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These predictors are the components of the history and physical exam that will be in the rule to be developed order 2.5 mg prinivil visa just started blood pressure medication. If signiﬁcant components are left out of the prediction rule cheap prinivil 5 mg otc heart attack back pain, providers are less likely to use the rule order prinivil 2.5 mg mastercard blood pressure chart senior citizens, as it will not have face validity for them purchase 2.5mg prinivil with amex blood pressure chart jpg. The predictor variables all must be present in a signiﬁcant pro- portion of the study population or they are not likely to be useful in making the diagnosis. They must be eas- ily understandable by all providers and be clinically important to the patient. Finding people with a genetic defect that is not clinically important may be interesting for physicians and researchers, but may not directly beneﬁt patients. Therefore, most providers will not be interested in this outcome and will not seek to accomplish it using that particular guideline. The persons observing the outcome should be different from those recording and assessing the predictor variables. In cases where the person assessing the predictor variable is also the one determining the outcome, observation bias can occur. This occurs when the people doing the study are aware of the assessment and the outcome and may change their deﬁnitions of the outcome or the assess- ment of the patient. This may occur in subtle ways yet still produce dramatic alterations in the results. The selection of a sample should include the process of selection, inclusion and exclusion criteria, and the clinical and demo- graphic characteristics of the sample. Patient selection should be free of bias and there should be a wide spectrum of patient and disease characteristics. The study Practice guidelines and clinical prediction rules 329 should determine the population of patients to which this rule will be applied. In the Ottawa ankle rules, there were no children under age 18 and therefore initially the rule could not be applied to them. Subsequent studies found that the rule applied equally well in children as young as 12. Studies that are done only in a special- ized setting will result in referral bias. In these cases, the rules developed may not apply in settings where physicians are not as academic or where the patient base has a broader spectrum of the target disorder. A rule that is validated in a spe- cialized setting must be further validated in more diverse community settings. The original Ottawa ankle rule was derived and validated in both a university- teaching-hospital emergency department and a community hospital. If there are too few outcome events, the rule will not be particularly accurate or precise and have wide conﬁdence intervals for sensitivity or speciﬁcity. As a rule of thumb, there should be at least 10–20 desired outcome events for each independent variable. For example, if we want to study a predic- tion rule for cervical spine fracture in injured patients and have ﬁve predictor variables, we should have at least 50 and preferably 100 signiﬁcant cervical spine fractures. A Type I error can also occur if there are too many predictor variables compared to the number of outcome events. If the rule worked perfectly, it would have a sensitivity of 100%, the deﬁnition of a perfect screening rule. However since a sample size of 50 patients without cervical spine fractures is pretty small, the conﬁdence intervals on this would go from 94% to 100%. However if the outcome were possible paralysis, missing up to 6% of the patients with a potential for this out- come would be disastrous. In each of these, the various pre- dictor variables are modeled to see how well they can predict the ultimate outcome. In the recursive-partitioning method, the most powerful predictor variable is tested to see which of the positive patients are identiﬁed. Those patients are then removed from the analysis and the rest are tested with the next most powerful predictor variable. If fewer patients are followed to completion of the study, the effect of patient loss should be assessed. This can be done with a best case/worst case analysis, which will give a range of values of sensitivity and speciﬁcity within which the rule can be expected to operate. This means it must be clinically reasonable, easy to use, and with a clear-cut course of action if the rule is positive or negative. A nine-point checklist for determining which heart-attack patient should go to the intensive care unit and which can be admitted to a lower level of care is not likely to be useful to most clinicians. One way of making it useful is to incorporate it into the order form for admitting patients to these units, or creating a clinical pathway with a written checklist that incorporates the rule and must be used prior to admission to the cardiac unit. For most physicians, rules that give probability of the outcome are less use- ful than those that tell the physician there are speciﬁc things that must be done when a certain outcome is achieved. However, future physicians, who will be bet- ter versed in the techniques of Bayesian medical decision making, will have an easier time using rules that give probability of disease rather than speciﬁc out- come actions. They will also be better able to explain the rationale for a par- ticular decision to their patients. Each of these has a probability that is pretty well deﬁned through the use of experimental studies of diagnostic tests. Ideally this should be done with a population and setting different than that used in the derivation set. This is a test for misclassiﬁcation when the rule is put into effect prospectively. If the rule still functions in the same manner that it did in the derivation set, it has passed the test of applicability. If it takes too long, most providers in community settings will be reluctant to take the time to learn it. They will feel that the rule is something that will be only marginally useful in a few instances. Providers who have a stake in development of the rule are more likely to use it better and more effectively than those who are grudgingly goaded into using it by an outside agency. Value of assessment of pretest probability of deep-vein thrombosis in clinical manage- ment. As part of this testing, the use of the rule should be able to reduce unnecessary medical care. A rule designed to reduce the number of x-rays taken of the neck, if correctly applied, will result in less x-rays ordered. Of course, if there is a complex and lengthy training process involved some of the cost savings will be transferred to the training program, making the rule less effective. Of course, if the rule doesn’t work well, it may lead to malpractice suits because of errors in patient care mak- ing it even more expensive. The model should include all those factors that physicians might take into account when making the diagnosis. The descrip- tion of the outcomes and predictors should be easily reproducible by any- one in clinical practice. There should be at least 10–20 cases of the desired outcome, patients with a positive diagnosis, for each of the predictor variables being tested. The rule should not ﬂy in the face of current clinical practice otherwise it will not be used.
Persons with this skin disease can accidentally spread the virus to other parts of their body 5mg prinivil sale prehypertension medication. Spread can occur by touching or scratching the bumps and then touching another part of the body (autoinoculation) cheap prinivil 5 mg overnight delivery arrhythmia 24. Researchers who have investigated this idea think it is more likely that the virus is spread by sharing towels and other items around a pool or sauna than through water buy cheap prinivil 10mg on line blood pressure medication that starts with an l. After that purchase prinivil 5 mg on-line blood pressure ranges uk, the bumps will begin to heal and the risk of spreading the infections will be very low. Encourage parents/guardians to cover bumps with clothing when there is a possibility that others will come in contact with the skin. Activities: Exclude any child with bumps that cannot be covered with a watertight bandage from participating in swimming or other contact sports. Wash hands thoroughly with soap and warm running water after touching the bumps or discarding bandages. Contagiosum If you think your child Symptoms has Molluscum Contagiosum: Your child may have bumps on the face, body, arms, or legs. Avoid participating in - By touching or scratching your bumps and then swimming or contact touching another part of your body. After the bumps begin to heal, the risk of spreading the infection will be very low. Contact sports or using shared equipment: Avoid sharing towels, wash cloths, uniforms, clothing, or other personal items. It may take weeks to months to regain energy; however, this will vary from person to person. Less common problems include jaundice (yellowing of the skin or eyes) and/or enlarged spleen or liver. Since this virus does not live long on surfaces and objects, you need to be exposed to fresh saliva to become infected. Because students/adults can have the virus without any symptoms and can be contagious for such a long time, exclusion will not prevent spread. Sports: Contact sports should be avoided until the student is recovered fully and the spleen is no longer palpable. Wash hands thoroughly with soap and warm running water after any contact with saliva or items contaminated with saliva. If you think your child Symptoms has Mono: Your child may have a sore throat, swollen glands, Tell your childcare headache, fever, and sometimes a rash. Childcare and School: Less common problems include jaundice (yellowing of the No, as long as the child skin or eyes) and/or enlarged spleen or liver. Sports: Children with an Spread enlarged spleen should avoid contact sports - By kissing or sharing items contaminated with saliva. Call your Healthcare Provider ♦ If anyone in your home has symptoms of mononucleosis. Your child may need bed rest, to drink plenty of water, and to avoid some physical activities. Prevention Wash hands after touching anything that could be contaminated with secretions from the nose or mouth. Mosquito-borne diseases are viral diseases that are spread by infected mosquitoes. The many viruses have the potential of causing serious disease affecting the brain and central nervous system. Removal of potential breeding sites is important in preventing the spread of mosquitoes. Birdbaths, wading pools, dog bowls, and other artificial containers of water should be emptied weekly to eliminate mosquito-breeding areas. Mosquitoes breed in water and artificial containers, especially flower pots, birdbaths, cans, children’s toys, wading pools, tire swings, old tires, or anything that will hold a small pool of water should be emptied or discarded. Rarely, swelling of the spinal cord and brain (encephalitis), inflammation of the ovaries (oophoritis) or breasts (mastitis), and deafness may occur. Other examples of how the virus can be spread is through sharing toys, beverage containers, eating utensils, and smoking materials (cigarettes), and kissing. Exclusion will last through at least 26 days after the onset of parotid gland swelling in the last person who developed mumps. A blood test specific for mumps antibody should be done as soon as possible after symptoms begin. Sometimes, healthcare providers will obtain a second blood test 2 to 3 weeks later. Encourage parents/guardians to keep their child home if they develop symptoms of mumps. Wash hands thoroughly with soap and warm running water after contact with secretions from the nose or mouth. If you think your child Symptoms has Mumps: Your child may have swollen glands in front of and below the ear. Childcare and School: Contagious Period Yes, until 5 days after For 2 days before until 5 days after swelling begins. Call your Healthcare Provider If two or more cases of If anyone in your home: mumps occur in your ♦ was exposed to mumps and has not had mumps or childcare or school, public mumps vaccine in the past. Prevention All children by the age of 15 months must be vaccinated against mumps or have an exemption for childcare enrollment. An additional dose of mumps is highly recommended for kindergarten or two doses by eighth grade enrollment. When a mumps outbreak is identified, exemptions in childcare centers or schools will not be allowed. Students who refuse immunization should be excluded until at least 26 days after the onset of parotitis in the last person with mumps in the affected school or childcare center. Norovirus is often incorrectly called the “stomach flu”, although it is not caused by the influenza virus. In addition, fever, headache, muscle aches, fatigue, and stomach cramps can occur. The illness can be mild to moderately severe with symptoms usually lasting 24 to 48 hours. Spread can occur when people do not wash their hands after using the toilet or changing diapers. People can also get sick by eating food items contaminated during preparation or serving. Person-to-person spread often occurs within families, schools, nursing homes, cruise ships, in childcare settings, and communities. No one with vomiting and/or diarrhea should use pools, swimming beaches, recreational water parks, spas, or hot tubs for 2 weeks after diarrhea and/or vomiting symptoms have stopped. Staff must avoid food preparation when diarrhea and vomiting are present and for at least 3 days after diarrhea and/or vomiting have stopped. Wash hands thoroughly with soap and warm running water after using the toilet and changing diapers and before preparing or eating food. Staff should closely monitor or assist all children, as appropriate, with handwashing after children have used the bathroom or been diapered. In the classroom, children should not serve themselves food items that are not individually wrapped. If you think your child Symptoms has Norovirus: Your child may have watery diarrhea, vomiting, and Tell your childcare fever. Other symptoms may include headache, stomach provider or call the cramps, and tiredness.
Alcohol may exacerbate cough buy discount prinivil 2.5 mg on line blood pressure medication and pregnancy, cold purchase 2.5 mg prinivil visa hypertension foods to avoid, and flu medications may related inhibition of warfarin metab- that risk by enhancing the ability contain aspirin prinivil 10mg without a prescription blood pressure equipment, acetaminophen order prinivil 10 mg mastercard blood pressure low heart rate high, or olism by cytochrome P450 in the liver of these medications to damage the ibuprofen, all of which might con- (Lieber 1994). Alcohol accentuates required to achieve the desired antico- to be enhanced by concurrent alco- the opioids’ sedating effects. Therefore, patients taking possibly by inhibiting first-pass Overdoses of alcohol and opioids are warfarin generally should avoid alcohol. Accord- ulcers or gastrointestinal bleeding and also is oxycodone) are manufactured as ing to a recent survey, 85 percent of unlikely to cause a certain type of inflammation of the stomach lining (i. Furthermore, Given the variety and complexity of a recent scientific panel convened by • For children ages 6 to 12, the alco- observed interactions between alcohol the American Pharmaceutical Associa- hol content should range between and numerous medications, it is diffi- tion (1997) reported that although 0. Finally, con- content should not exceed 5 to 10 rule, people taking either prescription sumers frequently are unaware of the percent. For example, These levels represent only guide- determine whether possible interactions only one in three adults are familiar lines, however, and are not enforced exist. As a result, many con- products as close to these suggestions the desired therapeutic actions of a sumers are not fully aware of the as possible. International Journal of Addictions tion or alcohol-medication interac- Herbal medications currently are 30:1903–1923, 1995. Klinische be potentially dangerous when used sedation, these herbal products may W ochenschrift 57:125–130, 1979. Effects of H-2 receptor antagonists on gastric meal to prevent heartburn symptoms by various natural products have now alcohol dehydrogenase activity. Digestive Disease may lead consumers to believe that been identified (Heathcote and W anless Sciences 36:1673–1679, 1991. New England Journal Alcohol concentrations in these products of M edicine 306:852–854, 1982. The effects of moderate samples using allele-specific oligonucleotides: the following limits on the amount of alcohol consumption, however, have Comparison with phenotyping in hair roots. This response is health problems, such as diabetes and high particularly critical in diabetics taking medications M blood pressure (i. As described patients should be advised to drink alcohol only with in the main article, alcohol consumption, even at mod- or shortly after meals. In addi- to the fact that the symptoms of mild intoxication tion, however, alcohol use may contribute to or exac- closely resemble those of hypoglycemia. Finally, patients sugar glucose in the blood is severely impaired, either using certain diabetes medications (e. Alcohol consumption in dia- Hyperlipidemia betics can result either in higher-than-normal blood sugar levels (i. Alcohol consumption may exacerbate hyper- who have not eaten for a while and whose glucose lipidemia, because the same metabolic alcohol effects resources are exhausted (i. Both hyperglycemia and As a result, the production of certain molecules called hypoglycemia can have serious health consequences. Thus, people with elevated triglyceride lev- the body’s own insulin production (e. Gluconeogenesis, Elevated blood pressure is a risk factor for cardiovas- which occurs in the liver, requires certain compounds cular disease, including heart attacks. These important potential risks associated of those patients, cessation of drinking alone may with even moderate alcohol consumption (i. Furthermore, patients ered when discussing the cardiovascular benefits taking certain kinds of cardiac medications (e. The only Alcohol-consuming diabetic patients should effective treatment to date involves a substance called consider the following general suggestions interferon-α, often in combination with an agent for preventing alcohol-induced hypoglycemia: called ribavirin, and has a cure rate of approximately 40 percent. Heavy alcohol use in patients infected • Never consume alcohol without food with hepatitis C accelerates the rate of liver damage or while in a fasting state. M oreover, heavy alcohol use appears to reduce the number of hepati- • Consume only moderate amounts of tis C-infected people who respond to treatment with alcohol (i. Researchers do not yet know how glasses of wine, or mixed drinks at one alcohol consumption exacerbates disease progression sitting), and drink no more than once and interferes with treatment. Alcoholism: Clinical and Experimental tration decreases enhanced ethanol elimination in 19:1083–1087, 1995. Journal of the American compartment model to assess the pharmacokinet- study of ethanol metabolism. Alcoholism: Clinical Alcoholism: Clinical and Experimental Research 32:117–119, 1998. The terms ‘substance’ and ‘drug’ are used interchangeably throughout this handbook. Desmond Corrigan, Chairperson, National Advisory Council on Drugs, for his permission to quote extensively from ‘Facts about Drug Misuse in Ireland’ and for his comments and support for the handbook Dr. The Steering Committee of the Walk Tall Programme (Substance Misuse Prevention Programme) Gerard McHugh Director, Dublin West Education Centre The Management Committee and Staff of Dublin West Education Centre The Department of Education and Science Teacher Education Section, Department of Education and Science Social Inclusion Section, Department of Education and Science Mary Johnston National Support Officer, Walk Tall Programme Susan Dixon Assistant National Support Officer, Walk Tall Programme The Department of Health & Children for its permission to use the photographs contained in the handbook. Joseph’s Academy, Kildare Don Delaney, Director of Communications, South Western Area Health Board Contents Section Title Page 1 Introduction 5 2 Defining Drug Terms 7 3 Stages of Drug Use 10 4 Slang Terms 15 5 The Epidemiological Triangle of Drug Use 16 6 Why Do Young People Use Drugs? Hopefully it will enable all teachers to become part of our national prevention effort. It is important that the numbers experimenting with drugs be reduced because in doing so the number of regular users reduces and in turn, the number of problematic and/or dependent users can also be reduced. Despite the fact, as the authors point out, that very few human beings can describe themselves as drug free (how many among us have never taken a medicine, drank tea, coffee or a cola drink containing caffeine? More worrying, sin view of the potential for harm, is the fact that most young people not only experiment with the two most harmful legal drugs – tobacco and alcohol – but use large amounts on a regular basis from quite an early age. This poses a huge challenge to those of us who see prevention, not as a universal panacea for “the drug problem” but as one, albeit essential element in our National Drugs Strategy. Recent research shows that programmes which are properly planned and delivered can have an impact on young peoples’ choices about using chemicals to alter consciousness and reality. Like vaccines, they must be reinforced by booster sessions at home and in the out-of-school environment. Effective interventions, such as those which underpin this handbook, can all too easily be undermined by overt and subconscious messages to young people that chemicals are glamourous, fun, life-enhancing and, above all, risk free. School-based programmes have the potential, if used as directed, to foster an environment among young people which allows them to thrive and develop within a knowledge-based, information-led, technological society. It is doubtful if an individual, who is chemically impaired on a regular basis, can develop their true potential and worth in the modem world we now inhabit. The challenge faced by young people and their educators is how to optimise opportunities to avoid chemical impairment, to strengthen each individual’s ability to assess the value and worth of chemical intoxication in their own lives, thereby maximising outcomes which enhance physical and mental well-being. I have no doubt that the enormous work which has gone into this handbook will successfully help teachers and pupils achieve their goals. Desmond Corrigan Chairperson National Advisory Committee on Drugs Introduction rug use and its impact on society is an emotive issue, particularly D where young people are concerned. Much of the debate which surrounds drug issues in Ireland in both the media and at more local, intimate levels is fuelled by a range of misapprehensions, misunderstandings and misinformation. In this climate it can be challenging for those working in schools to ensure that drugs education is properly seen as part of an integrated, holistic approach to a young person’s development based on educational principles, rather than have it informed by divisive, reactionary responses to wider social issues. The aim of this booklet is to provide you with accurate, evidence-based information to promote your understanding of drugs and drug use. The booklet looks at: y Defining drug terms y The different stages or levels of drug use y The epidemiological triangle y Drug facts y Signs and symptoms of drug use y Responses to drug-related scenarios within the school context y The National Drug Strategy and the development of substance use policy for schools y Guidelines for the use of guest speakers y Useful contacts y Sources for further information 5 Introduction This approach is informed by the understanding that if drugs education is to be effective, it needs to be cognisant of the habits and meanings attached to drug use and specifically differentiate between the levels of use and move away from a myopic focus on dependence at the expense of the type of use young people are most likely to experience, directly or indirectly.