Wednesday, July 29, 2020

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.

Monday, June 29, 2020

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 (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 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 (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 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!

Friday, May 22, 2020

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.

Tuesday, May 19, 2020

The Effect Of A Mood Disorder On Maternal Behavioral Outcomes

The birth of a baby can provoke a lot of emotions. Mothers particularly can have a range of emotions, including depression. Many mothers experience postpartum â€Å"baby blues†. Baby blues include symptoms of crying, anxiety, mood swings, and problems sleeping for about two weeks (Postpartum, n.d.). However, postpartum depression (PPD) is more severe and long-term. Mothers with postpartum depression experience similar symptoms of baby blues, however these symptoms are more intense and extreme. This disorder not only makes it difficult for them to complete daily care activities for themselves, but also for their baby and others. The purpose of this paper is to investigate the extent and impact of how a mood disorder can influence maternal behavioral outcomes. Background There is sometimes an assumption that mothers from other cultures do not experience PPD. Postpartum depression occurs in 10% to 15% of women who have recently given birth and is not non-existent in other cultures (Surkan, 2013). Rather, this form of depression may be less tolerated, less likely to be discussed, and other cultures may have less resources to help these women. As mentioned earlier, childbirth can provoke a range of emotions. With that being said, cultural standards have put it upon the mother to only experience joy and happiness upon the birth of her child. It may be expected that the new mother know what she is doing and she will be shamed upon for feeling sad or depressed. Furthermore, since theShow MoreRelatedNo Perinatal Mental Illnesses Have Linked With An Increased Risk Of Suicide Essay920 Words   |  4 Pagescauses of maternal mortality in the last two decades and in the perinatal period the rate is not showing any signs of improvement. In 2005 among women age d 15 to 44 years suicide was the fourth cause of death in the US (Mendez-Bustos, Lopez-Castroman, Baca-Garcà ­a, Ceverino, 2013). A 2006-2008 review of maternal death in the UK identified psychiatric disorders and suicide in particular as the leading cause of maternal death. In those same years there were 1.27 maternal deaths per 100,000 maternal deliveriesRead MoreThe Maternal Depression During Pregnancy Essay1120 Words   |  5 PagesMATERNAL DEPRESSION DURING PREGNANCY Sasha Safi 20122595 Notre Dame University PSL 310 Dr. Lara El Khatib January, 7, 2016 MATERNAL DEPRESSION DURING PREGNANCY When pregnant especially for the first time many women inform themselves on things they can do that are beneficial for the growth and development of their baby and things they should avoid or not do since it can be dangerous for their baby such as smokingRead MoreChildhood Illness : A Look At Postpartum Depression1538 Words   |  7 PagesMaternal Mental illness: A look at Postpartum Depression, its new inclusion into DSM-5, and treatment issues Antonella Uribe John Jay College of Criminal Justice INTRODUCTION Sandra was a 26 year old mother of four children who had been married for eight years. She had given birth to her fourth child two months ago, with the help of a midwife. Due to her husband’s recent pay cut, and already difficult financial situation, Sandra did not receive any antenatal or postnatalRead MoreChildren s Mental Health Problems1537 Words   |  7 Pagesworsen. The child may develop Conduct Disorders and also negatively affect their adult life (adult criminality and substance abuse). Treatment is imperative for these children as they are extremely malleable and positive intervention can only help them in the future. Another important aspect to note is parental characteristics and involvement. Children do not develop externalizing behavior isolated. Parents play an immense role in their child’s emotional, behavioral and social functioning. Every uniqueRead MoreCeleste Karr. Mhs 4408. Research Paper. 04/26/17. I Chose1424 Words   |  6 Pagesprevention of d eveloping mental, emotional and behavioral disorders. Being able to identify risk factors in a child s life and their displaying behaviors that may lead to a disorder. The preventive models that can be put in place early on to prevent a cognitive or emotional disorder from forming. To introduce this topic we will first identify what a MEB disorder consists of. MEB disorders are health conditions that are characterized by alterations in thinking, mood, and/or behavior that are associated withRead MoreSickle Cell Disease : African Americans1378 Words   |  6 PagesAmericans Cristina Martinez Nova Southeastern University Sickle Cell Disease on African Americans Sickle cell anemia is an autosomal recessive hereditary blood disorder which causes damage to the cerebrovascular system including important organs such as the spleen and liver due to abnormal red blood cells (Scott Scott, 1999). Sickle cell disorder is caused by mutations in the HBB gene then hemoglobin S and other abnormal beta-globin chains create a rigid consistency that is effortlessly lysed and moreRead MoreDepression And Anxiety786 Words   |  4 Pagesanxiety are common during pregnancy and greatly effect a women’s health behaviors. The impact of women’s mental health on alcohol use is very significant to examine as prenatal alcohol use, which is common and can have serious negative consequences for the evolving fetus. Elevated symptoms of depression and anxiety can increase risk for binge drinking during pregnancy. Alcohol use during pregnancy may be associated with extremely detrimental effects for the developing fetus. Prenatal alcohol exposureRead MoreThe Uk System Is That Of Health Visitors1665 Words   |  7 Pagespregnant and postpartum are assessed and treated promptly (within four weeks and three months) of referral respectively (NICE guidelines, 2014). They are trained to recognize clinical features and risk factors associated with perinatal psychiatric disorder and to promptly refer to perinatal mental health and psychological services. Unlike the US, in the UK midwives are the coordinators of care for all women throughout pregnancy, birth and the postpartum period. During pregnancy they are responsibleRead MoreMother Infant Dyads Completed All Aspects Of The Study Essay2058 Words   |  9 Pageschanges perceptions of mood, skewing the results, and there is not enough women in the study to make a concise prognosis. To assess the mothers’ postpartum psychiatric difficulties the Postpartum Depression Screening Scale (PDSS; Beck Gable, 2000) was used. Prior to treatment, mothers completed a self-report questionnaire packed comprised of the Brief Symptom Inventory (BSI; Derogatis, 1993), the Parenting Stress Index-Short Form (PSI-SF; Abidin, 1995), and the Maternal Self-Report Inventory-ShortRead MorePrevalence Of Depression Among Pregnant Women1465 Words   |  6 Pagesinhibitors are the most popular antidepressants taken during pregnancy. Side effects that could take place from these antidepressants are persistent pulmonary hypertension of the newborn, ADHD, increased chances of spontaneous abortion, and smaller birth size in the infant.3,4 Introduction: When a woman is pregnant it is extremely important that she is physically and emotionally healthy. Depression is a common psychiatric disorder among many people. Depression tends to have a social stigma attached to

Saturday, May 9, 2020

What Everybody Dislikes About How to Write College Papers and Why

What Everybody Dislikes About How to Write College Papers and Why Top Choices of How to Write College Papers An excellent sample should aid in improving your vocabulary. The many years they've spent writing college papers for students give them with the capacity to supply excellent papers. With the many activities that they have on their daily schedules, it can be hard to find the time to all the requisite research and writing. Although modern students are not content with different assignments they must finish, every paper has a critical aim. Buying a research paper sample for college submission is among the options. Our Harvard style papers are also custom written in line with the instructions offered by our clientele. Write down whatever you deem even slightly pertinent to your paper when you're researching. You may have to acquire a term paper in order to provide your teacher a high superior assignment in a timely method. You may possibly purchase essay that's afford able the world-wide-web online website. Our website is just one of the most appropriate for essay help. Instead, writers should consider the folks who are likely to read the essay and quit considering how so many people are reading the essay that's barely readable (quantification a part of the issue but that's for another essay). When you place your purchase, it is going to be assigned to the best writer quickly. You may not discover any sections of your essay online and are sure to find an exceptional and individualized undertaking, compiled by the best writers within the country. There are several essay writing services that think they're the very best, and therefore don't be cheated and check the legitimate collection of the very best. Most Noticeable How to Write College Papers Thus, you will know all that is necessary. To begin with, you should understand how to compose an appeal letter for reinstatement to college for academic dismissal as it's a common issue for a student. You could be thinking about why college students would decide to purchase college papers online when they can do it by themselves. Vital Pieces of How to Write College Papers Not everybody can lead to a paper that's high-quality and that's why an expanding quantity of individuals are attempting to use guide review solutions to ensure the final result would be really well worth it for reading. If you're fighting to compose an essay, you find it possible to either place an order for a wholly new part of work on the topic of your choice or maybe you compose it yourself and then order a re-write or proofreading services. By creating your ideas about your institution's purpose and values concrete, you'll be taking a huge first step toward the introduction of a plan that may lead you to success. While there may be numerous alternatives for you, you have to select the best options that won't make your situation worse. The Fight Against How to Write College Papers There are times that you do your best and even then you're not able to score well in your home tasks. There are times that you chance to have a great deal of school work to be submitted in a short time. As a consequence, you get a good deal of free time and completed homework. It is crucial to look at buying college papers online instead of doing it by yourself. How to Choose How to Write College Papers Make a choice to purchase a paper today to address any problem you've got with writing college researches. When you use our website, you get college papers that were written by qualified writing professional. College paper is a kind of academic assignment where you must prepare a synopsis of a particular subject, analyze a selected topic and consistently express your ideas and arguments. Pick a fascinating topic and develop a significant college paper heading. Regardless of what your reasons are, we're here to supply you with quality, academic writing products, including that paper you are fighting at this time. To begin with, you ought to read essay that's top solutions reviews, which you are going to have the ability to find at our website. So to pick the most appropriate for your requirements solution you've got to observe the best essay composing solution reviews to create the choice. Knowing the legality of the organization you're purchasing the sample paper is paramount. Academic papers need you to determine a specific angle to pursue in writing, which is going to be the basis of the paper. A term paper is a trying nut to crack. You need to make sure that you're in a position to submit the very best research paper possible. Reading samples of response papers is also an additional way by which you can easily discover how to compose a reaction paper to documentary. Nowadays you know which factors reflect the caliber of your college paper. You might expect your paper will probably be of premium quality as well as the guidelines adopted to steer clear of disappointing your professor. The need to produce strong arguments in the paper might not be as easy as non-writers would think. Commonly, essays are demonstrated to be always a remarkable section of the education method of a significant number of nations. The major tuition are likewise less expensive. Some colleges supply you with the very best education that money can purchase. Lies You've Been Told About How to Write College Papers Try to remember, your understanding of the way to compose a very good appeal letter for college can serve you well and it's worth a try, but a lot of appeals are still not profitable. The overwhelming majority of individuals who come to us are hardworking, bright individuals who only require a little expertise. Sometimes you need to let boys believe they'r e the wise ones. You're able to easily depend on us to find essay help as we have a tendency to assist and guide the students with the aid of our professional experts.

Wednesday, May 6, 2020

Similarities and Differences Between the Juvenile Justice...

Running Head: JUVENILE V. CRIMINAL 1 Juvenile Justice System V. Criminal Justice System Ronda Cauchon CJ150-01 Professor Abreu Kaplan University October 9, 2012 JUVENILE V CRIMINAL 2 Juvenile Justice System V. Criminal Justice System In the earliest of times, juvenile offenders were treated the same as adult offenders. They were arrested, placed in custody, tried, as well as, imprisoned in the same facilities that housed adult offenders. Punishment was the primary goal when it came to the handling of either of these offenders, now†¦show more content†¦Juveniles involved in less serious crimes JUVENILE V CRIMINAL 3 such as shoplifting and runaways, have been diverted from court action. Court proceedings for juveniles as well as the records are sealed and not available to the public, while adult criminal proceedings and records are deemed public. Officers also deal with juvenile and adult offenders differently. They have several options when dealing with a juvenile offender; they may release the juvenile with a simple warning, they may also release the juvenile and file a report on the contact they had with them, they have the option to take the juvenile to the police station and make referrals to outside programs like youth services, they may also refer the juvenile to juvenile court intake either with or without detention. In dealing with adult criminal cases the options of officers pale in comparison, they offender is either arrested or released with a warning. Once in custo dy of the police, juvenile are generally released to the custody of their parent or guardians and adult offenders are offered the opportunity to pay bail. Parents in juvenile proceeding have a greater involvement in the trial process where in the adult process; parentalShow MoreRelatedJuvenile And Juvenile Justice System752 Words   |  4 PagesThe juvenile justice system and criminal justice system also known as the adult justice system is two different systems. The juvenile justice system is children who are under the age of 18 years old. After the age of 18, it is considered to be an adult it will enter through the adult justice system. There ate states that allows youth to stay in the juvenile justice system from age 18 until 21. The main differences between the juvenile justice system and criminal justice system is rehabilitation andRead MoreJuvenile vs Adult Justice System Essay989 Words   |  4 PagesAdult Justice v Juvenile Justice System There is no question that if a person is involved in any type of crime they will at some time make their way through the justice system. However, when that person is an adolescent they will go through the juvenile justice system, as an adult would go through the adult justice system. Even though the crimes of each can be of the same manner or hold the same severity the punishment results can differ. The main reason for having the two different justiceRead MoreEssay on Adult Justice System vs. Juvenile Justice System1145 Words   |  5 PagesAdult Justice System vs. Juvenile Justice System Versus CJ150: Juvenile Delinquency Josh Skaggs There are many similarities and differences between the adult and juvenile justice systems. Although juvenile crimes have increased in violence and intensity in the last decade, there is still enough difference between the two legal proceedings, and the behaviors themselves, to keep the systems separated. There is room for changes in each structure. However, we cannot treat/punish juvenileRead MoreJuvenile Vs Juvenile915 Words   |  4 PagesJuvenile v. Adult Corrections Juvenile delinquents use to not face police or a correction system, only the fear and punishment of their families. However, as the juvenile delinquents aged they were faced with harsher punishments, but it was not until the 1800s reformers started looking for ways to teach values and built asylum and training schools. Then the concept of parens patriae occurred to establish the right to intervene in a child’s life when there were issues (Siegel, 2016). The next majorRead MoreCrime And Juvenile And Adult Crimes1019 Words   |  5 PagesIn today’s criminal justice system in the United States, there is a lot of dispute between what the qualifications are for juvenile and adult crimes. Some believe that the only difference is age. Others say it is the severity of the crime. It’s obvious that when adults commit crimes, whether they are a misdemeanor offense or a felony, they pay for it. The confliction comes when a juvenile commits a crime. What exactly determines if they are tried as an adult or a juvenile? Does it vary by state-to-stateRead MoreJuvenile Justice System And Adult Justice Systems1589 Words   |  7 Pagesbe discussing both the juvenile and the adult justice systems. There are several differences between the two systems, which may surprise you. I will be discussing many aspects within the justice systems. These include Terminology, Due Process rights, the process of Arrest to Corrections, Juvenile crime compared to Adult crime, age limits and waivers for the adult system and the different community correctional options, which are available to the offenders. The two systems share many of the same termsRead MoreJuvenile Justice And Criminal Justice1368 Words   |  6 Pages The border between juvenile justice and criminal justice did not endure the juvenile court’s first century. By the 1980s, there was general disappointment with both the means and the ends of normal juvenile justice. As with every other social repair efforts, it is difficult to say whether frustration with juvenile justice was born of erroneous concept or of wretched execution. The administering accepted by justice policy, however, was unmistakable. Juvenile courts began to adopt the sentiment andRead MoreJuvenile System vs Adult System609 Words   |  3 PagesMy thoughts on this subject are pretty limited in reference to the similarities and differences between the juvenile and adult justice systems. What I have known is that in Colorado anyone under the age of 18 is considered a juvenile and if they commit a crime and if they are charged they go to a juvenile facility. Depending on the seriousness of the charge determines if they would be held or released to their parents. I believe their parents must be notified and present when they are advised ofRead More French and American Criminal Justice Systems Essay1169 Words   |  5 PagesAmerican Criminal Justice Systems There many different criminal justice systems in the world today. Some that consists of many of the same policies and some that are considerably different. In the case of France and the U.S. there are a lot of similarities, but I will be focusing on the differences between each of their systems. The aspects that I will be comparing are police, courts, the legal profession, legal education, criminal procedural law, corrections, and juvenile justice and the advantagesRead MoreJuvenile Justice And Its Effects On Society1722 Words   |  7 PagesJuvenile justice is compared in chapter thirteen. In the nineteenth century, there was an increased number of children at risk and chronic poverty. This overall was a general concern because there was an increase of people in the â€Å"dangerous classes†. There was a child saving movement, in which the poor children represented a threat to the moral fabric of society. The nineteenth century was a time where they had a house of refuge. In this house of refuge, they had a society for the prevention of pauperism

Environmental Awareness Among Prospective Teachers Free Essays

Environmental Awareness among Prospective Teachers of Himachal Pradesh Dr. Ajay Kumar Attri Lecturer, Deptt. Of Education, MLSM College Sundernagar, Mandi (HP) ABSTRACT The present study was undertaken to compare the environmental awareness of male and female, science and arts and rural and urban prospective teachers of Himachal Pradesh. We will write a custom essay sample on Environmental Awareness Among Prospective Teachers or any similar topic only for you Order Now The sample comprised 260 (130 male and 130 female) prospective teachers. For the study Environment Awareness Ability Measure (EAAM) was developed and standardized by Parveen Kumar Jha (1998) consisted of 71 items was used. It was found that environmental awareness of prospective teachers of Himachal Pradesh remains almost the same as far as effect of gender, stream and locale is concerned. This may be attributed to the fact that prospective teachers of Himachal Pradesh were studying ‘Education for Human Value, Environment and Human Right’ as a compulsory subject during their B. Ed course. INTRODUCTION: India is one of the first countries where the constitution recognized the need for harmonizing environmental concerns with development. Article 48A specifically directs ‘The state shall endeavor to protect and improve the environment and to safeguard the forest and wildlife in the country’ and Article 51A (g) enjoins upon Indian citizens a fundamental duty ‘to protect and improve the natural. The concept environment can be understood in totally of all components surrounding the man i. e. environment is the sum of all social, biological, physical and chemical factors which compose the surroundings of man. Each component of these surroundings constitutes a resource on which man draws with a view of promoting human welfare. According to a Report of a Conference of African Education at Nairobi (1968) â€Å"Environmental Education is to create an awareness and understanding of the evolving social and physical environment as a whole, its natural, manmade, cultural, spiritual resources together with the rational use and conservation of these resources for development†. CONCEPT OF ENVIRONMENTAL AWARENESS: The issue of environmental awareness is becoming global in nature. It has also drawn the attention of common people as environmental degradation and pollution are causing a serious threat to survival of mankind. There are several factors like thinning of ozone layer, creation of ozone hole, over population of many developing countries, the ever-increasing natural and technological disasters and threat of chemical and radiation hazards are threatening to wipe out the humanity from the earth. There are four major and integrating components of environmental awareness–knowledge, real life situation, conservation and sustainable development. Himachal Pradesh Government is trying to promote the development of an economically and environmentally sound eco-system while endeavoring to improve the living standards of the people in the state. The government is conscious of the intrinsic value of the environment and of ecological, genetic, social, economic, scientific, educational, cultural, recreational and aesthetic values there of further the government of Himachal Pradesh is trying to conserve and enhance the environment and follow a policy of sustainable development. Being aware of its central role in directing the development on a sustainable matrix, it calls upon people of Panchayatiraj, Local bodies, institutions and the organs of state for extending their full cooperation in this effort. REVIEW OF RELATED RESEARCH: The number of research studies has been undertaken by investigators on environmental awareness of students at various levels of education and findings of the same are as: Shahnawaj (1990) found that a very high level of awareness existed on the part of teachers and students and also found that environmental awareness was more in urban groups than in the rural group. Santipapwiwatana (1991) concluded that awareness of students was satisfactory with respect to environment. Gopalkrishan (1992) inferred that children were inspired from nvironmental education. Patel (1994) observed that the male teachers with long school experience of urban area are more aware about the environment education. Vashisht (1995) inferred that the level of awareness was found to be higher in case of boys as compared to girls. Bala (1996) indicated that level of awareness of university students especially university boys were satisfactory with respect to environment. Kumari (1999) fo und that private school teachers were more aware about environment as compared to government school teachers. Sharma (2000) indicated that urban students were more aware about their environment, about forests and environment component as compared to rural students. Owena (2000) concluded that the environmental literacy of urban middle school teachers were almost satisfactory. Thakur (2003) concluded that at primary stage both the rural and urban students are not much aware about environmental situation. Biasan (2005) concluded that both government and private school students have the same level of environmental awareness. Nagra and Dhillon (2006) inferred that Science teachers showed higher environmental education awareness than art teachers. Nagra, et. al. (2007) showed that secondary school teachers showed significant variation in environmental education awareness than elementary school teachers. The male and female secondary school teacher showed significant variation in environmental educational awareness. OBJECTIVES: 1. To find out the significant difference between mean scores of Male and Female prospective teachers of Himachal Pradesh on environmental awareness. 2. To investigate the significant difference between mean scores of Science and Arts prospective teachers of Himachal Pradesh on environmental awareness. 3. To study the significant difference between mean scores of rural and urban prospective teachers of Himachal Pradesh on environmental awareness. HYPOTHESES: 1. There will be no significant difference between mean scores of Male and Female prospective teachers of Himachal Pradesh on environmental awareness. 2. There will be no significant difference between mean scores of Science and Arts prospective teachers of Himachal Pradesh on environmental awareness. . There will be no significant difference between mean scores of rural and urban prospective teachers of Himachal Pradesh on environmental awareness. METHOD AND PROCEDURE: In the present study descriptive survey method of research was used and following method and procedure was used. POPULATION: All the prospective teachers of private B. Ed colleges of Himachal Pradesh constituted t he population of the study. SAMPLE: For the selection of 260 prospective teachers (130 male and 130 female) from the 8 private B. Ed colleges, method of convenient sampling was adopted. VARIABLE STRUCTURE: Gender, Stream and locale constituted the independent variables whereas Environmental awareness was the criterion variable. TOOLS USED IN THE STUDY: Environment Awareness Ability Measure (EAAM) was developed and standardized by Parveen Kumar Jha (1998) consisted of 71 items was used. The value of Reliability co-efficient varies between 0. 61 to 0. 84. It was quite valid as the items in it had already been treated and their content made relevant by incorporating the suggestions of the various experts. RESULTS AND DISCUSSION: To test the hypothesis of the study t-test was performed on the scores of environmental awareness. The summary of the obtained results has been presented in Table-1. It is evident from the table-1 that the ‘t’-value testing the significance of mean difference among the Male and Female prospective teachers was calculated as 0. 15, which is non-significant both at 0. 05 and 0. 01 levels of confidence, which reflects that mean scores of Male and Female prospective teachers of Himachal Pradesh do not differ significantly on environmental awareness. Thus, the null hypothesis that â€Å"There will be no significant difference between mean scores of total Male and total Female prospective teachers of Himachal Pradesh on environmental awareness† is accepted. Thus it may be concluded that Male and Female prospective teachers don’t differ significantly in their awareness toward environment. Table 1 Summary of the Statistical Calculations for Obtaining ‘t’-values with regard to Environmental Awareness among Prospective Teachers of Himachal Pradesh on Gender, Stream and Locale |Group |N |Mean |S. D. |t-value |Result | |(Prospective | | | | | | |Teachers) | | | | | | |Male |130 |44. 20 |4. 52 |0. 15 |Non-significant at | | | | | | |0. 05 level | |Female |130 |44. 12 |3. 91 | | | |Science |130 |44. 8 |4. 88 |0. 44 |Non-significant at | | | | | | |0. 05 level | |Arts |130 |44. 05 |3. 45 | | | |Rural |65 |43. 94 |5. 10 | |Non-significant at | | | | | |0. 66 |0. 05 level | |Urban |65 |44. 46 |3. 87 | | | Further, Table-1 indicates that the calculated ‘t’ value showing the significant difference in the mean scores of Science and Arts prospective teachers came out to be 0. 44, which is not significant even at 0. 05 level of confidence thereby, accepting the null hypothesis that â€Å"There will be no significant difference between mean scores of Science and Arts prospective teachers of Himachal Pradesh on environmental awareness†. Hence it may be concluded that Science and Arts prospective teachers of Himachal Pradesh don’t differ significantly on environmental awareness i. e. they have almost similar awareness toward environment. Table-1 further shows that the‘t’-value reflecting the significance of mean difference among the rural and rural prospective teachers of Himachal Pradesh was calculated as 0. 66, which is non-significant at 0. 05 level of confidence. Thus, the null hypothesis that â€Å"There will be no significant difference between mean scores of rural and urban prospective teachers of Himachal Pradesh on environmental awareness† stands accepted. Thus, it may be concluded from the above interpretation that rural and urban prospective teachers of Himachal Pradesh don’t differ significantly at environmental awareness i. . locale does not show much effect on environmental awareness of prospective teachers of Himachal Pradesh. Thus, on the basis of the conclusions, it is inferred that environmental awareness of prospective teachers of Himachal Pradesh remains almost the same as far as effect of gender, stream and locale is concerned thereby showing that gender, stream and loc ale do not show much impact on their environmental awareness. This may be attributed to the fact that environmental education has become the integral part of school as well as college curriculum. Same is the case with prospective teachers of Himachal Pradesh who study ‘Education for Human Value, Environment and Human Right’ as a compulsory subject. This gives them complete awareness about environment in relation to both stream and sex. Also, our findings get support from the study of Thakur (2003) which reflected that sex groups had equal awareness regarding the environment. REFERENCES: Bala, I. (1996) A Study of Environmental Awareness among University Students, M. Ed. Dissertation, Department of Education, Himachal Pradesh University, Shimla. Biasan, A. 2005) Comparative Study of Environmental Awareness Among Government and Private Secondary School Students in District Kangra of Himachal Pradesh, M. Ed. Dissertation, Himachal Pradesh University, Shimla,. Constitution of India (Part IV Directive Principles of State Policy) †¦ Article 48A Protection and improvement of environment and safeguarding of forests. Gopal Krishan, S. (1992) An Impact of Environmenta l Education on Primary School Children, Fifth Survey of Research in Education (1988-92), Vol. II, NCERT, New Delhi. Kumari, S. (1999) A Study of Environmental Awareness among Elementary School Teachers. M. Ed Dissertation, Department of Education H. P. U, Shimla. Maheswari, B. K. and Sharma, B. L. (2004) Education for Values, Environment and Human Rights. Merrut: Surya Publication, PP. 1-4. Ministry of Education, Government of India (1985) Challenge of education: a policy perspective. Document C06370 Nagra, V. and Dhillion, S. Jaiswinder (2006) Environmental Education Awareness among Secondary School Teachers. Perspective in Education, Vol. 21, No. 3 Nagra Vipinder and Dhillion, S. Jaiswinder (2007) Environmental Education Awareness among School Teachers in Relation to Level and Gender. Perspective in Education, Vol. 3, No. 2 Nairobi(1968), Third Conference of Ministers of Education in African Member States (MINEDAF III) Owena and Marcia, A. (2001) The Environmental Literacy of Urban Middle School Teachers. Dissertation Abstracts International, Vol. 61. No. 4 Patel, Delip, G. , (1994) Environmental Awareness of Primary School Teachers in the Progress of Education, Dissertation Abstract s International, Vol. 58 (10-11), P. 234. Santipapwiwatana, Winyoo (1991), Knowledge and Opinions Concerning Environmental Conservation of Prathomsuksa, Six Students in Amphur, Chaiangkham, Phayao Province, Dissertation Abstracts International, Vol. 2. Shahnawaj, (1990) Environmental Awareness and Environmental Attitude of Secondary and Higher Secondary School Teachers and Students, Fifth Survey of Educational Research, Trend Reports, vol. I, New Delhi: NCERT. Sharma, Rajeshwar. (2000) A Study of Environmental Awareness among Primary School Students, M. Ed. Dissertation, Himachal Pradesh University, Shimla. Vashisht, K. Narinder (1995) A Study of Environmental Awareness among Adolescent Students, M. Ed. Dissertation, Department of Education, H. P. U. , Shimla. How to cite Environmental Awareness Among Prospective Teachers, Essay examples