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Maternal and child undernutrition: Consequences for adult health and human capital effective cafergot 100 mg. Maternal and child undernutrition: Global and regional exposures and health consequences buy discount cafergot 100mg line. Obese women exhibit differences in ovarian metabolites, hormones, and gene expression compared with moderate-weight women. Neonatal bone mass: Influence of parental birthweight, maternal smoking, body composition, and activity during pregnancy. Maternal predictors of neonatal bone size and geometry: The Southampton Women’s Survey. Maternal vitamin D status during pregnancy and bone mass in offspring at 20 years of age: A prospective cohort study. Genome-wide association study of 14,000 cases of seven common diseases and 3000 shared controls. Large-scale association analysis provides insights into the genetic architecture and pathophysiology of type 2 diabetes. Towards a new developmental synthesis: Adaptive developmental plasticity and human disease. Persistent epigenetic differences associated with prenatal exposure to famine in humans. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks; World Health Organisation: Geneva, Switzerland, 2009. Maternal mortality in adolescents compared with women of other ages: Evidence from 144 countries. Improving women’s diet quality preconceptionally and during gestation: Effects on birth weight and prevalence of low birth weight—A randomized controlled efficacy trial in India (Mumbai Maternal Nutrition Project). Maternal antenatal multiple micronutrient supplementation for long-term health benefits in children: A systematic review and meta-analysis. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. Changing health behaviour of young women from disadvantaged backgrounds: Evidence from systematic reviews. Low-income groups and behaviour change interventions: A review of intervention content, effectiveness and theoretical frameworks. The Southampton Initiative for Health: A complex intervention to improve the diets and increase the physical activity levels of women from disadvantaged communities. The effect of a behaviour change intervention on the diets and physical activity levels of women attending Sure Start Children’s Centres: Results from a complex public health intervention. Engaging teenagers in improving their health behaviours and increasing their interest in science (Evaluation of LifeLab Southampton): Study protocol for a cluster randomized controlled trial. Application of Intervention Mapping to develop a community-based health promotion pre-pregnancy intervention for adolescent girls in rural South Africa: Project Ntshembo (Hope). Innovative interventions to promote behavioral change in overweight or obese individuals: A review of the literature. Theory-based strategies for enhancing the impact and usage of digital health behaviour change interventions: A review. Economic and Nutritional Analyses Offer Substantial Synergies for Understanding Human Nutrition. Schlechter Pediatric Orthopaedics and Sports Medicine Osgood-Schlatter Disease Description Osgood-Schlatter disease is an inflammatory injury of the growth plate on the tibia (shin bone) just below the level of the knee at the tibial tubercle This disease may also be referred to as osteochondrosis or apophysitis of the tibial tubercle The tibial tubercle is the bony attachment for the quadriceps (front thigh muscle). Contraction of the quadriceps results primarily in straightening of the leg at the level of the knee A growth plate is an area of developing tissue near the ends of long bones or areas of muscle attachment. The growth plates in children allow the bones to expand in length thus allowing a child to reach his or her full height by the age of 16 to 19 Compared to the surrounding bone and muscles, the growth plate serves as a weak point. Thus repetitive pulling on a growth plate, especially from a large powerful muscle like the quadriceps, can result in injury to the growth plate and subsequent pain Osgood-Schlatter Disease is usually a self limited disease – upon reaching skeletal maturity, the growth plate seals and thus can no longer cause pain This condition is very similar in presentation and treatment to Sinding-Larsen- Johansson Syndrome, which is a traction apophysitis of the inferior pole of the patella Cause Repetitive stress or injury to the growth plate of the tibial tubercle results in inflammation and subsequent pain The injury has a waxing-and-waning course. Even after pain has subsided for some time, repetitive stress can cause a flare-up Risk factors Activities that involve jumping and/or jogging Boys, especially those between the age of 11 and 18 Rapid skeletal growth Poor physical conditioning Symptoms Swelling, warmth, and/or tenderness below the knee A firm bump under the knee that is exquisitely tender to touch Pain with activity, especially with knee straightening or vigorous activity Diagnosis Page 1 Dr. Schlechter Pediatric Orthopaedics and Sports Medicine Diagnosis of Osgood-Schlatter disease is made primarily by physical exam Difficulty may be present with a straight leg raise, especially against resistance The area of skin overlying the tibial tubercle may be enlarged and firm. This area is also exquisitely tender to touch Radiographs may be used to rule out underlying fractures or other bony injuries in the area Prevention Weight loss to acquire a proper body mass index for age and height Warm up and stretching before partaking in physical activity. Similarly, application of a heat pack can be applied to the area before participating in activities or exercises Your physician can provide a set of at home exercises to help improve strength and flexibility. In some instances, a referral to physical therapy or an athletic trainer is needed to augment treatment Pain medications such as nonsteroidal anti-inflammatories (like ibuprofen or naproxen) or acetaminophen can be used to relieve pain and irritation. These medications should be taken as directed by your physician A patellar band, which is a brace situated between the tibial tubercle and the kneecap, may help relieve symptoms In rare instances, surgery is necessary if conservative treatment has failed. A trial of immobilization with an elastic knee support, cast, or splint may be tried for 6 to 8 weeks before considering surgery Complications of this condition include a persistence of a bump overlying the tibial tubercle, reoccurrence in adulthood, tearing away (avulsion) of the growth plate from the tibia Page 2 Dr. Schlechter Pediatric Orthopaedics and Sports Medicine Surgical Fixation Page 3 Dr. Please remember: Flexible tissue is more tolerant of the stresses placed on it during activities. If you are too “tight” to do this, loop a belt or towel around your ankle and grasp that. Pull your heel toward your buttock until you feel a stretching sensation in the front of your thigh. Stand and prop the leg you are stretching on a chair, table, or other stable object. Your buttock should be as close to the wall as possible and the other leg should be kept flat on the floor. Schlechter Pediatric Orthopaedics and Sports Medicine Strengthening Exercises for Excessive Lateral Patellar Compression Syndrome. These are some of the initial exercises you may start your rehabilitation program with until you see your physician, physical therapist, or athletic trainer again or until your symptoms are resolved.

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In the limiting situation every newborn infant has passive immunity 100mg cafergot with visa, so that m0 → 1 and s0 → 0 generic cafergot 100mg with amex. Note that the formula for λ is for an endemic steady state for a virulent disease, so it does not imply that R0δ/(δ + d + q) > 1 is the threshold condition for existence of a positive endemic steady state age distribution; compare with [12, p. Thus for a very virulent disease, adding a passively immune class to a model increases the average age of attack by the mean period of passive immunity. Solving for R0 in terms of the average period p of passive immunity and the average lifetime L =1/d, we obtain [q +1/(A − p)](1 + pq) (5. In epidemiological terminology, g is the product of the fraction vaccinated and the vaccine efficacy. This vaccination at age Av causes a jump discontinuity in the sus- ceptible age distribution given by s(Av +0)=(1− g)s(Av − 0), where s(Av − 0) is the limit from the left and s(Av + 0) is the limit from the right. The details are omitted, but sub- stituting the steady state solutions i(a) on these intervals into the expression for λ yields R0(d + q) δ(1 − s0) −(λ+d+q)Av −(δ+d+q)Av (5. Given g, Av, and the values for the parameters β, γ, ε, δ, d, and q, the equations (5. Recall that a population has herd immunity if a large enough fraction is immune, so that the disease would not spread if an outside infective were introduced into the population. To determine this threshold we consider the situation when the disease is at a very low level with λ nearly zero, so that almost no one is infected. Thus the initial passively immune fraction m0 is very small and the initial susceptible fraction s0 is nearly 1. If the successfully vaccinated fraction g at age A is large 0 v enough so that −(d+q)Av (5. A similar criterion for herd immunity with vaccination at two ages in a constant population is given in [98]. Intuitively, there are so many immunes that the average infective cannot replace itself with at least one new infective during the infectious period and, consequently, the disease dies out. If the inequality above is not satisfied and there are some infecteds initially, then we expect the susceptible fraction to approach the stable age distribution given by the jump solution with a positive, constant λ that satisfies (5. The negative signs in the expression for A make it seem as if A is a decreasing function of the successfully vaccinated fraction g, but this is not true since the force of infection λ is a decreasing function of g. For the demo- graphic model in which everyone survives until age L and then dies, d(a) is zero until age L and infinite after age L, so that D(a) is zero until age L and is infinite after age L. Expressions similar to those in this section can be found for a nonconstant population with ρ = q/(1 − e−qL), but they are not presented here. Typically the lifetime L is larger than the average age of attack A ≈ 1/λ, and both are much larger than the average latent period 1/ε and the average infectious period 1/γ. Thus for typical directly transmitted diseases, λL is larger than 5 and γL, εL, γ/λ, and ε/λ are larger than 50. Hence many of the formulas for 0 0 Type I mortality in the Anderson and May book [12, Ch. In sections 7 and 8 we estimate the basic reproduction number in models with age groups for measles in Niger and pertussis in the United States. The initial boundary value problem for this model is given below: ∂S/∂a + ∂S/∂t = −λ(a, t)S − d(a)S, ∞ ∞ λ(a, t)= b(a)˜b(˜a)I(˜a, t)da˜ U(˜a, t)da,˜ 0 0 (6. The boundary ∞ values at age 0 are all zero except for the births given by S(0,t)= 0 f(a)U(a, t)da. The population is partitioned into n age groups as in the demographic model in section 4. The subscripts i denote the parts of the epidemiologic classes in the ith ai age interval [ai−1,ai], so that Si(t)= a S(a, t)da, etc. The total in the four epidemiologic classes for the ith age group is the size N (t)=eqtP of i i the ith group, which is growing exponentially, but the age distribution P1,P2,. Because the numbers are all growing exponentially by eqt, the fractions of the population in the epidemiologic classes are of more interest than the numbers in these epidemiologic classes. Here we follow the same procedure used in the continuous model to find an expression for the basic re- production number R0. Substituting s successively, we find that s = C /[λˆ ···λˆ ] 1 1 1 i−1 i i−1 i 1 for i ≥ 2, where Ci−1 stands for ci−1 ···c1cˆ1P1. When the expressions for ei and ii−1 are substituted into the expression for i in (6. Now the expressions for i and λ = kb can be substituted into this j=1 j j i i i last summation to obtain n εj bj bj−1 b1 (6. Here the feasible region is the subset of the nonnegative orthant in the 4n-dimensional space with the class fractions in the ith group summing to Pi. In the Liapunov derivative V˙ , choose the α coefficients so that the e terms cancel out by letting i i αn = βnεn/εˆn and αj−1 =(βj−1εj−1 + cj−1αj)/εˆj−1 for αn−1,. Using s ≤ P , n n n j−1 j−1 j j−1 j−1 n−1 1 i i we obtain V˙ ≤ (R −1) ˜b i ≤ 0ifR ≤ 1. The set where V˙ = 0 is the boundary of 0 j j 0 the feasible region with ij = 0 for every j, but dij/dt = εjej on this boundary, so that ij moves off this boundary unless ej = 0. Thus the disease-free equilibrium is the only positively invariant subset of the set with V˙ = 0, so that all paths in the feasible region approach the disease-free equilib- rium by the Liapunov–Lasalle theorem [92, p. Thus if R0 ≤ 1, then the disease- free equilibrium is asymptotically stable in the feasible region. If R0 > 1, then we have V>˙ 0 for points sufficiently close to the disease-free equilibrium with s close to P and i i ij > 0 for some j, so that the disease-free equilibrium is unstable. A deterministic compartmental mathemati- cal model has been developed for the study of the effects of heterogeneous mixing and vaccination distribution on disease transmission in Africa [133]. This study focuses on vaccination against measles in the city of Naimey, Niger, in sub-Saharan Africa. The rapidly growing population consists of a majority group with low transmission rates and a minority group of seasonal urban migrants with higher transmission rates. De- mographic and measles epidemiological parameters are estimated from data on Niger. The fertility rates and the death rates in the 16 age groups are obtained from Niger census data. From measles data, it is estimated that the average period of passive immunity 1/δ is 6 months, the average latent period 1/ε is 14 days and the average infectious period 1/γ is 7 days.

Spreading best practices in scheduling and access may help to reduce professional and team frustration buy discount cafergot 100mg, and to rekindle the satisfaction and joy in care delivery discount cafergot 100mg visa. In addition, eliminating prolonged waits can alleviate unnecessary costs (Gilboy et al. The positive return on investment that might be anticipated from a redesign of scheduling processes could be substantial for the patient and the health care system. Scheduling improvements alone can maximize provider supply with a resulting decrease in wait times for appointments. The science of optimizing access and wait times is still evolving, with little comprehensive measurement of wait times for appointments, and with targets that are often pragmatic—reflecting practitioner, staff, room availability, and cost—as opposed to evidence based. While these components are measurable, many other confounding factors influence the capacity of health systems to offer appointments in a timely manner. Looking beyond the challenges in the ambulatory primary and subspecialty environments, hospitals and rehabilitation experience have their own struggles with scheduling and prolonged wait times causing patient and provider irritation, operational inefficiencies, and increased cost. The system complexities can be overwhelming to unbundle and the multiple improvement efforts that have occurred in clinics, hospitals, and rehabilitation centers may be uncoordinated, and opposing incentives often result in bottlenecks in other areas. Health Care The examination of wait times and scheduling complexities is occurring at a time of rapid change in U. National and statewide mandates are requiring that hospitals comply with resource intensive and—in many cases—unproven measure reporting methods aimed at monitoring and improving patient safety and quality. Simultaneously, public scrutiny of health care has been sparked by the burgeoning expense and complexity of our care delivery systems. All levels of health care organizations, from the private practice to the largest public- and private-sector systems, are attempting to improve efficiency and decrease costs through national policies and economic incentives while prioritizing quality in a "better, cheaper, faster" approach to health care (Thompson and Davis, 2001). Of note, these goals were successfully met within the Veterans Health Administration following transformative efforts in the 1990s, demonstrating that medically appropriate, cost- effective health care, delivered locally is certainly possible (Kizer and Dudley, 2009). Rather than relying on standards of acuity, scheduling is largely driven by other factors, such as when the patient calls, appointment availability, physician templates, and work-arounds including overbooking for certain patients and prioritizing referrals from certain doctors, and insurance status. These constraints add further complexity to an already overburdened scheduling process that is designed primarily to meet the needs of the organization, staff, and providers, which often overshadow the needs of the patient. Despite the national interest in moving to a person-centered model of care, patient and family preference is often a secondary factor, resulting in limited choices, little attention to patient preference, and often prolonged wait times. Insurance coverage, in particular, has been reported to be of key importance in the private setting where patients with Medicaid or no insurance coverage have longer wait times (Bisgaier and Rhodes, 2011). The many subtle yet additive nuances of factors particular to each health care system, and its providers and patients, are likely to be the determinant of scheduling delays and wait times for insured patients. Role of Patient Acuity and Triage Scheduling in health care is different from that in other industries. The physiologic state of a patient is dynamic, introducing an inherent uncertainty into patient flow. This uncertainty or clinical variability is not consistently addressed in scheduling systems for elective appointments, resulting in an ad-hoc method of triage. Most systems can respond to the most acute, emergent patient with the temporary re-allocation of staff to meet unexpected demand. However, for routine or elective visits, acuity is evaluated using disease- or circumstance-specific tools developed within each system with little standardization and few national benchmarks upon which to draw for comparison. In these environments, patient acuity is the driver of scheduling, with those patients who are most ill or at risk receiving care first. Although not standardized throughout the country, there are several common acuity-based examples of triage tools including the Emergency Severity Index, the Canadian Triage and Acuity Scale, and the Trauma Triage Tool (Gilboy et al. Thus, in nonacute settings, including ambulatory primary and specialty care, triage- and acuity- based scheduling has not proven effective for the allocation of appointments. A better orientation is an open access or same-day access model where schedulers do not allocate appointments based on attempts to estimate acuity (Murray, 2003). Appointments are not booked weeks or months in advance, rather each day starts with a sizable share of the day’s appointments left open, and the remainder booked for those who elected not to come to the office on the day they called. Balancing these factors when scheduling appointments makes the scheduling process exceedingly complex and often frustrating for patients and providers. Newer models of care aim to simplify this model, with the development of targeted strategies to standardize processes, simplify steps, and redesign the local system of care. In the acute care setting, the traditional model of managing patient flow based on acuity alone resulted in significant wait times for patients with issues that were not life threatening (McCarthy et al. As a result new approaches have been developed, such as “fast track” treatment, to provide care for patients not requiring complex acute care, real-time visualization of wait times, and active bed management for hospital admission. The inpatient setting also suffers from increasing waits and delays for a variety of testing and procedures as well as for discharge due to different staffing at night and on weekends, and imposed constraints of academic medicine. Thus, it is clear that scheduling and wait time problems exist throughout all settings in health care and require the same attention to operations management that exists in other industries but balanced with the needs of patients. The current challenges with scheduling, and resulting wait times, often occur with little regard to the patient and family. Although their preferences are noted in the scheduling process, patient and family understanding of patient acuity is typically incomplete. Clearly important to the design of scheduling and triage systems is incorporation of approaches aimed at setting expectations appropriately, and ensuring respect for patients’ anxiety and fear (Cosgrove et al. Adding to these challenges is the lack of appropriate measurement of the patient experience. Direct feedback is elicited by Press Ganey surveys and in a more rapid fashion using email, mail, or phone surveys. However, as patient experience reflects interaction with many interdependent processes and providers, often crossing multiple lines of authority, localized attempts to correct a problem may be only partially successful. Increasingly, patients are turning to an emerging model of health care: the retail clinic. Retail clinics have emerged as a low-cost and convenient alternative to the traditional model of ambulatory care, providing a discrete set of acute care and preventive services, on an as-needed basis. Patient response to this type of service has been overall quite positive, driving the proliferation of such clinics, and the accreditation of the two largest retailers by the Joint Commission has helped to ensure practices that are consistent with national quality standards (Kaissi and Charland, 2013; Zamosky, 2014; Cassel, 2012). Hospitals, clinics, and ambulatory practices are increasingly expanding hours and evaluating processes to achieve scheduling flexibility. Yet, the current model remains a one-size-fits-all appointment system, whether the patient is a healthy child or a complex, chronically ill adult. Although social workers, patient navigators, nurse practitioners, and other health care professionals have redesigned their roles to 7 proactively accommodate this gap, the persisting scheduling delays in both private and public health care indicate that further change is needed. There is an increasing call for the redesign of office practices to reduce inefficiency and improve capacity through better use of existing office staff, retooling of office processes, increased previsit work, and non-face-to-face visits (Shipman and Sinsky, 2013; Kanter et al.

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