For the year 2009 ( DAr) = 1827.80/794.20 = 2.30 For the year 2010 (DAr) = 1783.10/1086.70 = 1.64 End: The proportion of 2.30 in 2009 is indicating that segment of obligation in all out resources is right around more than multiple times that of value. Anyway this proportion is diminished in 2010 which is indicating that value level of obligation has been diminished in firm’s capital structure when contrasted with 2009 which is a decent sign for this firm as there is a danger of monetary pain and liquidation related with elevated levels of obligation trouble. 4. Conclusion of Firm Performance Benefit Ratios: Profitability proportions mirror the exhibition of an organization it shows that whether firm execution is improving or weakening. Profit for Assets = (Net benefit/absolute resources) * 100. This proportion shows that how much benefit is being created by firm’s resources or what is the commitment of firm’s all out resources in its gainfulness. For the year 2009 ROA = (48.80/794.20) * 100 =6.14 % For the year 2010 ROA = (327.30/1086.70) * 100 = 30.1 % End: ROA of 6.14% in the year 2009 is demonstrating that each $ 100 contributed creates $ 6.14 as benefit. ROA has been improved in the year 2010 as now each $ 100 contributed will create 30.1 as benefit. So the productivity is improved in the year 2010 which is a decent sign. Net Profit Margin = Net Profit/Sales It mirrors the measure of every deal dollar left over after the sum total of what costs have been made. This proportion enables an organization to decide how much real benefit is produced using every deal earned. The higher the net overall revenue, the better the organization is doing at transforming deals into benefit. For the year 2009 NPM = (48.80/1295.90) * 100 = 3.7 % For the year 2010 NPM = (327.30/1321.40) * 100 = 24.76 % End: Net overall revenue has been extraordinarily expanded in the year 2010 when contrasted with that of 2009 which is a solid positive sign. The improvement might be a direct result of solid deals or diminished expenses and overhead. Based on above determined proportions it very well may be inferred that general money related situation of the firm has been improved in 2010 when contrasted with 2009. Anyway there is high danger of money related misery because of overwhelming obligation trouble. 5. Answers for Issues looked by Starbucks Changing related with an outside air of the association prompted cause different issues identified with the business and added to the end of the shops of the association inside the USA. These issues are predominantly identified with the busin

Professional Development Plan Essay

Part IA: Description of Personal and Professional Goals From an early age, I was urged to go to school by my folks, my grandparents, and a darling uncle. They all instructed me that acquiring training, especially an advanced degree, was a benefit that had not generally been stood to ethnic minorities and that it ought not be underestimated. They likewise instructed me that training was the most ideal approach to achieve incredible achievement, regardless of how I decided to characterize achievement. It did, notwithstanding, take some time before I completely comprehended what they so enthusiastically endeavored to ingrain in me. It was not until I started working at Johnson C. Smith University (JCSU), in a situation of the scholarly community, that I comprehended the worth and significance of training, and the unfathomable effect that being a piece of a learning domain has on a youthful psyche. I have been blessed to have the option to use the administration aptitudes I gained from my undergrad examines and through different work openings in the wake of acquiring a master’s qualification in business organization. I have made the most of my encounters working in the business field, as various as they have been, and couldn't want anything more than to show business organization at the college level. I might want to seek after a Doctor of Business Administration (DBA) degree so I might be viewed as an authority inside the business field and potentially educate at JCSU as an assistant teacher. In the long run, both my degree and my encounters will help me in accomplishing the drawn out objectives that both my better half and I portion of working a non-benefit association for kids and a revenue driven security business. Our consolidated objectives are sweeping and our longing to see them achieved is energetic. I appreciate overseeing individuals, occasions, and ventures. I have found that I appreciate and am truly adept at structuring and executing plans that make it simpler for others to accomplish theirâ objectiveâ€which is at last the meaning of the executives. That is the reason I wished to structure my own focus inside Walden University’s doctoral program that will consolidate money related administration and authority ability courses. I likewise wish to at the same time get my affirmation as a Six Sigma Black Belt. As indicated by the American Society of Quality (2008): A Black Belt ought to exhibit group administration, comprehend group elements and appoint colleague jobs and obligations. Dark Belts have a careful comprehension of all parts of the DMAIC model as per Six Sigma standards. They have fundamental information on Lean venture ideas, can distinguish non-esteem included components and exercises and can utilize explicit apparatuses. (para. 1) The Walden University results for graduates that I accept are generally pertinent to my expert objectives as a DBA competitor are to: comprehend and persistently create and change themselves, the associations wherein they work, and society everywhere; make new information devoted to the improvement of social conditions, and to decidedly affect society by trying that information, by displaying their learning through activity, and by being communally drawn in; . . . accomplish proficient greatness as dynamic and persuasive experts by applying their figuring out how to explicit issues and difficulties in their work settings and expert practice; . . . [and] practice in their expert fields legitimately and morally. . . . (Walden University, 2008c) These results are straightforwardly lined up with my expert and individual objectives. Due to the way wherein Walden University has decided to develop experts and the notoriety it has in the e-learning condition, Walden was my first decision in training choices. Part IB: Outline and S.W.O.T. Examination Qualities I have a few qualities that I accept will be instrumental in getting a Doctor of Business Administration degree. Two incredible qualities are the fruition of my bachelor’s and master’s degrees. The two degrees are in regions of business in which I have extraordinary intrigue, and that intrigue has developed with each new expert position that I have gotten. Following finishing my bachelor’s qualification, I filled in as a monetary administrations specialist (ESW) for the West Virginia Department of Health and Human Services. Iâ worked intensely with monetary examination so as to decide the qualification of candidates for state and government programs. I appreciated the money related examination side of the position yet couldn't bear seeing the massive neediness of the customers I served in West Virginia. This position carried light to both a quality and a shortcoming that I have. I really appreciate helping other people and working with funds and financial plans. Be that as it may, I have a soft spot for empowering people to proceed in their situation by accomplishing for them as opposed to helping them accomplish autonomy. During the time that I functioned as an ESW in the West Virginia government assistance framework, I was really an empowering agent. I was provoked to leave the situation consequently. I found extra qualities in finding out about morals and consistence in business in my next expert situation, as I stirred my way up to the situation of director in a consistence call focus. I profited by extraordinary language aptitudes and got extra altering and administration abilities. This position likewise expanded my enthusiasm for consistence, especially in accordance with companies and their accounts. These interests will no uncertainty largy affect my doctoral examinations. The call community the board position showed me priceless aptitudes in overseeing individuals of different personalities and figuring out how to be imaginative in getting results from a various gathering of people. I acquired incredible time the executives and emergency the board aptitudes also that I keep with me and that have molded my authority abilities. It is these aptitudes that I would like to instruct to other youthful business pioneers, notwithstanding important business abilities. In my ebb and flow position as an awards chief and improvement official, I complete research on a regular reason for workforce and staff who wish to compose awards that are harmonious with the university’s key arrangement. These exploration abilities will most certainly be important during my doc toral investigations. Furthermore, the exploration assets available to me will be an extraordinary resource. Backing from loved ones is basic and it has been given to me genuinely. It is from this help I much of the time draw quality. In any case, my essential explanations behind not permitting annihilation to overwhelm me when it could have in the past are my two children. They are my most valuable achievements, and I will see them prevail in their fantasies by ingraining in them the guarantee of instruction that was imparted in me by my family. Shortcomings Measurable Analysis has consistently been my least most loved business course. Each time I have endure Statistical Analysis with a splendid evaluation, but since I have not aced it, I despite everything dread it a bit. I realize that I should call upon assets at the college where I work for coaching help during my doctoral program with expectations of at last acing Statistical Analysis. It is my craving to get settled and capable with measurable apparatuses on the grounds that it will be significant for both my scholastic and expert movement. To be effective in my quest for a doctoral certificate, I should limit my inclination to over-burden my plate with undertakings since I can do it, realizing beyond any doubt I don't have the opportunity. At my present work environment, I am called upon often to do things like fix a basic issue with the division printer or a PC, run reports, or complete an authoritative errand since I can complete it immediately, despite the fact that it might be somebody else’s duty. Despite the fact that my aims are decent, I am empowering others not to perform and am upsetting my own endeavors. Rapidly recouping from blunders caused will to likewise be a need. I can't stand to brood over disappointments since it doesn't profit my advancement in any way. Rehearsing these adjustments in mindfulness will be no simple assignment for me. Openings With a master’s qualification and now a doctoral certificate in my future, open doors are plentiful. I am hopeful, even in this present economy with outrageous joblessness, that in the event that I don't get an advancement at the college where I as of now work, I may in any case have a future in a scholastic setting. It is my craving to carry quality upgrades and more noteworthy greatness to Johnson C. Smith University, yet the suggestion that I am right now creating with respect to a division of value and greatness is a model that will work in most scholastic settings. The chance to finish look into that might be distributed is additionally a chance since I work in the scholarly community and on account of the idea of my activity as an improvement official. I have had one piece distributed in JCSU’s quarterly magazine, and it is my longing to have an article distributed in an academic diary through associations with the college. Our ebb and flow college president empowers insightful composition, and when offered theâ opportunity to compose, regardless of whether for look into or for propelling my monetary position, I will hold onto it. Whenever allowed to proceed down my present work way, I accept there will be open doors for partnerships, which are painfully required. The American Association of University Women, the National Black MBA Association, and the American Management Association, all offer one of a kind partnership chances to individuals who have put forth a concentrated effort and show greatness in their calling. Dangers The open door for cooperations is critical in my push to acquire a doctoral certificate in light of the fact that monetary obligation from subsidizing my training is mounting. Incidentally, the college where I work doesn't offer any sort of educational cost help toward an advanced education. It is my expectation that I can replace future credits with associations from one of the associations me

Rivotril (Clonazepam) Side Effects

Klonopin/Rivotril (Clonazepam) Side Effects Bipolar Disorder Treatment Medications Print Side Effects of Klonopin (Clonazepam) Knowing When Its Time to Call Your Doctor or 911 By Marcia Purse Marcia Purse is a mental health writer and bipolar disorder advocate who brings strong research skills and personal experiences to her writing. Learn about our editorial policy Marcia Purse Medically reviewed by Medically reviewed by Steven Gans, MD on December 29, 2015 Steven Gans, MD is board-certified in psychiatry and is an active supervisor, teacher, and mentor at Massachusetts General Hospital. Learn about our Medical Review Board Steven Gans, MD Updated on February 17, 2020 LAGUNA DESIGN/Getty Images   More in Bipolar Disorder Treatment Medications Symptoms Diagnosis Klonopin (clonazepam) is typically prescribed to treat conditions like panic disorder, anxiety, and certain types of seizures. It is possible to develop a physical dependence to Klonopin if you take the drug for two weeks or more??. It is for this reason that drug is prescribed with caution and gradually tapered off once treatment is no longer needed. If you have been prescribed Klonopin, you should take the time to educate yourself about the possible side effects, withdrawal symptoms, and symptoms of overdose. Rivotril is the Canadian brand name of the drug. Uses Klonopin is in a class of medications known as benzodiazepines. It comes both in a pill form and as a dissolvable tablet. It has been approved by the Food and Drug Administration to treat certain types of seizure disorders in adults and children and panic disorder with or without agoraphobia (fear of open spaces). Klonopin can also be used to treat alcohol withdrawal, sleeping difficulties caused by antipsychotic drug use, and anxiety related to bipolar disorder or other mood disorders. When combined with opioid drugs or alcohol, benzodiazepines can cause serious side effects. Including extreme sedation, difficulty breathing, coma, and even death. To avoid serious complications, you should let your doctor know about any and all over-the-counter, prescription, traditional, naturopathic, nutritional, or homeopathic medications you may be taking. Side Effects When combined with opioid drugs or alcohol, benzodiazepines can cause serious side effects.?? Some side effects may develop when first stating Klonopin, many of which will resolve on their own as your body begins to adjust to treatment. You should call your doctor if any of these common side effects are severe or fail to go away: DrowsinessDizzinessUnsteadinessProblems with coordinationDifficulty thinking or rememberingIncreased salivaMuscle or joint painFrequent urinationBlurred visionChanges in sex drive or sexual function Less commonly, Klonopin can cause chest congestion, runny nose, shortness of breath, heart palpitations, hair loss, hirsutism (excessive hair growth) skin rash, coated tongue, constipation, dry mouth, sore gums, lymphadenopathy (swollen lymph nodes), and anemia.  ?? If you experience these or any other unusual side effects, call your doctor right away. When to Call 911 In rare cases, side effects can develop rapidly and become potentially life-threatening. Call 911 or seek emergency care if you experience any of the following symptoms:Rash or hivesSwelling of the eyes, face, lips, tongue, or throatDifficulty swallowingShortness of breath and wheezingHoarsenessDisorientationRapid or irregular heartbeatNausea or vomitingA feeling of impending doom These are all symptoms of a severe, all-body allergic reaction known as anaphylaxis. If left untreated, anaphylaxis can lead to respiratory distress, seizure, coma, respiratory or cardiac failure, and death. Withdrawal Symptoms You should never suddenly stop taking Klonopin without your doctors approval if youve been on treatment for more than three months or are using it to control seizures. If you do need to stop, your doctor will gradually wean you off treatment. Some of the more common withdrawal symptoms include: IrritabilityNervousnessTrouble sleeping These symptoms are relatively manageable and will eventually resolve as the daily dosage is decreased. Withdrawal symptoms may last for months, however.?? When to Call Your Doctor Call your doctor immediately if you experience any of the following, more serious withdrawal symptoms: Abdominal crampsTingling, burning or prickly sensationsRapid heartbeatLight sensitivitySound sensitivityIncreased sensitivity to touch or painProfuse sweatingMuscle crampsNausea or vomitingDepressionConfusionParanoia or abnormal thoughtsHallucinations Overdose If you think that someone has overdosed on Klonopin, call 911 or go to your nearest emergency room. You can also call Poison Control at 1-800-222-1222 or go to the Poison Control website for immediate advice and assistance. Call 911 for Overdose Symptoms Symptoms of Klonopin overdose include:Clammy skinExtreme sedationPassing outDilated pupilsImpaired coordinationSlowed reflexesTrouble breathingWeak and rapid pulseComa Treatment may involve gastric lavage (emptying the stomach), intravenous fluids, mechanical ventilation, Romazicon (flumenazil) to reverse the sedative effects, and either Levarterenol (norepinephrine) or Aramine (metaraminol) to treat a dangerous drop in blood pressure.

Physician Assistant Pearls My Notes and Stuff!

These are quick notes I take when I attend conferences or find some info that I want to jot down for later. I often do not proof read and I write fast. So please any information you take from here should be carefully cross-checked for accuracy. If you are interested in adding to this leave a note in the comments section! MINIMALIST MEDICINE: Diabetes Mellitus Minimalist approach: Start Metformin 500 bid monitor fasting increase to 1000 bid add amaryl (cheap) or add Januvia Add Actos (cheaper) see where blood glucose is over 6 months if a1c greater than 9.0 consider starting basal insulin start at .2U/kg/day of Glargine titrate up to .5U/kg/day monitoring fasting glucose increase .1u/kg/day until fasting is less than 100 if still elevated need to address bolus insuin start at .1u/kg up to 10 units of Humalog (try pen) at biggest meal of day monitor pp glucose over one week if still high add same dose at next biggest meal of day monitor pp glucose over one week if still high add same dose at next biggest meal of day monitor pp glucose over next week now patient is on: Met 1000 bid Actos 30 qd (address potential side effects) Amaryl 2mg qd (cut this down from 4 mg (1/2 initial dose) when starting insulin or pt is on jauvia if money is not a factor glargine 50 units (or equivalent of .5u/kg/day) Humalog 10 units tid with meals REFER if a1c still 9.0 make sure pt is checking tid blood sugar before breakfast before dinner bedtime NOTES: Efficacy of Metformin is about 4 years after that it becomes less effective for treating chronic type 2 disease If you reduce your calorie intake by 100 Cal. per day you will loose 1-2 pounds per week Post Parandial Goal (2 Hours after meal): less than 150 Pre Parandial Goal less than 100 in reality you will only get a .3-.7% reduction in A1C after adding a drug (if no dietary changes) 80% of after dinner blood glucose is contributed by the liver, stimulated by brain from chewing to produce glucose. 9% A1C liver is not shutting off at night, needs to be addressed by insulin. A1C 9% Post Parandial Glucose is most important Aspirin Therapy Rules: WOMEN: 65 Aspirin Men: 55 Aspirin 10. Proton Pump inhibitor can cause low B12: so check B12 and Check Vitamin D 11. Glargine Insulin only causes a 2.6 lb weight gain at 24 weeks 12. INSULIN GLARGINE INITIATION based 100% on FASTING GLUCOSE LEVELS 80-100 no change 80 decrease dose by 3 100 increase dose by 1 unit per day until fasting Start at 0.2 Units per KG Per Day in a 200 lbs person that is going to be 18U per day or Start at 0.1 Unit per KG per Day keep going up 1 unit per day until you reach about 50 units basal insulin (up to Threshhold of 0.5 Units/kg basal, beyond this point improvement is less. Continue Oral Medicines will need 20-40 % less insulin When adding insulin cut sulfaneureas in 1/2 Tell Patients from the Start that they will most likely need 40-45 Units per day 10. you could give 10-20 units there in the office and send home with regimen they will then titrate up at home and follow up in 3 weeks Now aim for post parandial goal add 0.1 units before largest meal of day up to 10 unitl then start doing this after each meal until PP glucose is consistently less than 150 Weekly Titration of Basal: start biggest meal, 1 week, then next biggest meal, 1 week, then last biggest meal Co-Titration of Basal and Prandial Doses Adjust doses of basal and prandial doses onalternate days (every 3 days) Increase prandial dose by 1 unit to target 2 hourpostmeal glucose level 180 mg/dL Consider reducing carb intake or adjustinginsulin:carb ratio if patient has persistentpostprandial hyperglycemiaContinue 303 protocol to target fasting glucoselevel 80-110 mg/dL 13. Insulin Syrines 1/2 cc or 1cc 14. Can obtain about a 0.5% decrease in A1C for each 0.1-U/kg/day increment in insulin dose Up to a threshold of 0.5 U/kg Beyond this dose, the improvement in terms of A1C decreases is less add a basal insulin analog and asked initially to test his blood sugar level 3x/day Before breakfast Before dinner Bedtime Research clearly shows that achieving good control early on prevents diabetic complications, including nerve, kidney, eye, and heart disease for up to 20 years In general, the sooner insulin is started, the better offthe patient will be in terms of preventing complications Modern insulin analogs and treatment regimens makeinsulin a user-friendly therapy HYPERTENSION Minimalist Approach start pt on Chlorthalidone 12.5 and see how they respond, next titrate up to 25mg then add ace lisinopril titrate up to max then add amlodipine 5mg and titrate up if still not working change amlodopine to labetolol if still not working consider adding bblocker or probably better refer American Heart Association (AHA) recommends you take blood pressure readings in the early morning and evening Otherthoughts: in diabetics ACE First if ace induced cough should change to another class of meicins as arb will not show any benefit for patient, what should we do if they have DM Chlorthalidone is twice as potent as HCTHas longer half life than HCTZ and approaches24 hours More effective at lowering night time bp Most positive diuretic trials have usedchlorthalidone HCTZ most commonly prescribed in U.S. Chlorthalidone should now become ourpreferred diuretic for Rx of hypertension Start at 12.5 mg daily Pt example on 3 meds (Resistant htn) pt on chlorthalidone + ACE + Amlodopine don't add a 3'rd line agent change amlodopine to Labetolol This will work just great!!! MIGRAINE HEADACHES Minimalist Approach: Apply 2 out of 3 rule start with Triptan if no relief add naproxen if no relief try up to 3 differnt triptans never use opioid or bultalbitol for more than 8 days per month develop relief stratisfication may try medrol dosepak if migraine still persists triptan 2x per day for up to 3 days in a row propranolol sustained release first line 10 mg of elavil and titrate up second verapami 180mg qd to start Simplified Diagnostic Criteria: ID Migraine Light sensitivity with headache Nausea with headache Decreased ability to function with headache Any 2 out of 3 = Migraine Migraine should be the default diagnosis for any headache that is brought to the attention of a health care provider EPISODIC NAUSEA AND VOMITING WITH NO OTHER SYMPTOMS THINK MIGRAINE HEADACHES MORE THAN 8 DAYS PER MONTH OF OPOID OR BULTALBITAL AT RISK FOR CHRONIC MIGRAINES TRY 3 DIFFERENT TRIPTANS BEFORE GIVING UP NECK PAIN IS A SYMPTOM OF MIGRAINE THE MORE AEROBIC EXERCISE YOU DO THE BETTER IT IS FOR MIGRAINES MEDS THAT MAY MAKE MIGRAINES WORSE SSRI AMBIEN AND BONE MINERAL DENSITY DRUGS 5% OF WOMEN HAVE MORE THAN 15 MIGRAINES PER MONTH 10. Acutey Use Meperidine (reglan) + dihydroErgotomine IV decrease Narcotics by 10% per week 11. Chronic daily tension type headache is dfined as tension type headache occuring more than 15 days per month 12. Tricylcics are helpful in treating analgesic rebound headaches 13. In Elderly patient with new onset headache temporal arteritis must be excluded check ESR 14. TA treatment is high dose Prednisone 50mg x 4 weeks 15. Pathogenesis of migraine headache is seratonin depletion TIA Therefore, most authorities recommend a non-contrast CT scan be done to exclude a hemorrhage. If the episode is over, and MRI is available, some neurologists recommend it. ACUTE CORONARY SYNDROM FOR ALL PATIENTS AFTER ACUTE CORONARY SYNDROME ASA 325 FOR 30 DAYS THEN CHANGE TO 75 OR 150 MG PLAVIX FOR 12 MONTH AND INDEFINATELY IN VERY HIGH RISK INDIVIDUALS ATORVASTATIN 80 OR ZOCOR 40 LIFELONG BETA BLOCKER (41% REDUCTION IN ACS RECURRENCE) ACE INHIBITOR TRIGLYCERIDES LESS THAN 130 80% RELATIVE RISK REDUCTION IF ALL OF THESE ARE IMPLEMENTED PPI + PLAVIX SEEMS TO BE OK SLEEP: Go to bed at same time every night (try not to alter more than 2 hours or cannot recover) if night shift worker try to stay up till 2-3am on days off and sleep till noon family needs to be on board with plan GERD: pt should not have taken abx, ppi's or bismth within 2 weeks prior to administering the UBT PT should have fasted for at least 1 hour prior to administering the UBT should not use until 4 weeks after eradication of h-pylori not for age less than age 18 RAP SYNDROME:recurrent abdominal pain "The Rule out all possibilities" approach can lead to a spiral of investigations that simply reinforces the impression that some hidden cause has been overlooked and must be unmasked even when the clinician is convinced of the functional nature of the pain. W/up: CBC Urinalysis Stool for occult blood, white cells, culture, and OP Flat Plate of Abdomen to look for constipation abdominal U/S to look for renal gyn or cystic etiologies egd not needed the most convincing method of divesting the parents of this notion is to compare abdominal pain with headache in adults most adults have occaional headaches, and although the cause is rarely associated with any abnormal physical findings or investigations the pain is undoubtedly real and not immagined. Young children are highly suggestible, and parents should refrain from questioning the child about the pain if the child is not complaining. Maybe a trial of fiber and prn laxitives if sxs of constipation. Eneruresis: definition: involuntary discharge of urine after the age of 5 bedwetting alarms: not used in kids under 5, use for at least 15 weeks, dropout rate is 30% Pediatrics: Developemental Milestones: sits and rolls: 6 months fine princer grasp: 9months Stnds and Walks: 12 months Understands one step commands: 12 months Scribles: 18 months Feeds self: 18 months Speaks Short words and phrases: 2 year old Cancer: ALL: get CBC Women's Health: pH Measure Symptoms May Include Possible Infection Action 5.0 or Greater Unpleasant odor Unusual discharge Itching Bacterial Vaginosis (BV) See your doctor for further testing diagnosis 5.0 or Greater Itching Burning Unusual discharge Unusual odor Trichomoniasis (Trich) See your doctor for further testing diagnosis 4.5 Itching Burning Unusual discharge Yeasty odor Yeast Infection 1st time sufferers, Urology: Dermatology: 1. Diffuse Atopic dermatitis and warts on hands and mouth of a 5 year old femal Derm reccomends: imiquimod or aldara nighty to lesions on the mouth efudex 5% cream nightlyto hand warts cimetidine 300/5ml 4 ml tid triamcinalone 0.1% cream applied daily aquaphor on face because triamcinalone 0.1 did not help pt was increased to 2.5% cream on face bid as well as triamcinolone 0.1% ointment on the body's affected areas twice daily. and to continue aggresive emolliation with Vaseline and Aquaphor. 2 month treatement plan Celiac Dz: 1 percent of population Test people based on risk stratification see chart in handout Test with IGA tTG If positive get endoscopy Check vitamin D, Calcium, ANA, LFTs, Hepatitis Serology Dexa scan at the end of one year on gluten free diet Erectile Dysfunction: By the time a man reaches 50 he has a 1 in 2 chance of having some kind of erectile dysfunction Increase you inflow and prevent it from leaving all controlled by the cavernosa nerve Prevention of leakage of blood is controlled by the muscle This is a smooth muscle function problem The nerve that innervates the smooth muscle is controlled by NO The enzyme that makes NO is androgen sensitive NO rapidly degrades The nerve comes between prostate and rectum; people who have had prostate surgery of course are at danger. Testosterone also controls ability to have an erection Test. Level below 200 impacts ability to have an erection Psychological Hormonal (Libido) Neurological Vascular Most common cause of erectile dsfxn was leakage (the blood leaks out and doesnt stay there) Decrease in smooth muscle content and replaced by collagen, rarely is arterial flow the primary cause of erectile dsxn. Prevalence of Comorbidities in Men with ED: HTN has the highest relationship 70-80% When you age and loose that smooth muscle ED and HTN have the exact same prevalence. Look at the graph in the handout The Smooth muscle is what controls the ability of the artery to dilate (AGAIN SMOOTH MUDCLE DSFXN) relaxation is erection, contraction is normal penis how do we get the smooth muscle to do what we want it to do what is should do? 3 drugs available: PDE-5 inhibitors Tedalafil (2-3 hours after ingestion of drug) Food in stomach does not affect absorption of this drug. With Sildenafil 30% reduction in efficacy with food t=1 hour, t1/2 3-5 hours. If you double the dose you can improve the efficacy by 20% but increase side effects Make sure you check testosterone, if pt.s do not get testosterone the patient may not respond. TX for 3 months with androgens. A man who is normal and takes these drugs is only improving his refractory time. When oral drugs fail: inject the smooth muscle: alpha blockers, PGE-I, it is a self-injection, those that utilize it tend to stop but can get a good erectile response. 3rd line therapy is a prosthesis Mechanical device is 4th line therapy Start out at half the normal dose regardless of the med, especially if young 10mg and 50mg for sildenafil. The majority of patients respond at the highest dose. If it is an elderly patient with medical problems go ahead and start at the higher dose. The nitrogen from nitric oxide comes from L-Arginine no studies showing affectivity in ED in Men. Not an OTC amino acid that will warrant TX. Tolerance to PDE-5 inhibitors does not occur. Can get continued worsening of CAD etc. No evidence to show that these work in women. DO NOT PROVIDE ANY IMPROVEMENT IN FEMALE SEXUAL DYSFUNCTION. PT with BPH: put on alpha blockers to treat BPH do not take Viagra until 1-2 weeks after on the drug, if no side effects can take the Viagra. No problem with taking Viagra on a daily basis, besides cost. If you take 2 short acting drugs after 24 hours it is out. If you take long acting drug after 5-6 days it builds up in your body. This can be a problem. Celiac Sprue: (Handout) Develops secondary to antibiotic use (high risk vs. low risk) High risk Clindomycin Amox Cephalasporins Fluroquinolones Acid suppression (PPIs or H2 blockers) 2 fold increased risk IBD Pregnancy Chemotherapy Difficult to culture (why it was called Clostridium difficile) 3 million cases per year in the US (416% increase from 99-2004) 4x the rate of MRSA deaths. Community Acquired. 10-30% Up to 40% no clear antibiotic use Cell cytotoxicity or PCR in low risk individuals Go ahead and start tx with metronidazole while you are waiting to get the results back Dx: Diarrhea Fever Leukocytosis Tests: Toxin EIA, rapid test back in 2-4 hours but low sensitivity GOLD: Tissue culture cytotoxicity: PCR (not yet available) Two step testing: EIA testing for toxin A+B if positive get sell cytotoxicity for confirmation. Testing only performed on symptomatic individuals with loose stools!! TX: (get slides) Metronidazole TID is the gold standard x 14 days, Vanocmycin used in pregnant or breastfeeding or with serious infections (oral Vnco TID) Do not treat carriers will make them worse THEY MUST BE SYMPTOMATIC Severe or Blood Diarrhea (they should all be hospitalized and should all receive Vancomycin: significantly superior to Metronidazole) Colectomy is a last ditch resort CDIFF is only in large bowl. Other Testing: First get stool Then cbc, BUN, Creatinine, Albumin Level Flex sig is not absolutely necessary, but maybe in patients with inflammatory bowel dz. Patients can commonly get symptom again a few weeks or months later: Very common about 20% of treated patients. NOT DO TO RESISTANCE (look at slide for recurrence) Test stool again Can be relapse Can be reinfection Very common in new mothers because such high levels of colonization in infants Post infectious IBS (very common) If recurs and stool is positive Second course of metronidazole no need to switch to Vanco after first recurrence Or probiotics and hydration (ok if patient is looking well, functioning may not need another course of antibiotics) Second and 3rd relapse see handout Stool Transfer (stool donor healthy family member the best) Works remarkably well. Cloristorm? Escalarde? Best pro-biotic Yogurt may provide benefit Probably so much c-diff because of overuse of antibiotics in the community Even a single dose of antibiotics (for example dental prophylaxis is enough to increase your risk) No recommendation for prophylaxis in patients taking antibiotics who have had recurrence, this will only create more of a problem again only treat when people are symptomatic. Menopause: Menopause brain: memory problems during menopause but symptoms resolve after a short period of time after menopause. Hormone therapy reduces sxs by 90 percent Estrogen plus progesterone has to be given to women with uterus do to increase risk of cancer in women with unopposed estrogen on the uterus. Vaginal atrophy will improve, but not as much as topical therapy Prevents colon ca while women are taking it but this does not persist Estrogen causes Kidney Stones! ESTROGEN ALONE: This is for women without a uterus Study stopped early because of increased incidence of STROKE Risk for stroke is low in women who are otherwise health Benefits: Treats menopause sxs Probably ok to take for 5-6 years, it may actually help decrease Breast CA risk but any longer probably bad. MI risk is decreased but there is a stroke risk Estrogen and skin: Not a skin preserving modality Does estrogen therapy help depression: yes a bit compared to placebo. 25-50% reduction of hot flashes with placebo Nonhormonal Pharmaceuticals for Hot Flashes More Effective than Placebo in Randomized, Controlled Trials: Lowest Effective Dose, non-FDA Approved Venlafaxine XR 75 mg/d (37.5 mg/d also effective) Desvenlafaxine 100 mg/d Paroxetine CR 12.5 mg/d; Paroxetine 10 mg/d Fluoxetine 20 mg/d Sertraline 50 mg/d Citalopram 20 mg/d Escitalopram 10-20 mg/d Gabapentin 300 mg tid (up to 2700 mg/d may increase relief) Pregabalin 75 mg bid Clonidine 0.1 mg/d Loprinzi CL,, et al. Lancet.. 2000;356:20592063; [Evidence Level Oncol.. 2002;20:15781583; [Evidence Level A]; Stearns V, et al. J Complimentary Therapy: Efficacy is similar to placebo: Give black cohosh (because of the placebo effect) Other natural ways to stop menopause: Smoking cessation Weight loss really did allow a lot of improvement!! Exercise Lower temperature Weight loss doesnt make much sense if you think of estrogen conversion in fat. SSRI, SNRI, Gabapentin, or clonidine may have a limited role Alternative therapies Treatment of Vaginal Atrophy: Lubricants Eg, KY Jelly , Astroglide , etc, as needed or on a regular basis Replens on a regular basis Local hormone therapies- more effective Estring Vagifem Low dose topical estrogen Cochrane review found ? more risk of endometrial hyperplasia, Premarin vaginal cream .5 gm biw studied for one year Systemic hormone therapy Only indicated if also used for vasomotor symptoms Testosterone in the treatment of low libido: Doesnt seem really any better than placebo Urinary Incontinence: See One Note Vitamin D: See notebook Practice Updates: Best treatment for Neuropathic pain: Checked b12 etc. Pain not well controlled with gapentin The combination of Nortriptyline plus Gabentin are superior to either alone Side effect profile wasnt horrible Consider high dose combination therapy for refractory diabetic or post herpetic neuropathy What can you add to a Statin: (NIACIN unless the patient cant handle it) Ldl less than 100 and HDL less than 50 Ezetamibe (Zetia) 10 mg per day or Niaspan 200mg Early termination of study at 14 months Group that had the best change is the niacin group Extended release niacin Side effects were pretty high ADD NIACIN ER to standard statin therapy as it seems to confer better effect, really increases the HDL Is there a benefit to high rate control in A-Fib Lenient vs. Strict rate control Goal was to get resting HR less than 80 40% of patients needed a BB plus digoxin Bottom line for practice we should target HR from 90-105 resting. There was no value to targeting lower rates and there may be increased risk Is Testosterone safe for men with moderate levels of testosterone deficiency: Example 75 year old man healthy and active want to feel better Topical testosterone gel 1% gel 10gm daily adjusted to 15gm if testosterone level under 500ng (target testosterone) go from 300-1000 normal range (total testosterone) Low normal like 258 Their ability to generate strength was really in the legs the big muscles see the slide Had serious Cardiovascular SEs Cardiac events up 10 fold and Atherosclerotic changes much higher and this is just after 6 months. Big Litany of horrible Cardiovascular SEs Bottom line: testosterone will increase strength bit in this high risk but active men with at worst low normal testosterone levels Several died Blood Pressure for Type 2 Diabetics Intensive control less than 120 in one group Less than 140 in the other group 5 year study average was 120 for aggressive group, and 135 for other group The aggressive management of blood pressure showed no benefit but only side effects: 2x as many bad side effects The Notion of being aggressive in blood pressure management Target should be around 135 for Pt.s with type 2 DM This was a 5 years study could there have been a better outcome with more time Calcium and risk for MI Is it safe to encourage calcium supplementation 500 mg of Calcium over 40years of age Out of 190 studies published 162 excluded They had patient level data on a very small group Mostly in there 70s and mostly white Statistically 30% higher risk of heart attacks in people who took CA No increased risk of stroke or all Cardiovascular outcomes or death For every 100 patients given calcium for 5 years (see slide0 Bottom line: Calcium could increase risk Profoundly flawed study! Should not have been done Give gabapentin and neurotriptaline. Lyrica is a metabolite of Gabapentin (side note). Add Niaspan to patients with low HDL (average dose of Niaspan pushed to tolerance start with 500 QHS trying to get to 2000 QHS) but stop at tolerance. If LFTs increase would stop the Niacin. He denies knowing of a case of hepatic failure on the Statin or significant liver damage. Increases of HDL in 5 points equals a 10point decrease in LDL. Target 98-100 Dont give testosterone if pt.s 300 and above. Testosterone in old men like 80 and above it may be tempting to give a little testosterone, but this is a dangerous pathway. Androgens enhance the risk of prostate CA and a host of cardiovascular events. For men with low range of testosterone we need to follow these levels for example pt. with 150 and low free testosterone. Get to a target level of 300 -400. Patients with type 2 dm aim for 135 Need more data on the Calcium debate Contraception Update: I didnt know eve it must have been something you ate BCP still the most popular method Condoms 10 percent share IUD 3.4 percent DMPA 2% IUD: Has highest satisfaction rate No increased risk of tubal infertility Mirena 5 year Progesterone only Pill had its 50 year anniversary last year 1st pill contained 150 micrograms of estrogen Popularity of extended cycles Quick start First bcp taken on the same day of the office visit Perform pregnancy test Emergency contraceptive given if unprotected sex prior Repeat pregnancy test in 2 weeks Impact on Break through bleeding Use back up method for the first 7 days New Gen: reducing the pill free interval Lybrel 365 days per year 80 percent had no bleeding 60% of people stopped this pill because of break through bleeding Why shorten the pill free interval Reduce the risk for follicular development Reduces sxs during hormone free period New OCP released in August 2010 Wh new Contains estradiol valerate which is converted to estradiol valerate It is a 4 phasic OCP With this pill you have a higher level of breakthrough bleeding The First 4 Phasic Pill It has Dienogest (a new progesterone agent) it is anti androgenic does not have anti mineralocorticoid part Hormonal patch and ring: Patch around since 2001 in 2005 study came out showing 60%higher than the 35mcg ethinyl estradiol OCP Showed 2x higher risk of DVT compared to pill Another study showed no increased risk DO not use in OBESE women with weight of 90KG (not as effective and higher risk) Nuva Ring: Efficacy same as the pill Patients should leave it in for all 3 weeks 90% say it is not an issue during intercourse if it comes out need to put it in under 3 hours, if it is more than 3 hours need to use Condoms for 7 days 2006 the Iplanon DMPA 0.4 pregnancies among 100 women-years Suppresses ovulation Suppresses estrogen production as well Majority of studies show a loss of BMD especially if used prior to age 20 or more than 2-5 years. Black box warning, should really not be used for more than 2 years. Avoid use in women over 35 Ensure adequate calcium intake, exercise and stop smoking In long term users, DXA scan? After you D/C BMD returns to baseline of pregnancies unintended in US Emergency Contraception: 2 options: See slide for dosing of OCPs that can be used as Emergency Contraception using your slide Plan B: take one tab and repeat in 12 hours within 72 hours. Just as effective if you take both pills at the same time!! Alternative to plan B: crazy amount of pills New Addition: ELLA Take one tablet as a single dose approved in August 2010: Able to block ovulation even after the LH starts to peak Has been FDA approved for up to 5 days (120 hours after intercourse) Condom: Get Printed out instructions on how to put condoms on and take them off Help them deal with a reluctant partner DOWNLOAD HANDOUT WITH GREAT INFO Remove IUD when menopausal If pt. is 35 and smoker or CAD need alternative non hormonal method Pt. can be on something like LIBRYL indefinitely there is nothing wrong with not having a Period. SLEEP: Sleep is not something left to be done when there is nothing left to do What factors influence sleep Sleep deficit Circadian clock Sleep pressure = sleep deficit +circadian sleep drive Sleep drive Circadian rhythm runs in a 24:09 hour cycles Very sensitive to light Wake up with no pull to sleep and after lunch post-prandial drive Reaches its peak at around 3 am, and seems to really start building at 10pm Bright light in the evening delays sleep onset Bright light in the morning advances sleep onset at night 1 lux =light from candle at one meter 50 lux is all that is needed to alter circadian phase Melatonin ingested 5-6 hours prior to natural melatonin release will advance circadian drive If you delay the circadian rhythm by 3 hours it screws it all up Genetic Predisposition (owls versus larks) Is it possible to be an owl and a lark? Constant fogginess of sleepiness Interventions: Keep to a fixed wake up time both weekdays and weekends, vacations Lots of bright light exposure, activity in the mornings Avoidance of naps Enforce good sleep hygiene Sleep Hygiene: Schedule Light exposure Distractions (turn off the distractions) THIS IS THE BIG ONE Stimulants Night activities Use of bed for work Clocks Behavioral insomnia of childhood Limit setting disorder Refusal to go to bet or refusal to turn to bed following nighttime awakening Insufficient limit setting by the caregiver to establish appropriate sleeping behavior in child Can be confused with anxiety disorder, PTSD Sticker chart Establish a regular bedtime routing OBESITY: 1 out of 3 kids in California are overweight or obese 20 years ago bagel 140 calories and 3 inches Now 350 calories and 6 inches 55 minutes of walking to get rid of those calories To examine the effects on the prevention of overweight and obesity among Latino children ages 2-5years of age At 4 40% were obese Merged parent training and the addition of physical activity Parenting component FOOD INDUSTRY IS RESPONSIBLE FOR HEALTH CARE COSTS Praise, routines, commands, ignore, setting limits, time out Schedule in: nap time, TV time, meals and snacks, exercise and play time Assigning times: move backward, Plan for childrens speed (kids work at a slower speed) Common mistakes: parents get up to late and put children to bed too late. Children in childcare were protected from obesity compared to those cared for by relatives (probably because of routines) Meal as a family, nighttime sleep, and less TV time (best indicator for lack of obesity in children) DO NOT USE FOOD AS A REWARD or A PUNISHMENT No fruit juice Healthy breakfast Increase to 5 fruits and vegies per day 5 ingredients to avoid (Laminated Card) Sugar High Fructose Corn Syrup Enriched Flour/White Flour Hydrogenated Oils Saturated and Trans Fats No more than 2 hours of screen time per day for 2 year olds and over and 0 time for under 2 5-2-1-0- blast off Pedometers (buy Pedometers for everyone) Have classes in pre-school and family centers Education and Support 55--22--11--0 Blastoff! 0 Blastoff! 5: or more fruit and vegetable servings per day 2: No more than 2 hours of screen time per day p y y for 2 year olds and over and 0 time for under 2 1: year or more of breastfeeding with appropriate foods introduced at Around 6 months. 0: sweetened beverages Blastoff: Move, be active and have fun This is what I need to do: Make a card (Wendy Slusser, MD, MS) 54321 blastoff Wslusser@mednet.ucla.edu (write her and ask for the Spanish and English versions of this) Fast food restaurants still take food stamps Treatment of Depression: Persistence will change somebody from 30% to 80% chance of becoming better Persistence of symptoms is the norm Limbic symptoms of worthlessness helplessness If you ask the patients are you all the way better: they may say no, and that left over lingering part is what affects your quality of life Patients want to see family practice not shrink say we have a consultant What is initial management: Recheck Hp and labs Sig E Caps Sleep interest guilt energy appetite suicidality Tactic: Increase what is working first and then add a second agent Suspect 4-6 weeks to see significant improvement See the patient back in 2-3 weeks and then in another 2-3 weeks Switch agents when facing a non-response after a dose increase Augment with a complementary second antidepressant First start with celexa or Zoloft, if no effect in 4-6 weeks increase the dose, then check again in 4-6 weeks, if no improvement add wellbutrin Consider a more specific agent when residual symptoms are clustered Atypical antiphsychotic (low dose) Buspirone Traditional psychostimilant (ar) modafinil If you ask if anything is left you will see a symptom cluster, having trouble with anxiety or sleep Ok to be on three agents: example Zoloft 50-100 Wellbutrin SR (bupropion is generic) + low dose atypical antipsychotic or buspirone = Concentration/energy is problem2.5 mg of dexophenermine if no response may titrate up to 20mg once daily Mildafonil or armadafonil: Lots of anxiety and trouble sleeping: low dose of smallest pill of atypical antipsychotic. (example dyprexa 2.5 mg? look up dose) Email dr john r sharp PEARL Partnership Empathy Respect And legitimization Emotional Calendar: (have people track their feelings on a colander to see the pattern that they may be developing) Explains seasonal shift Recognize and learn to anticipate periods of increased stress, distress, turmoil and drama Make specific doctor-ly recommendations If counseling does not help then they may have a major depression, it is good to be kind but maybe we are undertreating. After you bump up the dose with one med and no help get rid of that medicine and change to something else Cross taper, go down to 20 then 10 and then stop, simultaneously as you decrease this agent start the next agent and increase the dose of the other agent BOOK : FEELING GOOD (check it out) How long to treat: (dance with the gal who brought you) stay with whatever combination is necessary to achieve remission: clock starts when they are better and then have them stay on it for 6-9 months and then consider tapering. If they relapse consider 6 months 2 years If continued relapse they may need to stay on it Medicines for the Female mind: Depression in women is different in women than in men PICTURE OF MEN AND WOMEN ON SWITCHBOARD Women are 2x as likely to be depressed as men (worldwide) Not only true for major depression but also dysthymic Is life harder for women? Yes Women are more likely to be reumative, to blame problems on their appearance, and blame problems on what people think about them Women more likely to ask for help Women more seasonal depression More somatic symptoms More comorbid anxiety and eating More hypothyroidism More IBS, more headaches, more somatic symptoms of mood More suicidal ideation less suicide PMDD: Not a DSM 4 diagnosis Physical and emotional symptoms that dissipate on the 1st or second day of menstrual cycle Pms is physical symptoms Pmdd is psych symptoms 3-9% of women worldwide Perspective rating scales for 2 months Aerobic exercise Caffeine restriction Calcium supplements may help SSRIs will alleviate PMDD immediately in over 85% of patients Zoloft, Paxil, and Prozac fda approved for PMDD If already on low dose bump up the ssri 2 weeks before period and then go back to low dose for 2 weeks and on and on RX for 12 months and then see if sxs return if it returns put them back on medication Physical sxs improve (no explanation for that) Sexual side effects: Viagra in women can help the sexual side effects of SSRIs Oral contraceptive is also an option for treatment Pregnancy and depression Women are happy when they are pregnant (hell know) pregnancy offers no immunity to depression. 10-16% of women will get depressed during pregnancy Impact of untreated depression in fetal de. Unclear No drugs approved in Pregnant women RISK: We dont think there is any real risk to fetus in first trimester WE WORRY IN THE THIRD TRIMESTER: discontinuation syndrome can affect the baby significantly SSRIs most studied, we would never even consider any other type of med It is a risk benefit ratio All are category C except Paxil, which is now category D: persistent pulmonary htn in infants 1st trimester fine 3rd trimester big worry Pregnancy and ECT Safe and effective without risk to fetus Postpartum Depression and Postpartum Blues: Blues do not need intervention 50-70% Depression 10% Blues: By day 4 goes away Depression: 4 weeks after up to a year If hx of depression at higher risk Marital problems etc. Edinburg Postnatal Depression Scale Fear of being labeled a bad mother Is there a gene, looks like there may be Consider bipolar illness Breastfeeding and Antidepressants: Meds are excreted in breast milk but in much smaller quantities Seems safe, ok to give them SSRIs as long as baby is coming in for regular well child care So say to mom it is OK to continue SSRI but make sure baby comes in for regular check ups Menopause Can use ssris Can give Neurontin (titrate to efficacy, it is generic and therefore cheap} OBESITY: National Weight Control Registry Have to have kept of 30 lbs. of weight loss People on registry have lost 66 lbs. Intensive counseling does work Intensive counseling 10 year follow up showed 34% decrease in DM 2 yr. rct of wt watchers vs self help What happens 2x more likely to lose weight if you tell them they are overweight Motivational interviewing: Miller and Rollnick www.Motivationalinteriewing.com Express empathy Help patient develop the discrepancy Roll with resistance Express confidence that you patient can change On a scale of 1-10 how interested are you in losing weight How confident are you you can achieve your goal, if confidence level is less than 8 ask why Realistic goal is to lose 1-2 lbs. per week At 12 months all began to regain Average weight loss of 9lbs per person in each group Loss of 1 pound requires a deficit of 3500 calories for a week Decrease calories by 500/day 500 per day x 7 days www.thedietplate.com (9-5 dollars on amazon Suggest meal replacement Walking 1 mile is 100 kcal Buy pedometers 30 minutes 2x per day is the same as 60 minutes at one time BOOK THIN TASTES BETTER Key strategies Self-monitoring Stress management Stimulus control Problem solving Social support www.Sparkpeople.com best free diet website drug therapy: bmi 30 pt. with BMI 27 Orlistat: decreases fat absorption dose 120mg tid Low dose is OTC Phentermine: increases norepi can cause htn, only officially approved for 3 months Cost 70 bucks per month Longer use need informed consent Sibutramine taken off the us market Fda declined to approve 3 new obesity drugs Bariatric Surgery Bmi 40 or higher Or 35 or higher with comorbid conditions New recommendation: lap band approved for patients with bmi of 30-34 with one or more obesity related complications 60-70 percent of excess bodyweight is average loss in 2 years, excess body weight is pre-op- ideal body weight See calculation Affects gut hormones in wonderful ways Laparoscopic banding: Average weight loss is 45% excess body weight at 2 years Sleeve Gastrecomy: Safer than bypass More weight loss than the lap band LOOK AT comparison of procedures Long term: 88 % diabetes resolved Mortality decreases in all-cause mortality in surgical group Caring for patients post bypass: Endocrine society guidelines for care after bariatric surgery Anticipate 25 percent weight gain over 10 years Cbc lfts lights glucose and creatinine Iron b12 folate, pth albumin, vit d Check every 6 months for 2 years Bmd annually ANOTHER GREAT SLIDE Motivational interviewing Refer appropriate patients for bariatric surgery Dr. Jane S Sillman What if the provider is obese what do you say to the patient We need to see if chbby doctors or skinny doctors do better No data to support efficacy of one diet type over another, depends on what the patients preferences HCG diet: seems to be very popular Office ENT: Eustachean Tube DSFXN: Tympanogram Saline lavage and nasal steroids Oral corticosteroids Gerd tx Pinch nose closed and valsava against pressure Tx: antibiotics Tubes Hemotympanum: (usually as the result of a trauma) CAT Scan and an audiogram may be 2ndary to a temporal bone fracture. Tympanosclerosis: White plaques on the surface of the TM Sign that there have been infections in the past No treatment unless it doesnt function right Tympanic Membrane Perforation: Oral antibiotics Ear drops to sterilize and prevent infection Dry ear precuations: No swimming Cotton ball 3-8 week period of time usually get full recovery If there is constant inflammation may need Otitis Externa: Anti Psudomonal drops and orals Otowick placement: remove after 2-3 days Malignant otitis very uncommon Any facial nerve weakness is an emergency: high dose antibiotics and possibly surgery Exostosis (surfers ear) Coming when they have pain and loss of hearing Nasal Polyps: Plain films of sinuses are worthless CT is the gold standard: LIMITED CT SCAN of the SINUSES Antibiotics Steroids Sinus lavage Lots of recurrence Nasal Septal Hematoma: Huge buldge at the tip of the nose after a trauma Can develop into a deformity Mucocele: Needle aspiration does nothing for this need to get the duct Oral Leukoplakia: White plaque on lateral aspect of the tongue Tonsillitis: Dont forget to think of a Lymphoma (especially if there is an asymmetry) Peritonsillar Abcess: TAKE HOME: DM Cholesterol: Use Niacin possibly adding etia Pain: use combo of Gabipentin plus neurotriptaline Depression: 1 + 2 + 3 step therapy Peds: Card for weight loss program ENT: possible Lymphoma if asymmetry 2/3 of all opiods given in the world are in the US number one prescribed drug!

Using the Spanish Word Seguro

As a cognate of the English word secure, seguro has most of the meanings of secure as well as a few of its own. It is used most often to refer to safety, security, dependability, and certainly, concepts that overlap. The most common translations are secure, safe, and certain, although others are possible. Seguro Referring to Safety Some examples of seguro as an adjective referring to safety: Segà ºn las estadà ­sticas, el avià ³n es el medio de transporte mà ¡s seguro. (Statistically, the airplane is the safest form of transport.)Los padres quieren saber que son seguros los juegos que està ¡n jugando sus hijos.  (The parents want to know that the games their children are playing are safe.)El hotel cerca del aeropuerto es el à ºltimo lugar seguro. (The hotel near the airport is the ultimate safe place.)Necesito un silloncito seguro para el bebà ©. (I need a safe chair for the baby.)Haz tu casa segura para tu familia. (Make your home safe for your family.) ¿Alguien sabe de una fuente segura de medicina? (Does anyone know of a safe source of medicine?) Seguro Related to Security Seguro is commonly used as an adjective when referring to various kinds of security, both physical and virtual: Sus datos estarà ¡n seguros. (Your data will be secure.)La ciudad tiene una estacià ³n de trenes segura y accesible. (The city has a secure and accessible train station.)Los telà ©fonos mà ³viles ya no son seguros. (Cellphones still arent secure.)La Sala de Situaciones de la Casa Blanca posee sistemas de comunicaciones seguras. (The White House Situation Room has secure communications systems.) ¿Se puede lograr que una ciudad sea segura contra los terroristas que utilizan vehà ­culos como armas? (Can a city achieve being secure against terrorists who use vehicles as weapons?) Other Meanings for Seguro In some contexts, seguro can refer to reliability or trustworthiness: No puedo arriesgar la vida de mis hombres en un plan poco seguro. (I cant risk the life of my men on an undependable plan.)Necesito respuestas seguras porque me muero de nervios. (I need reliable answers because Im dying of anxiety.)La biometrà ­a està ¡ creciendo como mà ©todo seguro de identificacià ³n de usuarios. (Biometrics is in creating as an effective  method of user identification.) Seguro can refer to certainty: La etimologà ­a de la palabra no es segura. (The etymology of the word isnt certain.)No estoy seguro de cà ³mo ayudar a alguien con problemas financieros. (Im not sure how to help someone with financial problems.)Pasaron tres o cuatro minutos, no estoy seguro.  (Three or four minutes passed, Im not sure.) Note again that the meanings above can overlap, and context may be necessary to determine what is meant. For example, one of the  sentence above — Los telà ©fonos mà ³viles ya no son seguros — came from an article about the security of information transmitted over the airwaves. But in a different context, the same sentence might have been referring to whether such cellphones can cause cancer. Seguro as a Noun As a noun, el seguro can refer to a safe place in general, or more specifically as a safety latch or other device that keeps something or someone safe. (In some regions, it can refer specifically to a safety pin.) A seguro can also refer to an insurance policy, especially one covering health or protection for injuries. Muchos alpinistas prefieran los mosquetones con seguros de acero. (Many climbers prefer carabiners with steel screw locks.)El seguro casero se requiere en cualquier prà ©stamo casero. (Homeowners insurance is required for any home loan.)Tiene seguros especiales para que el bebà © se quede fijo a la hamaca. (We have special devices so the baby can remain attached to the hammock.) Related Words and Etymology Words related to seguro include asegurar (to assure, to insure, to secure, to make sure), segurar (a shortened version of asegurar), seguridad (security, safety), and seguramente (securely, surely, probably). Seguro comes from the Latin securus, which had a similar meaning. The most closely related English words are secure, sure, and security, although there is also a more distant relationship with secret (secreto in Spanish). Key Takeaways Seguro is related to the English word secure and usually is an adjective that conveys the idea of safety or security.In some contexts, seguro can convey the idea of certainty or usefulness.As noun, seguro often refers to insurance or a thing that provides for safety.