Intramuscular ceftriaxone is especially appropriate for children younger than 3 years of age with vomiting that precludes oral treatment. Tympanocentesis may be required for patients who are difficult to treat or who do not respond to therapy. The disease progresses from a periostitis to an osteitis with mastoid abscess formation. Radiographs or computed tomography scan of the mastoid reveals clouding of the air cells, demineralization, or bone destruction. Treatment includes systemic antibiotics and drainage if the disease has progressed to abscess formation. Persistent middle ear effusion may last for many weeks or months in some children but usually resolves by 3 months following infection. Evaluating young children for this condition is part of all well-child examinations. Conductive hearing loss should be assumed to be present with persistent middle ear effusion; the loss is mild to moderate and often is transient or fluctuating. Normal tympanograms after 1 month of treatment obviate the need for further follow-up. Measurements of the resulting tympanogram correlate well with the presence or absence of middle ear effusion. Bacteria recovered from the nasopharynx do not correlate with bacteria isolated by tympanocentesis. Tympanocentesis and middle ear exudate culture are not always necessary, but they are required for accurate identification of bacterial pathogens and may be useful in neonates, immunocompromised patients, and patients not responding to therapy. A certain diagnosis can be made if there is rapid onset, signs of middle ear effusion, and signs and symptoms of middle ear inflammation. Children with an uncertain diagnosis who are older than 2 years of age may be observed if appropriate follow-up can be arranged. Amoxicillin (20 to 30 mg/kg/day) or sulfisoxazole (50 mg/kg/day) given Chapter 106 once daily at bedtime for 3 to 6 months or longer is used for prophylaxis. In malignant otitis externa, an elevated erythrocyte sedimentation rate is a constant finding. The most common bacterial pathogens are Pseudomonas aeruginosa, especially in association with swimming in pools or lakes, and Staphylococcus aureus. Otitis externa develops in approximately 20% of children with tympanostomy tubes, associated with S. Coagulase-negative staphylococci and Corynebacterium are isolated frequently from cultures of the external canal but represent normal flora. Otitis media with tympanic perforation and discharge into the auditory canal may be confused with otitis externa. Pain on movement of the pinnae or tragus, typical of otitis externa, is not present. Local and systemic signs of mastoiditis indicate a process more extensive than otitis externa. Malignancies or cholesteatoma presenting in the auditory canal are rare in children but may present with discharge, unusual pain, or hearing loss. Cleaning of the auditory canal, swimming, and, in particular, diving disrupt the integrity of the cutaneous lining of the ear canal and local defenses such as cerumen, predisposing to otitis externa. Tenderness with movement of the pinna, especially the tragus, and with chewing is particularly characteristic, symptoms notably absent in otitis media. Inspection usually reveals that the lining of the auditory canal is inflamed with mild to severe erythema and edema. Scant to copious discharge from the auditory canal may obscure the tympanic membrane. The most common symptoms of malignant otitis externa are similar, but facial nerve palsy occasionally occurs.
S households in 2007 is substantially below the 85 percent penetration found three years earlier in homes with eight- to eighteen -year-olds. Television is the most ubiquitous personal medium among children, but far from the only one. In 2003, 23 percent of children in the birth to six-year age range had a video player in their bedroom, 10 percent had a video game player, and 5 percent a personal computer. As new electronic media become more portable and more affordable, young people tend to number among the earlier adopters. Rapid diffusion of such media among youth is further attested to by estimates from 2005 that 45 percent of teens owned their own cell phone, up from 39 percent in 2004. Foehr people carry most forms of portable digital media to school with them, most schools in the United States are now "wired. Internet connections, according to differences in socioeconomic status, race and ethnicity, gender, and geography (rural and urban location). More recently, as the gap in access to computers has narrowed somewhat, the term has also been applied both to broadband connectivity and to differences in technical support and in how members of different socioeconomic status or ethnic groups use the technology. As figure 1 shows, fewer than 60 percent of homes with annual incomes under $20,000 have computers, as against more than 90 percent of homes with annual earnings of $60,000 or more. And although 93 percent the Digital Divide the term "digital divide" came into popular usage during the mid-1990s and originally referred to variations in access (in homes, schools, or other public locations) to personal computers and allied technologies, such as Figure 1. Share of Children Age 317 with Computers in Home, by Household Income Percent 100 80 60 40 20 0 05k 510k 1015k 1520k 2030k 3040k 4050k 5060k 6075k 75 100k 100 150k Household income Source: U. Census Bureau, Current Population Survey, 2003, Computer and Internet Use Supplement (Department of Commerce, 2003). Share of Households with Children 818 with Electronic Media, by Race and Ethnicity Percent 90 80 70 60 White 50 40 30 20 10 0 Personal computer Internet Instant messaging Video games African American Hispanic Source: Donald F. Roberts, Ulla Foehr, and Victoria Rideout, Generation M: Media in the Lives of 8- to 18-year-olds (Menlo Park, Calif. Ninety-one percent of eight- to eighteen-year-olds whose parents completed college have access to an in-home personal computer as compared with 84 percent of those whose parents attended but did not finish college and 82 percent of those whose parents completed no more than high school. Ownership of allied computer technologies such as Internet connections and instant messaging programs follows the same pattern, with more access in homes where parents completed college and less in homes where parents completed high school. Figure 2 illustrates differences of in-home computer availability as a function of race and ethnicity. A higher share of white (90 percent) than either African American (78 percent) or Hispanic (80 percent) eight- to eighteen-year-olds live with personal computers, and the pattern is similar for Internet connections and instant messaging programs. Moreover, the likelihood of having a website that can make information available to parents and students is lower both in schools with high minority enrollments and in schools with the highest concentrations of poverty. Television Videos and movies Audio Video games Computer Total media exposure Total media use Source: Data on sample of children 06 years (2005) from Rideout and Hamel (see table 1); on sample 27 years (1999) from Donald F. Because time-use diaries were not obtained for the 2005 sample of young children, total media use estimates are not available for them. It is more accurate to ask youngsters to report time they spend with each individual medium (Yesterday, how much time did you spend using a computer? Unfortunately, however, overall "media use" is not a straightforward summation of time exposed to each individual medium. To the extent that people "use" several media at the same time, playing a video game while listening to music, the sum of the two exposure estimates will be double the amount of time spent using media. That is, while engaged in one hour of Trends in Media Use media use (playing a video game while listening to music) a youngster is exposed to two hours of media content (one hour of video game content, one of music content). The exposure-use distinction has become especially important as new media, particularly the personal computer, have increased the amount of concurrent media use as well as the rate of media multitasking among young people. In what follows, then, "media use" refers to the amount of time young people devote to all media (that is, person hours devoted to using media); "media exposure" refers to media content encountered by young people expressed in units of time (that is, hours of television exposure). In 2005, children six years and younger averaged 2:24 (two hours and twenty-four minutes) daily exposure to media content. Data on concurrent media use were not collected for the birth to six-year-old samples. In 1999, however, parents reported that a national sample of two- to seven-year-olds experienced 3:30 of media exposure while engaged in 2:56 media use.
Diseases
Patients with less than 1% (severe hemophilia) factor 8 or factor 9 may have spontaneous bleeding or bleeding with minor trauma. Patients with 1% to 5% (moderate hemophilia) factor 8 or factor 9 usually require moderate trauma to induce bleeding episodes. In mild hemophilia (>5% factor 8 or factor 9), significant trauma is necessary to induce bleeding; spontaneous bleeding does not occur. Mild hemophilia may go undiagnosed for many years, whereas severe hemophilia manifests in infancy when the child reaches the toddler stage. In severe hemophilia, spontaneous bleeding occurs, usually in the muscles or joints (hemarthroses). Early, appropriate replacement therapy is the hallmark of excellent hemophilia care. Acute bleeding episodes are best treated in the home when the patient has attained the appropriate age and the parents have learned home treatment. Bleeding associated with surgery, trauma, or dental extraction often can be anticipated, and excessive bleeding can be prevented with appropriate replacement therapy. Prophylactic therapy starting in infancy has greatly diminished the likelihood of chronic arthropathy in children with hemophilia. For life-threatening bleeding, levels of 80% to 100% of normal factor 8 or factor 9 are necessary. For mild to moderate bleeding episodes (hemarthroses), a 40% level for factor 8 or a 30% to 40% level for factor 9 is appropriate. The dose can be calculated using the knowledge that 1 U/kg body weight of factor 8 increases the plasma level 2%, whereas 1. Desmopressin triples or quadruples the initial factor 8 level of a patient with mild or moderate (not severe) hemophilia A, but has no effect on factor 9 levels. When adequate hemostatic levels can be attained, desmopressin is the treatment of choice for individuals with mild and moderate hemophilia A. Aminocaproic acid is an inhibitor of fibrinolysis that may be useful for oral bleeding. Recombinant factor 8 and factor 9 concentrates are safe from virally transmitted illnesses. Inhibitors are IgG antibodies directed against transfused factor 8 or factor 9 in congenitally deficient patients. Inhibitors arise in 15% of severe factor 8 hemophiliacs but are less common in factor 9 hemophiliacs. For high titer inhibitors, it is usually necessary to administer a product that bypasses the inhibitor, preferably recombinant factor 7a. For long-term treatment of inhibitor patients, induction of immune tolerance by repeated infusion of the deficient factor with or without immunosuppression may be beneficial. Early institution of factor replacement and continuous prophylaxis beginning in early childhood should prevent the chronic joint disease associated with hemophilia. Von Willebrand disease usually is inherited as an autosomal dominant trait and rarely as an autosomal recessive trait. Approximately 80% of patients with von Willebrand disease have classic (type 1) disease. Several other subtypes are clinically important, each requiring different therapy. Mucocutaneous bleeding, epistaxis, gingival bleeding, cutaneous bruising, and menorrhagia occur in patients with von Willebrand disease. In severe disease, factor 8 deficiency may be profound, and the patient may also have manifestations similar to hemophilia A (hemarthrosis). Findings in classic von Willebrand disease differ from findings in hemophilia A and B (see Table 151-3). Desmopressin is the treatment of choice for most bleeding episodes in patients with type 1 disease and some patients with type 2 disease. Hepatitis B vaccine should be given before the patient is exposed to plasma-derived products.
Do you believe that good mothers make sure their kids keep their toys in good condition? But the idea is there, so we need to examine that belief that the toy might have feelings. Engagement Strategies Humor and inspirational quotations Schedule sorting times Listen to music while sorting Review progress via before and after photos Review life goals, esp. Teach skills to support/improve: Cognitive functioning Planning, preparation, organization, abstract reasoning, cognitive flexibility, problem solving skills In-session and homework compliance Prevent relapse back to old habits Cognitive Rehabilitation and Exposure/Sorting Therapy Session Outline 1. Relapse prevention and maintenance Comparison of Adult and Older Adult Treatments General Adult Older Adult (Steketee & Frost 2007) (Ayers et al. Evaluate each solution in terms of ease of implementation, costs and benefits, and likely consequences 4. Brainstorming Strategy verbalization Hypothesis testing by looking for disconfirming evidence Set shifting/ maintenance Standard Organizational Strategies Like those in Steketee and Frost 2007 Categories to keep & discard Filing system Places to discard & plan for discarding (Amvets, Goodwill, Recycle) Adequate storage Items for sorting (containers, files, shredder, etc) Developing rule system like with like Everything has final resting place if none, discard Staging areas Maintenance system Keeping cleared areas clean Discarding and Acquiring Practice · Most emphasized portion of treatment · Rationale based on process of habituation & distress tolerance · Expose to triggers: simply making a distressing decision about an object and/or reason for saving (utility, sentimental value, fear of making wrong decision/not feeling right, loss of information) Exposure Therapy in Session Discuss role of avoidance in maintaining hoarding problems Explain the process of habituation Exposure directly combats avoidance Develop a hierarchy Establish rules to use during exposure. Case example With help of therapist, she improved her discarding by linking practice to an established routine (nightly news). Through repeated practice, she learned to push through avoidance and that she could tolerate distress of letting go of possessions. At session 18, she completed an "advanced" exposure by leading a team of student volunteers in discarding exercises in her home for two 4-hour sessions. After 24 sessions, she reduced clutter in her living room by 50%, bedroom by 50%, and could complete most basic functions at home. Hoarding symptoms decreased by approximately 40% on clinician administered and selfreport measures. Also, kindergarten students who are five years old and deemed "high risk" because of developmental delays may be eligible. Money in the account can roll over from one year to the next, as long as the students remains in the program, and the account can remain in place until: A student graduates from a postsecondary education institution, such as college or technical institute Or, has gone four consecutive years after high school with no further education At that point, the account is closed and any remaining money reverts to the state. We will begin accepting applications for the 2015-16 school year in November 2014. Total Gross Monthly Household Income 2014-15 scholarship income guidelines 2015-16 may differ 14 Eligibility Criteria: Children who are in foster care or out-of-home care % · Income guidelines: There is no income threshold for a child who is in foster care or in out-ofhome care. If the child is in foster care, a copy of the foster care placement paperwork must be provided. A child in foster care or out-of-home care who receives a scholarship, may maintain the scholarship until he/she graduates high school or reaches the age of 21, whichever comes first. Documentation requirements: Documentation must be provided to validate that the child is homeless. The homeless liaison in the public school district to which the child is assigned can create a letter or document to be included with their application packet or a letter may be submitted (on letterhead) by the owner or Executive Director of the shelter or transitional housing facility. Both the transportation and private school scholarship have the same application and eligibility process. Each child has a personal learning plan, where the teacher, the parent and even the child have agreed upon specific responsibilities. Step Up For Students and its Office of Student Learning are dedicated to helping every child succeed. Families should check email (or login to account) during application processing period. S u b a c u t e, Si l e n t, a n d Po s t p a r t u m T h y ro i d i t i s Mary H. There are many types of thyroiditis, which can generally be divided into painful or painless categories. Painless types include Hashimoto thyroiditis, the most common type of chronic thyroid disease, as well as silent, postpartum, drug-induced, and Riedel thyroiditis. Thyroid function in patients with thyroiditis depends on the type of thyroiditis and, in certain cases, evolves from thyrotoxicosis to hypothyroidism and eventually to restoration of normal thyroid function. This classic triphasic course of thyroid dysfunction is characteristic of the 3 entities considered in this article: subacute, silent, and postpartum thyroiditis. The other types of thyroiditis are not discussed further, except in the context of the differential diagnosis. Table 1 provides a comprehensive summary of the text of this article and can be referenced throughout the discussion that follows. The thyroid gland becomes extremely painful and tender to palpation, with pain often radiating up to the jaw or ear and associated dysphagia.
Develop structure and neat habits To organize a room, home, or office, categorize your objects, deciding which are necessary and which can be stored or discarded. Designate specific areas for things like keys, bills, and other items that can be easily misplaced. Effective use of a day planner or a calendar on your smartphone or computer can help you remember appointments and deadlines. Make use of lists and notes to keep track of regularly scheduled tasks, projects, deadlines, and appointments. You can avoid forgetfulness, clutter, and procrastination by filing papers, cleaning up messes, or returning phone calls immediately, not sometime in the future. If a task can be done in two minutes or less, do it on the spot, rather than putting it off for later. Use dividers or separate file folders for different types of documents (such as medical records, receipts, and income statements). Set aside a few minutes each day to deal with the mail, preferably as soon as you bring it inside. It helps to have a designated spot where you can sort the mail and either trash it, file it, or act on it. You may frequently lose track of time, miss deadlines, procrastinate, underestimate how much time you need for tasks, or find yourself doing things in the wrong order. These difficulties can leave you feeling frustrated and inept, and make others impatient, but there are solutions to help you better manage your time. Time management tips Adults with attention deficit disorder often have a different perception of how time passes. To align your sense of time with everyone else, use the oldest trick in the book: a clock. Use a wristwatch or highly visible wall or desk clock to help you keep track of time. When you start a task, make a note of the time by saying it out loud or writing it down. Allot yourself limited amounts of time for each task and use a timer or alarm to alert you when your time is up. For longer tasks, consider setting an alarm to go off at regular intervals to keep you productive and aware of how much time is going by. For every thirty minutes of time you think it will take you to get someplace or complete a task, give yourself a cushion by adding ten minutes. Ask yourself what is the most important task you need to accomplish, and then order your other tasks after that one. Avoid getting sidetracked by sticking to your schedule, using a timer to enforce it if necessary. But a jam-packed schedule can leave you feeling overwhelmed, overtired, and affect the quality of your work. Turning things down may improve your ability to accomplish tasks, keep social dates, and live a healthier lifestyle. But if you create your own system that is both simple and consistent, you can get on top of your finances and put a stop to overspending, overdue bills, and penalties for missed deadlines. Control your budget An honest assessment of your financial situation is the first step to getting budgeting under control. You can then use this snapshot of your spending habits to create a monthly budget based on your income and needs. Set up a simple money management and bill paying system Establish an easy, organized system that helps you save documents, receipts, and stay on top of bills. Organizing money online means less paperwork, no messy handwriting, and no misplaced slips. Signing up for online banking can turn the hit-or-miss process of balancing your budget into a thing of the past.
Syndromes
Embryonal histologic variant is most common in younger children with head, neck, and genitourinary primary tumors. Alveolar histologic variant occurs in older patients and is seen most commonly in trunk and extremity tumors. Alveolar rhabdomyosarcoma often is characterized by specific translocations: t(2;13) or t(1;13). Chemotherapy includes vincristine, cyclophosphamide, ifosfamide, etoposide, and doxorubicin. Definitive diagnosis of osteosarcoma often is established by carefully placed needle biopsy. The presence of osteoid and immunohistochemical analysis confirms the diagnosis of osteosarcoma. Osteosarcoma tends to metastasize to the lung, most commonly, and rarely to other bones. The diagnosis of Ewing sarcoma is established with immunohistochemical analysis and cytogenetic and molecular diagnostic studies of the biopsy material. Ewing sarcoma is characterized by a specific chromosomal translocation, t(11;22), which is seen in 95% of tumors. If the local disease is controlled with surgery, the long-term sequelae may include loss of limb or limitation of function. If local control is accomplished with radiation therapy, the late effects depend on the dose of radiation given, the extent of the site radiated, and the development of the child at the time of radiation therapy. Irradiating tissues interfere with growth and development, so significant adverse consequences may occur in young children. The differential diagnosis for rhabdomyosarcoma depends on the location of the tumor. Tumors of the trunk and extremities often present as a painless mass and may be initially thought to be benign tumors. Periorbital rhabdomyosarcoma may be misdiagnosed as orbital cellulitis, and other head and neck rhabdomyosarcoma may be confused with chronic infection of ears or sinuses. The differential diagnosis for intra-abdominal rhabdomyosarcoma includes other abdominal malignancies, such as Wilms tumor or neuroblastoma. The staging system also involves a local tumor group assessment based on the extent of disease and surgical result. In the intergroup rhabdomyosarcoma studies, the most common chemotherapy agents used are cyclophosphamide, vincristine, and actinomycin. Doxorubicin, etoposide, ifosfamide, topotecan, and irinotecan are also active against rhabdomyosarcoma. Radiation is administered to patients who have residual disease after initial surgery or who have only had a primary biopsy of the tumor. The current treatment of osteosarcoma involves neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy. Agents effective against osteosarcoma are doxorubicin, cisplatin, high-dose methotrexate, ifosfamide, and etoposide. The treatment for Ewing sarcoma is similar to that for For all children with sarcoma, presence or absence of metastatic disease at presentation is the most important prognostic factor. The outlook remains poor for patients who have distant metastasis from Ewing sarcoma, rhabdomyosarcoma, or osteosarcoma at diagnosis. Patients with localized rhabdomyosarcomas in favorable sites have an excellent prognosis when treated with surgery followed by vincristine and actinomycin. In patients with osteosarcoma and Ewing sarcoma, another important prognostic factor is the degree of tumor necrosis after preoperative chemotherapy. In general, patients whose tumor specimens show a high degree (>90%) of necrosis following preoperative chemotherapy have an event-free survival rate greater than 80%. Patients who still have large amounts of viable tumor after presurgical chemotherapy have a much worse prognosis. The cure rate for patients with localized osteosarcoma and Ewing sarcoma is approximately 60% to 70%. Patients who have lung metastasis at diagnosis have a cure rate of approximately 30% to 35%. Renal disorders, by disturbing homeostasis, can affect growth and development and result in a variety of clinical manifestations (Table 161-1).
A careful general physical examination should focus on the chest wall, heart, lungs, and abdomen. A history of chest pain associated with exertion, syncope, or palpitations or acute onset associated with fever suggests a cardiac etiology. Cardiac causes of chest pain are generally ischemic, inflammatory, or arrhythmic in origin. Referral to a pediatric cardiologist is based on the history, physical examination findings, family history, and, frequently, the level of anxiety in the patient or family members regarding the pain. Many pediatric dysrhythmias are normal variants that do not require treatment or even further evaluation. Because normal rates vary with age, sinus bradycardia and sinus tachycardia are defined based on age. Sinus arrhythmia is a common finding in children and represents a normal variation in the heart rate associated with breathing. In a child with a structurally normal heart, most episodes are relatively asymptomatic other than a pounding heartbeat. If there is structural heart disease or the episode is prolonged (>12 hours), there may be alteration in the cardiac output and development of symptoms of heart failure. Any deviation from the presentation (history of syncope or a family history of sudden death) requires further investigation and possibly treatment with antiarrhythmic medications. Although there are multiple causes of ventricular tachycardia, it usually is a sign of serious cardiac dysfunction or disease. Rapid-rate ventricular tachycardia results in decreased cardiac output and cardiovascular instability. Medical management with lidocaine or amiodarone may be appropriate in a conscious asymptomatic patient. Complete evaluation of the etiologic picture is necessary, including electrophysiologic study. A premature P wave, usually with an abnormal axis consistent with its ectopic origin, is present. Premature atrial contractions are usually benign and, if present around the time of delivery, usually disappear during the first few weeks of life. Atrial flutter and atrial fibrillation are uncommon dysrhythmias in pediatrics and usually present after surgical repair of complex congenital heart disease. They may also be seen in patients with myocarditis or in association with drug toxicity. It is asymptomatic and, when present in otherwise normal children, requires no evaluation or treatment. It is often seen during sleep, usually does not progress to other forms of heart block, and does not require further evaluation or treatment in otherwise normal children. This form may progress to complete heart block and may require pacemaker placement. Thirddegree heart block, whether congenital or acquired, is present when there is no relationship between atrial and ventricular activity. Congenital complete heart block is associated with maternal collagen vascular disease (such as systemic lupus erythematosus or Sjцgren syndrome) or congenital heart disease. The acquired form most often occurs after cardiac surgery but may be secondary to infection, inflammation, or drugs. In patients with cardiovascular compromise at the time of presentation, syn chronized cardioversion is indicated using 1 to 2 J/kg. In patients with palpitations, it is important to document heart rate and rhythm during their symptoms before considering therapeutic options. Ongoing pharmacologic management with either digoxin or a -blocker is usually the first choice. However, digoxin is contraindicated in patients with Wolff-Parkinson-White syndrome. In patients who are symptomatic or those not wanting to take daily medications, radiofrequency ablation may be performed. A variety of antiarrhythmic agents are used to treat ventricular dysrhythmias that require intervention (Table 142-3). Management of third-degree heart block depends on the ventricular rate and presence of symptoms. Although most cases of congenital heart disease are multifactorial, some lesions are associated with chromosomal disorders, single gene defects, teratogens, or maternal metabolic disease (see Table 139-2).
A wet mount of vaginal fluids shows the presence or absence of sperm under the microscope. All materials must be maintained in a "chain of evidence" that cannot be called into question in court. A single oral dose of cefixime, 400 mg, and azithromycin, 1 g, treats Chlamydia, gonorrhea, and syphilis. An alternative regimen is a single intramuscular dose of ceftriaxone, 125 mg, with a single oral dose of azithromycin, 1 g. For prophylaxis against bacterial vaginosis and Trichomonas, a single oral dose of metronidazole, 2 g, is recommended. Longterm sequelae are common; patients should be offered immediate and ongoing psychological support, such as that offered by local rape crisis services. The diagnosis in young adolescents (pregrowth spurt, premenstrual) may not follow the typical diagnostic criteria (Table 70-1). The female-to-male ratio is approximately 20:1, and the condition shows a familial pattern. The cause of anorexia nervosa is unknown, but it involves a complex interaction between social, environmental, psychological, and biologic events. Although it is recommended that the adolescent be interviewed alone, he or she may minimize the problem; thus interviewing the parent(s) alone is also important. The first event usually described by an affected patient is a behavioral change in eating or exercise. The patient has an unrealistic body image and feels too fat, despite appearing excessively thin. The physician should be nonjudgmental, collect information, and assess the differential diagnosis. The differential diagnosis of weight loss includes gastroesophageal reflux, peptic ulcer, malignancy, chronic diarrhea, malabsorption, inflammatory bowel disease, increased energy demands, hypothalamic lesions, hyperthyroidism, diabetes mellitus, and Addison disease. The clinical features of anorexia include wearing oversized layered clothing to hide appearance, fine hair on the face and trunk (lanugo-like hair), rough and scaly skin, bradycardia, hypothermia, decreased body mass index, erosion of enamel of teeth (acid from emesis), and acrocyanosis of hands and feet. I = Increased food available N = New crisis G = Group influences "peers media" Figure 70-1 the eating disorder cycle. When 80% of normal weight is achieved, the patient is given freedom to gain weight at a personal pace. The prognosis includes a 3% to 5% mortality (suicide, malnutrition) rate, the development of bulimic symptoms (30% of individuals), and persistent anorexia nervosa syndrome (20% of individuals). Binge-eating episodes consist of large quantities of often forbidden foods or leftovers or both, consumed rapidly, followed by vomiting. Metabolic abnormalities result from the excessive vomiting or laxative Treatment and Prognosis Treatment requires a multidisciplinary approach, including a feeding program as well as individual and family therapy. Feeding is accomplished through voluntary intake of regular foods, nutritional formula orally or by nasogastric tube. When vital signs are stable, discussion and negotiation of a detailed treatment contract with the patient and the parents Chapter 70 Clinical features - Wearing oversized clothing - Fine hair on the face and trunk (lanugo-like hair) - Bradycardia, hypothermia - Decreased body mass index - Erosion of enamel of teeth (acid from emesis) - Acrocyanosis of hands and feet. Table 70-2 Diagnostic Criteria for Anorexia Nervosa Table 70-4 Diagnostic Criteria for Bulimia Nervosa Refusal to maintain body weight at or above a minimally normal weight for age and height. Recurrent episodes of binge eating, at least twice a week for 3 months, characterized by the following: Eating in a discrete period an amount of food that is definitely larger than most people would eat during a similar period A sense of lack of control over eating during the episode. Table 70-3 Risk of suicide When to Hospitalize an Anorexic Patient Weight loss >25% ideal body weight* Bradycardia, hypothermia Dehydration, hypokalemia, dysrhythmias Outpatient treatment fails *Less weight loss accepted in young adolescent. Binge-eating episodes and the loss of control over eating often occur in young women who are slightly overweight with a history of dieting. Nutritional, educational, and self-monitoring techniques are used to increase awareness of the maladaptive behavior, following which efforts are made to change the eating behavior. Patients with bulimia nervosa may respond to antidepressant therapy because they often have personality disturbances, impulse control difficulties, and family histories of affective disorders. Anabolic steroid use has increased in adolescent boys seeking enhanced athletic performance. A history of drug use should be taken in a nonjudgmental and supportive manner and include the types of substances, frequency, timing, circumstances, and outcomes of substance use. An adolescent may present in an overdose or intoxicated state, or in a psychosis triggered by a hallucinogen, such as phencyclidine ("angel dust"). Club drugs have direct (coma and seizures) and indirect (sexual assault and dehydration) adverse effects.
One individual in Group 1 was American Indian/African American, and 1 individual in Group 2 was Asian/African American. Feasibility and acceptability of the yoga intervention based on the Perceptions and Satisfaction Questionnaires were analyzed using Wilcoxon rank-sum tests. There were no differences between the groups based on their demographic data or baseline scores on most outcome measures (Table 1). The total scores on both scales and the other subscales did not differ between the groups at Time 1. The comparisons of the other subtests at Time 1 were not significantly different between the groups: flexibility (t(20) 5 22. Significant differences on commission errors were not found on other subtests. No differences were found for variability of reaction times on the alertness subtest or Figure 2. For symmetry, go/no-go errors of omission were omitted from this figure; differences between groups on this task outcome were not significant, p 5 0. Comparisons on the alertness subtest were not significantly different for reaction times (b 5 2148. We had insufficient data from Group 1 at follow-up to make any comparisons with confidence. Overall parent satisfaction with the program was promising (Group 1: 75 6 39 vs Group 2: 72 6 30), and most would recommend the program to others (Group 1: 74 6 43 vs Group 2: 78 6 32). Most parents also did not perceive changes in their stress level or parent-child relationships. Teacher satisfaction and perception ratings were also not significantly different between the groups: behavioral improvements (Group 1: 28 6 31 vs Group 2: 59 6 25; p 5 0. After each intervention, teachers rated that they would recommend the program to others at similar rates (Group 1: 73 6 22 vs Group 2: 78 6 22). Yoga Frequency There were 42 possible days to practice yoga during each intervention period. Overall, the children in both groups practiced yoga approximately 50% of the possible days (mean days of practice: Group 1: 25 6 14 and Group 2: 20 6 8), which averaged 3 to 4 days of yoga per week. None of the parents reported continuing to practice home yoga after their intervention period ended. Over the course of the intervention, the mean time-on-task ratings remained stable in both groups (b 5 20. Children with higher symptoms improved slightly over time, although this improvement was not statistically significant (see Figure, Supplemental Digital Content 3, links. Fidelity Each part of the school yoga classes were completed with rates of 63% to 100%. The poses missed most often in both groups included bird-dog, chair, airplane, and happy baby. Published theories about the underlying mechanisms of yoga draw connections between yoga and increases in mind-body awareness that lead to improvements in attention. However, it is important to note that teacher ratings of inattentive symptoms did not significantly improve after practicing yoga. This may be because teachers are trying to manage a busy classroom and are less likely to notice inattentive symptoms, as these symptoms are generally not disruptive. These results also suggest that children with more significant symptoms at baseline and/ or children with inattentive symptoms show more Copyright У 2018 Wolters Kluwer Health, Inc. Satisfaction and Perception Questionnaires Parent satisfaction and perception ratings were not significantly different between the groups. Many parents were satisfied with behavior changes they noticed after yoga (Group 1: 80 6 23 and Group 2: 67 6 30) and felt that learning yoga helped their children learn Vol. These findings are consistent with the study of yoga in typically developing preschoolers, which found that children with fewer self-regulation skills benefited most from yoga. This is consistent with the finding from the Multimodal Treatment of Attention Deficit Hyperactivity Disorder study regarding behavioral therapies. Unexpectedly, at Time 1, Group 1 showed higher impulsivity after yoga, with significantly more commission errors on the distractibility task. Thus, although children evidenced improved sustained attention after the intervention, they also evidenced greater impulsivity on this computerized measure. When we controlled for age, Group 2 also evidenced faster reaction times on correct responses for the go/nogo task after yoga.
Therefore, we proposed to expand the flexibility to employ or contract with application assisters to all direct enrollment entities, to create parity between issuers and other types of direct enrollment entities. We proposed to adopt the same approach for direct enrollment entity application assisters as the existing one for issuer application assisters. In other words, under our proposal, these application assisters would need to comply with applicable state law, including any licensure requirements, and we would continue to defer to existing state laws related to enrollment assistance when deciding which individuals may assist applicants and enrollees and whether licensure is required to provide such assistance. We intend to release future guidance about the form and manner of the registration and training processes under § 155. Two other commenters questioned whether direct enrollment entity application assisters would be subject to state laws applicable to licensed agents or brokers, such as those pertaining to protecting consumer information, conflicts of interest, and professional liability insurance. Two commenters also suggested direct enrollment entity application assisters should be subject to requirements similar to those for agents or brokers under § 155. Response: We are finalizing this proposal as proposed, with a clarifying edit to § 155. We understand that in some states a license may be required for application assisters to assist consumers applying for an eligibility determination or redetermination. We defer to existing state laws related to enrollment assistance when deciding which individuals may assist applicants and enrollees as described in this rule, and whether state licensure is required to provide such assistance. If state law requires a license to engage in these activities, then application assisters will need to follow state law for licensure requirements. Since application assisters under the federal definition are not licensed agents or brokers, we do not believe it is appropriate to subject them to the same requirements imposed on licensed agents and brokers under § 155. Notably, application assisters are not authorized to function in the same ways as licensed agents or brokers. However, no comparable special enrollment period exists for individuals who are enrolled in off-Exchange individual market coverage. We believe this may present a significant barrier for some individuals to remain in continuous coverage for the full plan year. This proposed new training and registration requirement for application assisters is captured in the new proposed § 155. For example, another state licensure law may exist for professionals whose functions are more similar to application assisters than licensed agents, brokers, and producers. We, therefore, proposed to amend this standard (proposed to be redesignated at § 155. We sought to provide individuals with more health coverage options and to empower them to enroll in the health coverage that best meets their needs and the needs of their families. However, these individuals or families may experience a change in household income during the benefit year that makes their current health coverage no longer affordable. Since no pathway to Exchange coverage currently exists, we believe that unsubsidized individual market enrollees whose household income has decreased may no longer be able to afford their unsubsidized health plans and may decide to terminate coverage mid-year. We believe that this policy will help promote continuous enrollment in health coverage and bring additional stability to the individual market risk pool, which will likely have a positive impact on health insurance premiums. To ensure that the special enrollment period is available to the intended population while mitigating risks of adverse selection and inappropriate use, we proposed to require the individual seeking access to the special enrollment period to provide evidence of both a change in household income and of prior health coverage. Verifying that a decrease in household income occurred will prevent individuals who enrolled in health coverage off-Exchange, but have not experienced a financial change, from attempting to use this special enrollment period for the sole purpose of purchasing a more or less comprehensive level of coverage midyear. To protect the individual market risk pool from adverse selection, as mentioned in this rule, we proposed to include a prior coverage requirement, which will protect against individuals who opted not to enroll in health coverage during the annual open enrollment period from using this special enrollment period to enroll in Exchange coverage mid-year. The prior-coverage requirement aligns with existing priorcoverage requirements for special enrollment periods at § 155. Consistent with current 141 Instructions for consumers to verify their eligibility for a special enrollment period are available at. We recognize that State Exchanges maintain flexibility to determine whether and how to implement preenrollment verification of eligibility for special enrollment periods and may not have the operational capacity to immediately implement and verify eligibility for this special enrollment period. Some State Exchanges may also determine there is insufficient need among off-Exchange consumers for this special enrollment period because of the rating and pricing practices specific to their state markets. Therefore, we proposed to make this special enrollment period available at the option of the Exchange. However, we proposed that the new special enrollment period will be subject to the rule in paragraph (a)(4)(iii). Therefore, should a qualified individual who qualifies for the special enrollment period in paragraph (d)(6)(v) already have members of his or her household enrolled in Exchange coverage and those enrollees do not qualify for another special enrollment period at the same time that provides them with additional plan enrollment flexibilities, the Exchange must allow 142 Available at.
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