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By M. Arakos. Corcoran College of Art + Design. 2018.

If there were people you want to get to know better buy discount alendronate 35 mg line, its more probable that theyll have things in common with you best 35mg alendronate. Promote a discussion or list places and ways you can meet new people and make friends alendronate 35 mg free shipping. You dont always have to say what you think buy 70mg alendronate free shipping, but its important to feel that you have that option. You can say things in a nice way that can help resolve situations and maintain the relationship healthy. Use the Weekly Activities Schedule to write down the types of contacts you had with people each day. Write a plus sign (+) if they were positive and a minus sign (-) if they were negative. Before talking about how these three areas are affected by your relationships, its important to evaluate first how they are when you are alone. Also, if you expect little from people, youre not giving them the chance to show you what they can really offer. Present the following information and discuss by relating to the adolescents experience. This is way its important to be able to identify and manage our feelings in a healthy way. For this, its important to: o Recognize how your feel and why youre feeling that way o Communicate in an assertive or appropriate way what you feel o The difference between being passive, assertive or aggressive: Assertiveness = is being able to share positive and negative feelings clearly and comfortably (even if you think the other person wont like what youre saying). Changing your point of view can help you to be more assertive instead of being passive. Examine the adolescents thoughts, feelings and actions in relation to a person with whom he/she has identified interpersonal difficulties. Learning to be assertive and practicing in your mind Exercise: Ask the adolescent to think about a situation with a person with whom he/she has difficulty in being assertive. Provide the following instructions: o Image the situation as if it were a photograph. This exercise is a useful way to rehearse being assertive before actually putting it into practice. Apply the following communication skills the situation discussed in the previous exercise. Active listening When you are talking to someone, listen to what they are saying instead of thinking about you are going to say back or respond. If youre thinking about what youre going to answer, you might miss part of what the person is telling 62 you. People often argue about what somebody said without knowing if that was what the person really wanted to say or express. To improve your active listening and communication skills: Repeat what the other person said in your own words so you can be sure you understood him/her correctly. Instead of saying You (are/always/never) Its better to say I feel /I think. The best times arent when the person is doing something, or there isnt enough time to talk or if youre in the middle of an argument. You can decide to change Before being with other people Thinking differently: To change your feelings towards others, you can decide beforehand the kind of thoughts you want to have when youre with them. After being with other people Learn from your experiences: think about the feelings you had while you were with them. If you use the strategies youve learned here, its less likely that you become depressed again or that you remain depressed for a long time. Contact with others is important for you mood because they can: Share pleasant experiences with you Help you reach your goals Provide you with company and a sense of security Provide you with valuable information about yourself, your strengths and areas to improve 2. When relationships dont work out, it doesnt necessarily mean that something is wrong with you or with the other person. Its helpful to consider the following questions: Do you both want the same thing from the relationship? Remember you always have the option to end a relationship that is not good for you. People can help you feel like a good person, as valuable and with good self-esteem. Closure When you finish the material for Session 12, discuss with the adolescent the following points: 1) Tell him/her that youre finished with the material in the manual. Tell the adolescent that he/she can be present during the meeting if he/she chooses to do so. Offer the adolescent information about his/her participation and progress throughout therapy. You can ask about what the adolescent liked most and least, what helped the most, etc. Offer recommendations in terms of referral to other types of therapy or services if needed. Say the following: As you know, your parents have a right to know how youve been doing in therapy so I am going to have a meeting with them. I am going to tell them about the main areas weve worked on in therapy and about your progress. I am going to tell them youve improved in; that you learned strategies such as. If necessary, Ill tell them there are still the following areas to work on and that I have the following recommendations. Establish an agenda with the adolescent for the meeting with the parents in which you discuss the following: a. The specific information the therapist will share with the parents and the purpose of the meeting. You can tell the adolescent that youre not going to go into specific details about what was said in therapy youre going to talk in general. Ask the adolescent if there is anything he/she doesnt want you to discuss with his/her parents. Ask the parents how they observed their adolescent during and now at the end of therapy. Offer general information about what was worked on in sessions: Explain that it consisted of 3 modules that worked on thoughts, activities and relationships to improve mood. Offer general information on the adolescents progress and participation in therapy. Recognize and reinforce the parents efforts and commitment in getting help for their adolescent.

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Blood transfusion contains enough B12 to correct the marrow and to make interpretation of serum B12 levels difcult purchase alendronate 35mg on-line. It may precipitate heart failure and deathsomeauthoritiesbelievethattransfusionmust never be given to patients with pernicious anaemia 35mg alendronate overnight delivery. In the tropics it is often seen in association with multiple deciencies and with gut infection and infestation order 70 mg alendronate with amex. If sufciently severe safe alendronate 35 mg, vitamin B12 and folate Haemolysis results in increased red cell formation, deciencies produce depression of all the marrow which requires folate more than B12. Phenytoin therapy interferes isusuallysomehaemolysiswitharaisedunconjugated with folate metabolism. Haematology 327 Hereditary haemolytic anaemias Haemolytic anaemia These are caused by defects in the red cell membrane or specic red cell enzyme deciencies. Haemolysis Hereditary spherocytosis is characterised by jaundice with a raised unconjugat- ed serum bilirubin, increased urobilinogen in urine An autosomal dominant disorder that causes in- and stools, increased haptoglobins and reticulocyto- creased osmotic fragility and produces spherocytes sis. There is no bile pigment in intermittent jaundice, which may be confused with the urine (the jaundice is acholuric). Gall- appearanceofchromium-taggedredcellsgivesamore stones, leg ulcers, splenomegaly and haemolytic or accurate measure of the rate of haemolysis. Spleno- aplastic crises during intercurrent infections may megalyandpigmentstonesmayoccur. During adult life the b- the X chromosome (affected males always show clin- globin variants combine with a-globin chains to form ical manifestations but females will have variable adult haemoglobin (HbA). Sickle-cell anaemia is usually drug-induced (sulphonamides, primaquine) caused by a point mutation, which involves substi- or occur during acute infections. Other features are tution of T for A in the second nucleotide of the sixth neonatal jaundice and favism. Sickle-cell haemoglobin (HbS) possesses two a- This is an acquired clonal disorder of haematopoiesis and two abnormal b-chains. Thisaccountsfortheincreasedsensitivityof red cells to complement, which forms the basis of Sickle-cell disease is found in Africa, the Middle East, Hams acid lysis test. Sickle-cell trait occurs in who develop paroxysmal haemolysis (with anaemia, heterozygotes (HbAHbS) whose haemoglobin con- macrocytosis, reticulocytosis, haemoglobinuria and tains characteristically 60% HbA and 40% HbS. Pa- haemosiderinuria) and life-threatening venous tients with the trait are usually symptom-free except thromboses. Normal adult haemoglobin is made up of two poly- This leads to the sickling phenomenon and to abnor- peptide chains, the alpha- and beta-chains, which are mal sequestration with thrombosis in small arterioles. Repeated renal infarction causes Haematology 329 tubular damage and failure to concentrate urine, Marrow disorders compounding sickle-cell crises. Median be given and penicillin prescribed to reduce mortality survival in both essential thrombocythaemia and from pneumococcus. Hydroxyurea can help by in- polycythaemia vera exceeds 15 years and the 10-year creasing HbF production. Bone marrow transplanta- risk of developing either myelobrosis or acute mye- tion is curative but limited by availability of well loid leukemia is relatively low. Polycythaemia vera presents in late middle age (5060 years), most commonly as a chance haem- Thalassaemia atological nding. Itisdiagnosedbyndingaraised A diagnosis of polycythaemia vera can also be HbA level generally (47%). HbF levels may also be made if there is a raised haemoglobin and two minor 2 slightly raised (13%). Secondary causes to be excluded include hypox- aemia and renal disease (ultrasound for polycystic b-Thalassaemia major disease and hypernephroma). Cerebellar haemangio- (homozygote) blastoma and hepatoma are associated but very rare. Treatment is with repeated venesection, low-dose Patientsarerelativelynormalatbirth(littlebeta-chain aspirin to reduce the incidence of intravascular coag- anyway) but develop severe anaemia later with failure ulation and hydroxyurea in high risk patients who are to thrive and are prone to infection. Treatment consists of transfusion to maintain the Diagnosis depends on nding all four major criteria: haemoglobin at 10g/dl, but this, combined with in- creased iron absorption, results in iron overload. Des- 1 a platelet count > 450109l1and ferrioxamine is given to reduce haemosiderosis with 2 megakaryocyte proliferation with no or little gran- folic acid replacement, and splenectomy may be in- ulocyte or erythroid proliferation and dicated if hypersplenism supervenes. Thrombocytosis (increased platelets) Primary myelobrosis typically presents with the. After haemorrhage, surgery or trauma nding of huge and increasing splenomegaly, and. Splenectomy or splenic atrophy evidence of bone marrow failure: anaemia, infection,. Hydroxyurea, thalidomide and the thalidomide analogue lenalidomide have been used in therapy. Allogeneic hematopoietic stem cell transplantation is Treatment potentially curative. Blood transfusion is necessary and has to be repeated reg- Myelodysplastic syndromes ularly. Chemotherapy, lenalidomide and allogenic bone marrow transplantation have all been used in Myelodysplastic syndromes are a heterogeneous therapy. Transformation to acute myeloid leukaemia occurs in approximately Anaemia (requiring the transfusion of about 1 unit 30% of cases. Survival following diagnosis varies from blood/week), infection, haemorrhage and blast a few months to > 10 years. Less commonly, patients may present with a refractory anaemia, pancytopenia, neutropenia Marrow aplasia or thrombocytopenia (Table 20. Classication is continuously under review, but Primary aplastic anaemia gives a pancytopenia with there are ve major subgroups which tend to have reduction in all the formed elements. If it is Although hereditary forms of sideroblastic anaemia difcult to aspirate (possible myelobrosis or malig- exist, sideroblasts are most frequently seen in myelo- nancy),atrephinebiopsymaybenecessarytoobtaina dysplastic syndromes. The drugs that most Haematology 331 commonly cause marrow suppression include cyto- Thrombocytopenia toxic drugs, gold, indometacin and chloramphenicol. Somemarrowsuppressionisassociatedwithuraemia, This may result from decreased production (marrow rheumatoid arthritis and hypothyroidism. If the platelet count is very linked recessive clotting disorders of men, carried by low, major bleeding may occur from the nose or gut or women, in which patients suffer mainly from spon- into the brain. The bleeding time is prolonged but taneous bleeding into joints and soft tissues and coagulation times are normal. Steroids or intravenous immunoglobulin All carriers who wish to have children should receive may be of benet in the more severe cases, occasion- genetic counselling. Aspirin-containing is characterised by microangiopathic haemolytic preparations should be avoided because they impair anaemia and thrombocytopenia, and microvascular platelet function and may cause gastric erosion. Prognosis is worse when it which causes abnormal bleeding, particularly from is associated with malignancy, drugs or transplan- mucous membranes.

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The cost and benefit: risk ratio is taken into consideration when choosing a medication and inef- fective therapies are stopped discount 35 mg alendronate with visa. Upon the diagnosis of type 2 diabetes in both countries cheap alendronate 35 mg on line, patients are educated about the disease: how to deal with it or manage it with their activi- ties of daily living and how their care plan is going to progress order alendronate 35 mg without a prescription. The care given is patient centred and the goals are to: safely lower blood glucose level suing phar- macological and non-pharmacological therapies discount alendronate 70mg on-line, improve patient wellbeing, edu- cate patients, evaluate micro and macro-vascular complications and reduce cardi- ovascular and other possible long term risk associated with type 2 diabetes. They both also have similar care pathways in the treatment of type 2 diabetes, it begins with lifestyle modifications, with possible bariatric surgery if the patient is very overweight. Then initiation of pharmacotherapy, if lifestyle modification measures alone are not providing the desired result. These steps in the treatment of type 2 diabetes are known as glycaemic control algorithm. For example, it explains what treatment to begin with and when to 48(55) initiate it as well as the appropriate time for next step in the treatment. Glycaemic control algorithm care pathway always begins with lifestyle modification interven- tions (diet + exercise) for every type 2 diabetic patient. Oral anti-diabetic agents are then added to lifestyle modifications when the target level of blood glucose level is not achieved or maintained. Both countries have the same medication, such as metformin, and the time frame in the medication usage is also the same. All dual or combination therapies were more efficient than mono-therapies and reduced HbA1c levels by an addi- tional 1%. There was also greater decrease in HbA1c level when metformin was combined with other agents, for example metformin + sulphonyurea. The risk of hypoglycaemia is increased when increatin-based therapies are added to sulpho- nylurae, though they are generally well tolerated and have a low risk of hy- poglygaemia. Nutritional therapy should focus on the lifestyle modifications to result in increased energy figure through physical activity and lowered energy intake. The nutritional therapy of diabetes type 2 emphasis on lifestyle planning to reduce glycaemia, dyslipidaemia and blood pressure; because many people with diabetes have hypertension and dyslipidaemia. This leads to reduction in the in- take of cholesterol, saturated fat and sodium desirable. This planning should start as soon as the patient has been diagnosed with diabetes. An increase in physical activity can result in improved glycaemia, lowered insulin resistance, and reduced cardiovascular risk factors. The distribution of the food intake, three meals or smaller meals and snacks, should be based on individual preferences. Treatment with insulin therapy requires firmness in timing of meals and carbohydrate content. Untreated diabetes type 2 can lead to different kind of health problem such as heart disease and stroke, nerve damage, kidney disease and foot problem. This litera- ture review describes the treatment both pharmacology and nutritional treatment. The quantity of food patient eat depend on weight, diet, exercise regularity and other health risk. Physical activity monitoring is also done and encouraged by nurses and care giver need to make sure that both pa- tient and the family member are well counselled. Dietician role is important when a patient is diagnosed with type 2 diabetes, they provided tailor-made dietary plan, considering the lifestyle modifica- tion and any medical conditions. Education needs a multidisciplinary approach, with dieticians and practice nurses providing evidence-based local advice to both patients and carers about nutrition and food, along with supporting other health-care staff to maintain an accurate and 52(55) consistent message. Health professionals can help patient in plan- ning their exercise schedule and diet intake and record their behaviour including challenges and positive outcome. Enough time should be taken in other for care givers to notice the change in social, physical, psychological factors that add to patient exercise and diet behaviour. Both health-care professionals and patients must aware that changing diet and exercise behaviour require a gradual process. Patient who are constantly supported either by family or care givers to take charge in their weight loss and make lifestyle changes are likely to have an adequate long-term result. Nurses, Doctors, Dietician, Family member as well as pa- tient must work together to ensure good result after treatment. Patient need to be well counseled so they know that the treatment is a process not something they do and in a day and expect to be better instantly. The thesis is literature review so it doesnt require patient opinion or ap- proval from health committee. The re- search is done by two student and the only background knowledge we have is from practical training in hospitals. Articles were been critically read through before deciding which once are important in relation to the research question. Management of Hyperglycemia in Type 2 Dia- betes, 2015: A Patient Centered Approach. Nearly 26 million Americans have diabetes, although more than one-third dont know they have it. Experts say that in the coming years, the number of people with diabetes will increase. Diabetes often comes with two other health risks, high blood pressure and high cholesterol. But each of these conditions can be treated and the more you learn, the better you can take care of yourself. This guide may not tell you everything you every chance for a healthy and satisfying life. Along with your healthcare stay healthy, and enjoy your life for a long time to come. This guide, and other diabetes education materials, are available on the internet at intermountainhealthcare. For individualized information and support, contact a diabetes educator in your area. But a friend with diabetes shared a saying that helped him when he was first diagnosed: Fear is a reaction, but courage is a decision. This section explains how diabetes changes your bodys normal processes and how the disease can affect your health. Heres how: Acting insulin as a key, insulin binds to a place receptor on the cell wall called an insulin receptor, unlocking the cell so that glucose can pass from the bloodstream into the cell. They rise after a meal, then drop again as the body uses up the glucose provided by the food. Heres how it normally works: As your blood glucose starts to rise as it does after you eat the pancreas senses this rise in blood glucose.

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Oral antibiotics are recommended if lesions are extensive cheap alendronate 35 mg line, there is widespread infection buy alendronate 35mg amex, or if systemic symptoms are present alendronate 35 mg online. Streptococcus pyogenes has caused outbreaks of necrotising fasciitis in residential care facilities discount 35mg alendronate mastercard, and if this is suspected it is important to use systemic treatment to eradicate carriage, and prevent infection to others. A formal decolonisation regimen, using topical antibiotic and antiseptic techniques, is not necessary for all patients, but may be appropriate for those with recurrent staphylococcal abscesses. Decolonisation should only begin after acute infection has been treated and has resolved. As part of the decolonisation treatment, the patient should be advised to shower or bathe for one week using an antiseptic. For a diluted bleach bath, add 1 mL of plain unscented 5% bleach per 1 L of bathwater (or 2 mL of 2. A regular- sized bath flled to a depth of 10 cm contains approximately 80 L of water and a babys bath holds approximately 15 L of water. Ideally, the household should also replace toothbrushes, razors, roll- on deodorants and skin products. Hair brushes, combs, nail fles, nail clippers can be washed in hot water or a dishwasher. Bleach baths or antiseptic washing can be carried out intermittently after the initial decolonisation period, to help prevent recurrence of infection. This can also be recommended for patients with recurrent skin infections who have not undergone formal decolonisation. Antibiotic treatment Recurrent skin infections First choice Fusidic acid 2% cream or ointment (if isolate sensitive to fusidic acid) Mupirocin 2% ointment (if isolate resistant to fusidic acid and sensitive to mupirocin) Apply inside the nostrils with a cotton bud or fnger, twice daily, for fve days N. If the isolate is resistant to both fusidic acid and mupirocin, topical treatment is not indicated discuss with an infectious diseases specialist Alternatives Nil 15 Gastrointestinal Campylobacter enterocolitis Management Most people will recover with symptomatic treatment only. Antibiotics have little impact on the duration and severity of symptoms but eradicate stool carriage. Treatment is indicated for severe or prolonged infection, for pregnant women nearing term and for people who are immunocompromised. Treatment may also be appropriate for food handlers, childcare workers and those caring for immunocompromised patients. Discontinue current antibiotic treatment if/ when possible in some cases this may lead to clinical resolution of symptoms. Antibiotic treatment is recommended in adults if the patient has diarrhoea or other symptoms consistent with colitis, and a positive test for C. Common pathogens Clostridium difcile Antibiotic treatment Clostridium difcile colitis First choice Metronidazole Adult: 400 mg, three times daily, for 10 days Alternatives Vancomycin If patient has not responded to two courses of metronidazole; discuss with an infectious diseases physician or clinical microbiologist. Common pathogens Giardia lamblia Antibiotic treatment Giardiasis First choice Ornidazole Child < 35 kg: 125 mg/3 kg/dose,* once daily, for one to two days Adult and child > 35 kg: 1. Dose is per 3 kg bodyweight; ornidazole is only available in tablet form, tablets may be crushed, child dosing equates to one quarter of a tablet per 3 kg. Nitazoxanide (hospital treatment) may be considered for recurrent treatment failures. Treat patients with severe disease, those who are immunocompromised and those with prosthetic vascular grafts. It is not usually necessary to treat bacterial vaginosis unless symptoms are present or an invasive procedure is planned, e. A test of cure should be done fve weeks after initiation of treatment in pregnant women, if a non-standard treatment has been used, e. If symptoms are initially severe or signs and symptoms do not resolve (or worsen) after 24 to 48 hours, refer to hospital. A test of cure should be done fve weeks after initiation of treatment in pregnant women, if a non-standard treatment has been used or if symptoms do not resolve. As co-infection with chlamydia is very common, azithromycin is also routinely given. Women with severe pelvic infammatory disease and women who are pregnant require referral for specialist assessment. Ornidazole may be considered as an alternative, if metronidazole is not tolerated. Pyelonephritis acute updated August, 2015 Management Only treat in the community if mild symptoms, e. Infants and children with pyelonephritis should be referred to hospital for treatment. Nitrofurantoin alone is not an appropriate choice for pyelonephritis as it fails to achieve tissue penetration. A urethral swab and frst void urine sample should be taken to exclude gonorrhoea and chlamydia (or use combination testing if available). Advise avoidance of unprotected sexual intercourse for seven days after treatment has been initiated, and for at least seven days after any sexual contacts have been treated, to avoid re-infection. Patients with symptoms persisting for more than two weeks, or with recurrence of symptoms, should be referred to a sexual health clinic or urologist. Common pathogens Urethritis not attributable to Neisseria gonorrhoeae or Chlamydia trachomatis is termed non-specifc urethritis and there may be a number of organisms responsible, e. Asymptomatic bacteriuria requires antibiotic treatment in women who are pregnant but not in elderly women or patients with long-term indwelling urinary catheters. However, urine culture is recommended in males, women who are pregnant, and those who fail to respond to empiric treatment within two days. Women who are pregnant should have repeat urine culture one to two weeks after completing treatment to ensure cure. Children aged over six months, without renal tract abnormalities, and who do not have acute pyelonephritis, may be treated with a short course (three days) of antibiotics. Management of infection guidance for primary care for consultation and local adaptation, 2012. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Challenges of antibiotic development the global antibiotic resistance pandemic heralds a post antibiotic era as bad as the pre antibiotic era. Cell wall synthesis inhibitors: lactam antibiotics lactam ring the lactam ring mimics the D-alanyl- D alanine portion of the peptide chain that is normally bound by pbps that assemble the peptidoglycan layer This prevents cross linking of the glycan strands leading to bacterial lysis Beta lactams penicillins cephalosporins carbapenems monobactams Natural penicillins Imipenem aztreonam Penicillin G Meropenem Penicillin V Ertapenem Benzathine P Procaine P Penicillinase R Methicillin Nafcillin st nd rd th th 1 gen 2 gen 3 gen 4 gen 5 gen Cloxacillin Cefadroxil Cefaclor Cefotaxime cefepime Ceftaroline aminopenicillins Cephalexin Cefamandole Ceftazidime ceftobiprole Amoxycillin Cephradine Cefuroxime ceftriaxone ampicillin cefazolin cefoxitin Extended spectrum Ticarcilin Piperacilin carbenicillin Spectrum of activity: Penicillins Natural penicillins Aminopenicillin/ B lactamase G+ve bacteria: streptococci,L. Inhibitors monocytogenes some anaerobes, Sulbactam and clavulanate some spirochaetes, G-ve: inactivate the B lactamases and N. Epidermidis enterobacteriaceae, clostridia except Aminopenicillins difficile, Bacteroides spp Similar to natural penicillins with Extended spectrum additional G-ve:E. Spectrum of activity: Cephalosporins rd Each successive generation has 3 gen: in addition, activity against broader activity against aerobic G- B burgdorferi, greater activity nd ves. Influenza Used in combination treatment for mycobacterial infections Metronidazole Small molecule that can passively diffuse into bacteria.

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