Emilie J. B. Calvello, MD, MPH
- Senior Resident
- Department of Emergency Medicine
- Johns Hopkins Hospital
- Baltimore, Maryland
When this exam is done in the first trimester queen herbals discount himplasia 30caps, the same indications for a standard first trimester ultrasound herbs n more order himplasia 30caps line, 76801 herbals and there uses buy himplasia 30caps, apply krishna herbals discount himplasia 30 caps overnight delivery. It has been shown that the use of multiple biometric parameters can allow for accuracy to within 3-4 days in a mid-trimester study (14-22 weeks) herbs nyc buy himplasia 30 caps otc. Accurate dating of a pregnancy is crucial as many important decisions might be made based on this date-whether or not to resuscitate an infant delivered prematurely jaikaran herbals buy generic himplasia 30caps, when to give antenatal steroids, when to electively deliver a term infant, and when to induce for post-dates. Pregnancy dating with a first trimester or mid-trimester ultrasound will reduce the number of misdated pregnancies and subsequent unnecessary inductions for post-dates pregnancies. Despite these technical advantages, proof of a clinical advantage of threedimensional ultrasonography in prenatal diagnosis in general still is lacking. Rather, it is intended for a known or suspected fetal anatomic or genetic abnormality. Once this detailed fetal anatomical exam (76811) is done, a second one should not be performed unless there are extenuating circumstances with a new diagnosis. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services. Added "as an adjunct to embryo transfer" as an indication for standard first trimester ultrasound in "classifications of fetal ultrasound" section I. Second-trimester evaluation of cervical length for prediction of spontaneous preterm birth in singleton gestations. Important Reminder this clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. References Alcoholism Alcohol and Health: Research-based information on drinking and its impact. Genetic risk variants associated with comorbid alcohol dependence and major depression. A relationship between the aldosterone-mineralocorticoid receptor pathway and alcohol drinking: preliminary translational findings across rats, monkeys and humans. Recruitment of a neuronal ensemble in the central nucleus of the amygdala is required for alcohol dependence. Results of a pilot test of a self-administered smartphone-based treatment system for alcohol use disorders: Usability and early outcomes. Development of a smartphone-based, self-administered intervention system for alcohol use disorders. Ultra-brief mindfulness training reduces alcohol consumption in at-risk drinkers: A randomized double-blind active-controlled experiment. Addiction treatment should be the work of liberation-but what does such a model look like Intestinal microbiota contributes to individual susceptibility to alcoholic liver disease. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful Gloucester Police: 17 people have so far sought opioid addiction treatment in new program. Research shows how to implement chronic care model into primary care for addiction. The glucagon-like peptide-1 receptor as a potential treatment target in alcohol use disorder: evidence from 14 human genetic association studies and a mouse model of alcohol dependence. The glucagon-like peptide 1 receptor agonist liraglutide attenuates the reinforcing properties of alcohol in rodents. Randomized trial of motivational interviewing plus feedback for soldiers with untreated alcohol abuse. Alcohol elicits functional and structural plasticity selectively in dopamine D1 receptor-expressing neurons of the dorsomedial striatum. Implementing the chronic care model for opioid and alcohol use disorders in primary care. Presented at: American Psychiatric Association Annual Meeting; May 20-24, 2017; San Diego. Effectiveness and safety of baclofen for maintenance of alcohol abstinence in 17 alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study. Clinical effectiveness of baclofen for the treatment of alcohol dependence: a review. Suppression of alcohol dependence using baclofen: A 2-year observational study of 100 patients. Clinical experience with baclofen in the management of alcohol-dependent patients with psychiatric comorbidity. The cure for alcoholism: the medically proven way to eliminate alcohol addiction (2nd ed. Efficacy and safety of baclofen for alcohol dependence: a randomized, double-blind, placebo-controlled trial. D-cycloserine to enhance extinction of cue-elicited craving for alcohol: a translational approach. Extending the treatment options in alcohol dependence: A randomized controlled study of as-needed nalmefene. Received: January 24, 2015; Received in revised form: March 13, 2015; Accepted: April 1, 2015; Published Online: April 13, 2015. Normalizing dopamine levels in the brain can reduce alcohol cravings, study shows. New treatment option for alcohol dependence: Reduced consumption rather than abstinence. Breaking good: Vivitrol, a new drug given as a monthly shot, is helping addicts stay clean. Safety, tolerability, and feasibility of high-dose naltrexone in alcohol dependence: an open-label study. Relative Efficacy of Mindfulness-Based Relapse Prevention, Standard Relapse Prevention, and Treatment as Usual for Substance Use Disorders: A Randomized Clinical Trial. Jan Gryczynski and Robert Schwartz for their revisions to the pages on "Clinical Treatment. Division of Gastroenterology and Hepatology, University of California-Irvine, Irvine, California Corresponding address: Timothy R. Although the incidence of hepatitis C infection has dramatically decreased during the past decade, the worldwide reservoir of chronically infected persons is estimated at 170 million, or 3% of the global population. There is much controversy surrounding the natural history of hepatitis C infection. Introduction Chronic hepatitis C is the most common cause of chronic liver disease and cirrhosis, and the most common indication for liver transplantation in the United States (U. Risks for transmission include blood transfusion before 1992, intravenous drug use, highrisk sexual activity, solid organ transplantation from an infected donor, occupational exposure, hemodialysis, household exposure, birth to an infected mother, and intranasal cocaine use. Other modes of transmission (occupational, hemodialysis, household, and perinatal) accounted for approximately 10% of infections. In the remaining 10%, no recognized source of infection can be identified, although most persons in this category are associated with low socioeconomic level. Many have speculated that the jaundice may be associated with a more robust immune Th1 lymphocyte 4. Approximately 75%-85% of infected patients do not clear the virus by 6 months, and chronic hepatitis develops. Age at Time of Infection Several studies have shown a significant association between the rate of fibrosis and the age at time of infection. Patients with humoral immunoglobulin deficiency (hypogammaglobulinemic) or cellular immune impairment (organ transplant recipients) have shown significantly higher rates of progression to cirrhosis than immunocompetent patients. Progression of Liver Fibrosis In the setting of persistent hepatitis C viremia, the rate of progression of liver fibrosis varies widely. The liver biopsy is the gold standard for the grading and staging of chronic hepatitis C. The activity of liver disease or grade, is gauged by the number of mononuclear inflammatory cells present in and around the portal areas, and by the number of dead or dying hepatocytes. More advanced changes are defined by fibrosis that extends from one portal area to another, also known as "bridging fibrosis. The features of decompensated cirrhosis include the development of ascites, upper gastrointestinal bleeding secondary to varices or portal hypertensive gastropathy, hepatorenal syndrome and hepatic encephalopathy. Studies have estimated the 3, 5, and 10-year survival rates of compensated cirrhosis to be 96%, 91%, and 79%, respectively. The cumulative probability of an episode of clinical decompensation is 5% at 1 year, and increases to 30% at 10 years from the diagnosis of cirrhosis. In a meta-analysis of 21 case-control studies, the risk for Alcohol consumption Alcohol consumption appears to be one of the most influential factors driving fibrosis progression in patients with chronic hepatitis C. There is convincing evidence that higher levels of alcohol consumption contributes to the development of progressive liver disease. Frequently, the initial time of infection is not known, and therefore must be estimated. Summary the chronic nature of hepatitis C infection influences the clinical approach and management of this disease. These manifestations can involve multiple organ systems, including renal, dermatologic, hematologic, and rheumatologic systems. Severe symptoms from cryoglobulinemia appear to respond to interferon treatment, but relapse occurs frequently once treatment is discontinued. Identification of additional viral, host, and external factors would help in developing means of prevention, early detection, and treatment. The spectrum of liver disease in the general population: lesson from the Dionysos study. Clinical outcomes after hepatitis C infection from contaminated anti-D immune globulin. Low frequency of cirrhosis in a hepatitis C (genotype 1b) single-source outbreak in germany: a 20-year multicenter study. Long-term mortality and morbidity of transfusionassociated non-A, non-B, and type C hepatitis: A National Heart, Lung, and Blood Institute collaborative study. Persistence of viremia and the importance of longterm follow-up after acute hepatitis C infection. Role of ethnicity in risk for hepatocellular carcinoma in patients with chronic hepatitis C and cirrhosis. Analysis of successful immune responses in persons infected with hepatitis C virus. The natural history of hepatitis C virus infection: host, viral, and environmental factors. Impact of alcohol on the histological and clinical progression of hepatitis C infection. Progression of type C chronic hepatitis to liver cirrhosis and hepatocellular carcinoma-its relationship to alcohol drinking and the age of transfusion. Role of alcohol in the progression of liver disease caused by hepatitis C virus infection. Independent and combined action of hepatitis C virus infection and alcohol consumption on the risk of symptomatic liver cirrhosis.
However yashwant herbals buy generic himplasia 30caps line, only six of them compared outcomes by sputum smear status [15-17 jenith herbals cheap himplasia 30caps without prescription,24 herbals teas for the lungs order generic himplasia online,27 herbals shoppe hedgehog products cheap himplasia line,29] herbals and diabetes 30 caps himplasia with amex. Among the contacts of local-born index cases herbs like viagra order genuine himplasia line, only 15% were infected, compared to 44% among the contacts of foreign-born index cases. Ta b l e 5 Median with interquartile range of effectiveness indicators for contact tracing in close contacts and non-close contacts in foreignborn index cases and index cases of the general population Group Foreign-born index cases with close contacts with non-close contacts General population index cases with close contacts with non-close contacts n. The collection and reporting of data showed a high level of heterogeneity across the studies, which made the results difficult to compare and no firm conclusions could be drawn. Slightly different definitions were used across the studies, for instance for close and non-close contacts. In the included studies among contacts of the index cases from the general population, close contacts included more often only household contacts than in studies reporting contacts of foreignborn index cases, which more often included workplace contacts. The characteristics of the index cases differed in terms of sputum and culture status. Not all studies accounted for or reported people lost to follow-up, and the duration of contact tracing differed between studies. Challenges of contact tracing among foreign-born individuals Sputum smear status of the index case As mentioned, only six studies compared outcomes by sputum smear status. However, there is a need to asses if the test is equally effective in people from high- versus low-incidence countries . Thus, not all contacts have been infected by the presumed index case, but some have been infected by another source. Genetic characterisation of the pathogen can therefore have important implications for source finding. In most low-incidence countries, foreign-born cases have a lower rate of clustering than local-born cases [36,37]. Similarly, clustering among local-born people could be due to specific sociological factors. These findings suggest that the use of molecular typing and cluster analysis in support of traditional contact tracing should be further explored. Stigma might also prevent foreign-born index cases from naming (all of) their contacts. Fear might play a significant role in naming contacts when these are staying illegally in the country of residence. The number of exposed contacts can therefore be underreported, which can result in a bias. These limited results did not indicate a difference in adherence between foreign-born contacts and contacts from the general population (including foreign-born). Cost-effectiveness of contact tracing Although this was not the scope of this literature review, research indicated that contact tracing was highly cost-effective and resulted in net savings . The latter two ways of case detection were less cost-effective largely because of substantial operational problems such as additional visits for education and reassurance, evaluation of side effects or new medical problems, or assistance with social problems, all of which are common in newly arrived immigrants. Conclusions From this review several conclusions can be drawn to address the challenges facing contact tracing among migrants. Not every contact investigation can reasonably be conducted with the same strategy, uniform decisions about who needs to be assessed and why a certain strategy has been chosen should be agreed upon. Key questions to be answered are for example: which considerations are made to decide the initial size of the contact investigation When do local health services expand the contact investigation to the next circle of contacts Uniform data collection and reporting To compare the effectiveness of the different contact tracing strategies used, data need to be collected and reported more uniformly. Definitions should be used uniformly throughout studies to be able to better compare results. There is an urgent need for a diagnostic tool to identify people with recent latent infection that are at highest risk for developing active disease. Identifying for which infected contacts close follow-up or preventive treatment should be offered remains a priority. Control and prevention of tuberculosis in the United Kingdom: code of practice 2000. The impact of immigration on the elimination of tuberculosis in the Netherlands: a model based approach. Tuberculosis contact investigation in low prevalence countries; Consensus document from the 13th Wolfheze Workshop; 2008 June 1-2; the Hague, the Netherlands. Contact tracing and population screening for tuberculosis-who should be assessed Pseudo-outbreak of tuberculosis in poultry plant workers, Sussex County, Delaware. Survey of tuberculosis incidents in hospital healthcare workers, England and Wales, 2005. Contact tracing for tuberculosis and treatment for latent infection in a low incidence country. Molecular and conventional epidemiology of tuberculosis in an inner city district. Tuberculosis infection in children who are contacts of immigrant tuberculosis patients. Contact investigation and genotyping to identify tuberculosis transmission to children. Predictive value of contact investigation for identifying recent transmission of Mycobacterium tuberculosis. Risk factors for tuberculin skin test positivity in an industrial workforce results of a contact investigation. Investigation of sudden death from Mycobacterium tuberculosis in a foreign-born worker at a resort hotel. A tuberculosis outbreak in a private-home family child care center in San Francisco, 2002 to 2004. Mycobacterium tuberculosis transmission in a newborn nursery and maternity ward-New York City, 2003. Impact of policy and practice on the effectiveness of contact screening for tuberculosis. Use of an interferon-gamma release assay to diagnose latent tuberculosis infection in foreign-born patients. Postsanatorium pattern of antituberculous drug resistance in the Canadian-born population of western Canada: effect of outpatient care and immigration. Comparison of cost-effectiveness of tuberculosis screening of close contacts and foreign-born populations. Transmission is usually by the faecal-oral route, including via person-to-person spread, contaminated water or food products. It has also been associated with injecting drug use and outbreaks among men having sex with men. These clusters countries, the overall incidence of hepatitis A has decreased therefore highlight the importance over the last 10 years from 15. In these papers, the authors describe the prevent the spread to the general community. However, the Czech extent to which hepatitis A can spread within at-risk susceptible example shows that such a strategy for control may not be effective populations and in the cases of Czech Republic and Latvia within with hard-to-reach communities such as injecting drug users. In these reports, a significant proportion of cases are young adults, resulting in potentially more severe clinical Once the outbreak spreads to the general population, vaccination presentation and posing a challenge to the health authorities in the of contacts, as carried out in Czech Republic, represents an option area of safety of blood and tissue donation. This stresses the need to promote immunisation of all travellers to endemic areas to prevent return introduction and to develop evidence-based guidance for outbreak control strategies. European Centre for Disease Prevention and Control: Annual Epidemiological Report on Communicable Diseases in Europe 2008. ArticleId=19091 Perevoscikovs J, Lucenko I, Magone S, Brila A, Curikova J, Vennema H. Cluster of cases of hepatitis A with a travel history to Eg ypt, SeptemberNovember 2008, France. Cluster of hepatitis A cases among travellers returning from Eg ypt, Germany, September through November 2008. Hepatitis A in the European Union: responding to challenges related to new epidemiological patterns. Laboratory of Virolog y, Faculty of Veterinary Medicine, Ghent University, Belgium 2. Many swine influenza viruses are a result of reassortment and their genes are composed of human and avian and/or swine virus genes. Indeed, it is known that both human and avian influenza viruses occasionally transmit to pigs, and that pigs can serve as "mixing vessels" for these viruses, meaning that viruses can exchange genetic material and lead to the production of a new "hybrid" virus . This has led to the thinking that perhaps pandemic viruses could emerge following reassortment in pigs. However, since nobody has observed the start of a pandemic, there remains no direct evidence to make this more than a theory. This was passed on to the laboratory as a regular surveillance specimen and then recognised as being influenza A (H1N1) phylogenetically close to European H1N1 swine influenza viruses. Infection with swine influenza virus has been detected sporadically in humans since the 1950s and the human disease is usually clinically similar to disease caused by infections with human influenza viruses . However, complications that include Influenza is one of the major causes of acute respiratory disease pneumonia and death have occasionally been reported in the in pigs, but subclinical infections are also common. Unlike the literature in otherwise healthy adults without underlying disease non-zoonotic swine fevers it is not a disease that comes under . The with avian influenza A (H5N1)  and more similar to infections symptoms and pathogenesis of influenza in pigs show remarkable with low pathogenic avian influenza viruses . Single generation similarities with those of seasonal influenza in humans, but the person to person transmission has been reported but appears to epidemiology is different. Part of this is due to the structure of be rare and chains of transmission have not been observed in the swine industry and the extremely rapid turnover of the swine general . In swinethey discover such human infections, dense regions in particular, most pigs it seems reasonable to regard them as show serological evidence of having On the whole, human infections with comparable to low pathogenic avian been infected with influenza by the end influenza and so deserving a similar of the six-month-long fattening period, swine influenza virus, to date, have been approach . Unlike human viruses in seen with avian influenza A (H5N1) an outbreak of swine influenza virus temperate climates, swine influenza infections in humans was detected in viruses circulate at comparable levels recruits in a military camp in Fort Dix, year round. The presumed link to pigs was never differ significantly in their antigenic and genetic make-up from discovered but there was extensive human to human transmission, those circulating in North America, even though they consist of the with over 200 infections resulting in 12 hospitalisations and one same H and N subtypes, and hence findings in the United States death . This was human to human transmission of a novel should not necessarily be extrapolated to Europe. The Humans in contact with pigs occasionally become infected by unilateral decision was made by the national authorities to develop, swine influenza viruses . This issue of Eurosurveillance reports produce and deploy a specific pandemic vaccine based on the new on a case of swine influenza in a middle-aged woman in Spain  strain. However, the infections petered out and the vaccine was which came to attention almost by chance. Mass immunisation was terminated but the incident remains part of public health lore and has been reviewed extensively for its learning points [10,11]. While the reported case in this issue and other sporadic cases pose little direct threat to humans, they expose important gaps in knowledge about these zoonotic influenzas. Recent serologic studies in the United States, where there has been more attention to zoonotic swine influenza than in Europe, have consistently found higher seroprevalence rates and higher antibody titres against all swine influenza viruses in those working with pigs than in non-swine-exposed controls [12-15]. This, and the fact that the current infection was detected by accident, suggests that the few reported cases of symptomatic swine influenza in humans represent a larger number of undetected infections among those in contact with pigs. However, there are no comparable data available for Europe and the prevalence of swine influenza in humans cannot be estimated from such studies because of the possibility of partial serologic cross-reactivity in the haemagglutination-inhibition test between human and swine influenza virus strains of the same subtype. Epidemiologists have tried to adjust for this by statistical methods, but they agree "it is possible that the elevated titers compared by proportional odds modeling do not correlate with infection" . This stresses the need for combined serological and virological surveillance in humans exposed to pigs to gain this information. There have been recent developments in surveillance of influenza in European swine populations, which is an essential starting point for the monitoring of swine flu in humans. Even if the magnitude of the risk of swine influenza virus infections to human health is unknown, it seems unlikely to be high. Two factors are probably restricting infection of humans, though both are neglected research areas. Firstly, the host range of influenza viruses is generally very restricted by a limited fitness of a given virus in a different host species. Studies on the infectivity of animal influenza viruses for cells of the human respiratory tract, and the molecular determinants involved, have however so far focused almost exclusively on avian influenza viruses [16-18]. Secondly, immunity to human H1 or H3 influenza viruses may partially protect against infection with swine viruses. This type of research is needed if we want to understand the risk of zoonotic influenza based on scientifically proven facts rather than hypotheses. The unknown element is the risk of reassortment to produce a novel virus, even a pandemic strain either in the pig "mixing vessel" or in a human dually infected with a human and pig strain. In the United States there have recently appeared triple reassortant swine influenza viruses with avian, human and swine genes and these have then transmitted to humans [19,20]. Fortunately, these and similar swine influenza viruses  that can infect humans have not yet met any of the criteria to cause a human pandemic. The true risk can only become clear if epidemiological investigations are combined with experimental research. Some scientists have advocated offering seasonal influenza vaccination to persons working with pigs to reduce their risk of getting infected . However, experience with workers with domestic poultry on this point is not encouraging . In one audit attempt in Europe uptake of the vaccine was low and those offered immunisation were confused as to what they were being protected against.
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Use information from monitoring activities to advocate for healthy public policies xena herbals buy genuine himplasia line. Cohen & Reutter herbs used for medicine buy cheap himplasia 30 caps on-line, 2007 Level 5 source: Wheel notes Human rights and social justice perspectives Nursing literature highlights the use of advocacy to address both human rights and social justice issues aasha herbals - best himplasia 30 caps. Researchers framing advocacy from a human rights perspective often address advocacy at the individual level phoenix herbals 50x discount himplasia 30 caps overnight delivery, while those working from a social justice perspective more often focus on advocating for change in systems to improve population health herbs meaning buy discount himplasia 30caps on-line. Historically herbals export buy himplasia 30caps on-line, nursing advocacy has emphasized human rights, beginning with the writings of Florence Nightingale. Although nursing literature continues to feature a human rights emphasis (Vaartio & Keino-Kilpi, 2004), current literature also highlights policy advocacy at the systems level (Ezeonwu, 2015; Falk-Rafael & Betker, 2012; International Council of Nurses, 2008). Relational ethics promotes advocacy actions through the nurse/client relationship (MacDonald, 2007). How does the client embody or balance the implications of the scientific knowledge presented and its emotional ramifications Does true engagement exist, where the nurse and the client are sufficiently invested in each other to assure mutual concern The literature reveals that advocacy and empowerment overlap, with both enabling self-reliance in others, communities, and systems. Empowerment involves assisting others to discover and use the power within individuals/families, communities, or systems; advocacy is not something done or given to another. While empowerment may be a consequence of advocacy actions, some individuals, families, groups, communities, and systems may continue to require someone to speak or act on their behalf. Development of the role of public health nurses in addressing child and family poverty: a framework for action. More than a message: Framing public health advocacy to change corporate practices. Witnessing social injustice downstream and advocating for health equity upstream: "The trombone slide" of nursing. Public health campaigns to change industry practices that damage health: An analysis of 12 case studies. Patient advocacy: Japanese psychiatric nurses recognizing necessity for intervention. Key social marketing themes include: Influencing behaviors Applying marketing principles and techniques via a systematic planning process Focusing on priority audience segments Delivering a positive benefit for individuals and society "In the case of health-related social marketing, the social good can be articulated in terms of achieving specific, achievable, and manageable behavior goals, relevant to improving health and reducing health inequalities" (Quinn, Ellery, Thomas, & Marshall, 2010, p. An initiative is consistent with social marketing when its driving concern focuses on understanding the customer (client) and on achieving and sustaining specific behaviors (French & Blair-Stevens, 2010). Problem: Bullying among adolescents occurs worldwide, resulting in negative health consequences like school absenteeism, lower academic achievement, and adverse mental and physical health outcomes. Systems level A school nurse convenes a district task group, including student representatives, to discuss and identify anti-bullying social marketing interventions at the district level. The school nurse asks the group to consider using systems-level strategies found at StopBullying. Community level the Howard County Public School System in Maryland joined together with students and the community to create bully-free zones. Individual/family level School nurses marketed bullying prevention messages to adolescents, their families, and school staff with posters, online communication, newsletters, and classroom presentations. The school nurses adapted messages from resources like StandUp, an online school-based bullying prevention program that focuses on developing healthy relationships (Timmons-Mitchell et al. Relationship with other interventions Social marketing, first introduced in 1971, contains similarities to some longerestablished interventions. Like health teaching, social marketing aims to change attitudes and behaviors, and some see it as a special application of health teaching. At the community level, social marketing overlaps with advocacy, often implemented as media advocacy. Describe plan background, purpose, and focus Prior to developing a targeted plan, identify the social issue or problem, and factors that contribute to the issue or problem. Develop a purpose statement that communicates the benefit of the social marketing plan. For example, in order to improve water quality (purpose), one could choose to address pesticide use (option). Conduct a situation analysis Understanding factors and forces in the environment determines the relevance of planning decisions. Internal factors include available resources, expertise, administrative support, and partners, which may constitute strengths or weaknesses. External factors include cultural, technological, demographic, economic, political, and legal forces that represent opportunities or threats. Select target audience Identifying the audience determines additional planning steps. Target market characteristics include stages of change, demographics, geography, behaviors, psychographics, and size of market. Segment the market or population (break it into smaller groups) based on specific criteria, and choose one or more groups for marketing strategies. Set behavior objectives and goals Goals and objectives guide social marketing decisions. Craft a positioning statement A positioning statement "[explains how you] want the target audience to see the targeted behavior, highlighting unique benefits" (Lee & Kotler, 2016, p. Include a description of the target audience, competitors, barriers, and motivators to action. Product Using the example of promoting mammograms, the product is the benefits associated with the behavior change: Core product: Bundle of benefits. The price may include intangible costs that accompany the change (loss of time, psychological hassle, embarrassment). Questions about the cost for the mammogram screening example include: Place the place includes where and when the target market performs the desired behavior: Where considers physical location, organizations and people who provide information, goods and services, attractiveness and comfort, and accessibility (parking and public transportation). Consider the following questions about place for the mammogram screening example: Promotion Promotion includes persuasive messages communicating product benefits, services, pricing, and place: Consider multiple elements, including specific communication objectives for each target example, guidelines for developing prominent, effective messages, and designating communication channels. Outline a monitoring and evaluation plan Develop an evaluation strategy prior to plan implementation to ensure outcomes are monitored on an ongoing basis: Clarify the evaluation purpose and audience. Refer to established goals for the desired levels of change in behavior, knowledge, and beliefs. Establish three categories of measures: Output measures (campaign activities) Outcome measures (the responses of the target market, including changes in knowledge, beliefs, and behavior) Impact measures (contributions to the plan purpose) 9. Establish budgets and find funding sources Determine if available budget and funding stream(s) support the selected strategies: Summarize funding requirements and potential funding sources for product benefits, features, and distribution channels. Revise goals, target audience, and strategies based on secured funding sources, including partner contributions. During implementation, pay attention to client response (Thackeray & Neiger, 2009): Structure interactions so clients focus on the positive outcomes. Provide clients with messaging that encourages them to talk about products to friends and family. For each segment, identify the following components in a matrix: Segment Relevant characteristics Message Channels Evaluation For example, a social marketing campaign that promotes immunization might include the segments "unaware," "afraid and untrusting," and "religious opponents" (Slater, Kelly, & Thackeray, 2006). Monitor and evaluate plan implementation Monitoring and evaluating social marketing activities during implementation helps identify mid-course revisions, and can help refine the social marketing program. Answer the question: "Did we change what we intended to change (knowledge, behaviors, or attitudes) Example the Howard County Public School System in Maryland joined with community partners to implement a campaign to prevent cyberbullying and other bullying behaviors (Howard County Public School System, 2017a; StopBullying. A school nurse contributed knowledge and skills to planning and implementing bullying prevention social marketing strategies. Describe the plan background, purpose, and focus After serious bullying incidents (including a suicide), Howard County Public School System, including school nurses throughout the district, decided to tackle bullying and cyber harassment by raising awareness. Conduct a situation analysis Planners reviewed current laws and discussed whether to advocate for new state legislation. They looked at how the public schools collected and handled bullying reports and incidents. Select target audience After exploration and discussion, planners chose a multi-faceted and comprehensive approach including community partners. Set behavior objectives and goals the planners invited community partners and identified three approaches: a. The bullying prevention campaign used lessons learned from that work to develop a similar message around bullying. Developing a tool to report bullying when it happens, in real time: the planners used a customized web-based reporting application called Sprigeo, in which a person anonymously reports bullying in schools, at a park or library, or elsewhere in the community. Making materials and training available for those who work with students on the skills and knowledge needed to address bullying: For example, StopBullying. Identify benefits, motivators, barriers, and change strategies Bullying prevention messages needed to address motivators for bullying and behaviors to change. The planners met with students to identify barriers and motivators, and to discuss perceptions of factors that contribute to and prevent bullying behavior. Craft a positioning statement [The Howard County Public School System] has taken a strong stand against bullying with a goal to eradicate bullying. Unfortunately, bullying is a reality that lives within the hallways of our schools and one that we must root out once and for all. We know that those who are bullied may experience depression, anxiety, sadness and loneliness. They can suffer from changes in sleep and eating patterns and loss of interest in activities that they typically enjoy. Children who have suffered through bullying have gone so far as to injure themselves and even take their own life. Price: Although there was a cost involved in developing and implementing the bullying prevention plan, fewer bullying incidents decreased the staff burden related to response, and results in a cost savings. Place: the target market was the community served by the Howard County Public School System. Promotion: One example of a promotional tool was the public service announcement at a school-sponsored prevention event, Bullying prevention message (2017c). The number of forms submitted provides a strategy for measuring change in the incidence of bullying behaviors. Implement the plan During implementation, the planners noted the response of different market segments within the community-students, parents, school staff, community organizations, and the public. Monitor and evaluate plan implementation the evaluation plan initially called for evaluating whether the bullying prevention campaign changed knowledge, behaviors, and attitudes related to bullying. Intermediate measures on community responses were important for refining social marketing messages. Later measures would compare bullying incidence rates to the rate occurring during the 2016-2017 (baseline) school year. Theories supporting social marketing Several theories support social marketing: Exchange theory, the Theory of Planned Behavior, and the health belief model. These theories explain how motivation and incentives lead individuals or groups to adopt healthy behaviors. Identifying social marketing interventions Interventions can be categorized as social marketing if they meet the following criteria: the intervention focuses on actual change of behavior rather than a change in awareness or knowledge. Research is conducted to provide insight into the consumer experience and to drive decision-making. Consumer research analysis provides those planning the intervention with insight into targets of opportunity. The intervention strategy is tailored to targets of opportunity and marketing mix (product, price, place, promotion, exchange, competition). Concepts related to the intervention strategy and the marketing mix are pretested with the intended audience. Effective social marketing Tips for effective social marketing include: Develop a plan that includes attention to all aspects of the marketing mix-product, price, place, and promotion-as well as policy and partnerships. Use research throughout the process-carefully review existing literature, and collect new data through focus groups, surveys, and observation. Involve the target population, including opinion leaders, to actively participate in and co-create the development process. Consider socioeconomic factors, cultural beliefs, values, geographic location, and local norms and values. The target audience must perceive benefits that equal or exceed perceived costs associated with performing the behavior. Employ marketing techniques, including consumer-oriented market research, segmentation and targeting, and marketing mix of strategies. Focus on the end goal of improving individual and societal well-being, rather than focusing on the organization. Use multiple approaches (written, oral, visual graphics, electronic) and repetition to maximize your promotion messaging. Avoid terminology, phrases, or visual cues that reinforce stereotypes or contradict verbal messages. Social media is one valuable marketing channel, but do not neglect other methods like radio/podcasts, television, posters, periodicals, and other written material. Firestone, Rowe, Modi, & Sievers, 2017 Stead, Gordon, Angus, & McDermott, 2007 Schoon, Porta, & Schaffer, 2019 Level 2 source: Level 3 source: Level 5 source: 4. Augmented products and questions to consider Consider the following when designing a new augmented product (tangible good or service) or modifying an existing one: Should a new service be developed and offered Should a new product be developed (or be encouraged to be developed) to encourage behavior change Criteria for identifying and validating good practice Specific benchmark criteria for identifying and validating good social marketing practice include: Customer (client) orientation Behavioral goals Theory-based factors that contribute to behavior (biological and physical, psychological, social, environmental) Insight into what motivates people Exchange (what is the person willing to give in order to get expected benefits Ethical norms and values Ethical norms and values for social marketing include: Do no harm by avoiding harmful actions and omissions. Foster trust in the marketing system by avoiding deception in design, communication, and/or distribution. Embrace ethical values by building relationships and adhering to core values of honesty, responsibility, fairness, respect, transparency, and citizenship.
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Hallways must be cleared where possible and only essential staff should accompany the patient. Additionally, there is no evidence for use of the following medications for outpatients or mildly ill patients. Use of these resources for that purpose should be discouraged through prescribing restricted to critical care, infectious disease, or rheumatology physicians. There is genuine uncertainty in the expert medical community over whether proposed off-label and investigational treatments are beneficial. The position of "equipoise"-genuine uncertainty in the expert medical community over whether a treatment will be beneficial-"is the ethical basis for assigning only some participants to receive the agent. If the relative risks and benefits of an agent are unknown, participants who receive the experimental agent may receive a benefit or may be made worse off. Providing the experimental agent to all would expose all participants to potentially harmful effects. Remdesivir is potentially available under compassionate use from Gilead for patients with clinical pneumonia: compassionateaccess@gilead. These drugs have been widely used as anti-malarial treatment and prophylaxis and to treat autoimmune conditions. An additional preliminary report on chloroquine clinical activity was released by investigators in China, but detailed information is pending. Coronavirus cellular infectivity and replication are dependent on virally-encoded and cellular protease activity. Do not use in combination with amiodarone (fatal arrhythmia), quetiapine (severe coma), or simvastatin (rhabdomyolysis). A variety of therapies are being administered to severely ill patients in China and elsewhere. Several additional agents are under investigation and information is expected to emerge rapidly. Discernment of benefits and harms from novel therapies will require diligent attention to quality of evidence reported. Pregnant women experience immunologic and physiologic changes that make them more susceptible to viral respiratory infections. Pregnant women might be at greater risk for severe illness, morbidity, or mortality compared with the general population, as is observed with other related coronavirus infections. Pregnant women should receive the same care as those who are not pregnant in regard to screening, radiology studies, laboratory evaluations and critical care. Case series suggest no evidence of vertical transmission, similar to other viral respiratory illnesses, such as influenza. For women infected in the third trimester who recover, attempts to postpone delivery until a negative test result or quarantine status is lifted. Cesarean section: Cesarean section should be reserved for maternal and fetal indications. Antenatal surveillance: Gestational age appropriate fetal monitoring should be part of the initial assessment of any women with respiratory symptoms and continuous fetal monitoring should be provided for any critically ill pregnant woman. Third trimester growth assessment is reasonable to consider for later second trimester and third trimester infections. When patient is discharged from the hospital a plan for follow up should be established. For that reason close follow up with patients via phone triage should be performed. If patients symptoms worsen arrangements should be made for patient to be seen by a health care provider to assess clinical status. Women who intend to breastfeed should be provided a dedicated breast pump to express breast milk. Considerations can be made to delay delivery to prevent unnecessary exposure to neonate but ultimately delivery timing should be made based on maternal and fetal indications. Vertical transmission does not appear to occur, but perinatal infection leading to severe manifestations has been documented. They will also be encouraged to wash any skin that may come in contact with the infant (e. They will be encouraged to limit other close contact with the infant(s) and a separate non-infected caregiver should be present to help care for the infant. Wipe the surface where syringes/bottles will be placed after collection with a germicidal disposable wipe, and cover surface with clean paper towel or cloth. Mother will wash hands and breasts before use and cleaning equipment before and after use. Mother collects breast milk by hand or by pump into clean syringes or bottles then ensures syringe/bottle cap is secured. Transport and storage of breast milk from isolation room to common refrigerated storage should follow strict infection control procedures per hospital policy. Prior to discharge, inpatient providers will directly discuss care of the infant with the follow-up provider. Patients requiring nasal cannula or those who are intubated on mechanical ventilation (closed circuit) require contact/droplet precautions when handling to include surgical mask, gown, hair cover, and gloves. The partner and doula should only be allowed in areas on the hospital necessary to support birth. The partner should be isolated to the post-partum room and not be traveling elsewhere within the hospital. Severe symptoms requiring admission for supplemental oxygen have been described in up to 10% of symptomatic children, particularly those under the age of 5, with the highest risk in those under 12 months of age. The mortality rate appears to be extremely low: one study out of China reported only one death in 2,143 pediatrics patients. The intersection with chronic pediatric respiratory conditions such as asthma, cystic fibrosis, and chronic lung disease, and with the attendant increased risk of severe disease, is unknown. Pediatric symptoms, if present, are similar to common viral respiratory infections with a majority of symptoms affecting the upper airway. This differs from adults, who tend to have lower respiratory symptoms most prominent. Treatment of severe disease remains supportive, to include critical care interventions as required. Enrollment in clinical trials, or compassionate use of experimental therapies, should be considered for children with severe disease just as they would be for severely affected adults. There is no evidence to suggest that prophylaxis is necessary or effective for the majority of children. Viral load is detectable in respiratory secretions for up to 2 weeks and in stool for up to 4 weeks. Early data from China suggest that a majority of deaths have occurred among adults aged 60 years especially those with underlying health conditions. In the United States, mortality rates in patients above age 85 have ranged 10-27%, and 3-11% among patients 65-84 years. Ensure that care for the older adult and severely ill is in keeping with their goals of care, advance directives and patient and family wishes. Patients should be informed about their condition, and, if desired, their prognosis, in a way that is easy to understand. If the patient is unable to communicate meaningfully, ensure that a surrogate decision maker or health care agent has been identified in accordance with state law based on facility location. Symptom management: Aggressive control of symptoms such as pain, dyspnea or other bothersome symptoms relieves unnecessary suffering and is therefore crucial for all patients regarding of age, function, comorbidities and prognosis. All providers should be able to provide basic symptom management, routine discussions about code status and goals of care in patients that are seriously ill. If complex symptom management, difficult discussions about code status, and care goals arise, consider consultation from a palliative medicine subspecialist if available at your institution. Compassionate extubation in the setting of comfort oriented care or the actively dying patient should be considered a medical procedure similar to ventilator initiation and follow a specific plan as removal of the ventilator can cause discomfort. Additional guidance is available in Fair Allocation of Scarce Medical Resources in the Time of Covid-19 Decisions regarding allocation of resources should be made at local, regional, state or federal levels. Providers should avoid discussing rationing care at the bedside and should continue to provide compassionate care for the individual patient. Age and comorbidities should not be a factor for provision of care for older adults. Individual decisions and institutional policy regarding allocation of resources should be discussed in an interdisciplinary fashion and include input from stakeholders such as palliative medicine and healthcare ethics experts. Institutional policy should be frequently reevaluated given the rapidly evolving nature of this crisis. Institutional Clinical Ethics Committees should work closely with palliative medicine services to review process and decision making in resource scarce environments. If assistance is needed with transport, every attempt should be made to use someone from the care team (nurse, surgeon, tech) to minimize exposure. Hook the Ambu bag up prior to opening the door in the negative pressure room and ensure the door is closed when returning the patient and switching to the ventilator. The same filter may also be used on the exhalation loop of the anesthesia machine- do not throw it away. Make every attempt to take out all necessary meds and equipment from the carts prior to bringing patient into the room. Routine breaks for anesthesia providers should be avoided to limit exposure and conserve supplies. Rapid Sequence Intubation should be performed when at all possible to avoid mask ventilation due to increased aerosolization of secretions. Double glove and immediately remove outer glove after the airway is confirmed secure. Outer gloves may be used to wrap disposable portions of airway equipment after use. Consider, at a minimum, using hand sanitizer on inner gloves or exchange with new gloves. Intubation and extubation generate a transient, significant droplet load for the room. Ensure all nonessential personnel are given the chance to leave the room if possible before performing the procedures. Executive Order 2020-17 temporarily restricts non-emergency medical and dental surgeries and procedures. When there are questions or controversies whether or not a surgical procedure is elective, the time sensitivity and/or medical necessity should be determined at the local level, preferably the Department of Surgery Chief. Classification of cases should be based on operative capacity (available, constrained, or none) as well as patient needs and adjusted based on the above assessment. Telemedicine encompasses a set of tools that leverage information and communication technologies to most commonly extend medical care across geographic distances and boundaries. These same tools have a significant and unique potential to support care delivery during an infectious pandemic in order to decrease healthcare worker exposure to contagion. Direct-to-patient where the health care provider examines the patient in real-time, interactive audio or visual (or both) telecommunication system and the patient interacts with the offsite health care professional at the time the services are provided. Services delivered in this manner may occur using telephonic (audio) only service delivery. The Telehealth protocol may be utilized as appropriate to obtain medical control guidance in taking patient to an alternate destination such as urgent care, or treating in place. Eye protection: goggles or a disposable face shield that fully covers the front and sides of the face should be worn. If there are shortages of gowns, they should be prioritized for aerosolgenerating procedures, and high-contact patient care activities that allow transfer of pathogens (e. When possible, use vehicles that have isolated driver and patient compartments that can provide separate ventilation to each area. Close the door/window between these compartments before bringing the patient on board. During transport, vehicle ventilation in both compartments should be on non-recirculated mode to maximize air changes that reduce potentially infectious particles in the vehicle. If the vehicle is without an isolated driver compartment and ventilation must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting. If an aerosol-generating procedure is required/recommended, the doors to the patient compartment of the ambulance should remain open to allow ventilation of the area during these procedures if possible. After transporting the patient, leave the rear doors of the transport vehicle open to allow for sufficient air changes to remove potentially infectious particles. The time to complete transfer of the patient to the receiving facility and complete all documentation should suffice. A face shield or facemask and goggles should be worn if splashes or sprays during cleaning are anticipated. Ensure disinfection procedures are followed consistently, to include the provision of adequate ventilation when chemicals are in use. Local public health authorities should be notified about the patient so that appropriate follow-up monitoring can occur.