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You remind the residents of the top causes of adolescent and young adult (age 15-24 years) mortality and stress the importance of thorough psychosocial risk assessments during adolescent preventive care visits. Of the following, the top 3 leading causes of death for this age group are unintentional injury, A. The mortality rate of males between 15 to 19 years of age was more than twice that of females in 2010. Additionally, non-Hispanic, American Indian/Alaska Native adolescents had the highest rate of mortality among both males and females. Non-Hispanic black males had the second highest rate; non-Hispanic, Asian/Pacific Islander females had the lowest rate. Unintentional injury was the leading cause of death for adolescents of all racial and ethnic groups, except non-Hispanic black males, for whom homicide was the leading cause of death. The major causes of adolescent mortality are largely preventable, therefore routinely reviewing and counseling on issues such as driving and personal safety with adolescents are important in the provision of adolescent preventive services. The patient was seen at an urgent care clinic on the day of injury, where radiographs were performed and were unremarkable. The urgent care clinician fitted her with a knee immobilizer and recommended follow-up with her primary care physician. The patient is guarding, and therefore you are unable to adequately assess for ligamentous laxity. Another reasonable option would be to recommend protected ambulation with crutches, gentle range-ofmotion exercises, application of ice to reduce swelling and a return visit to the clinic for repeat examination in about 2 weeks. Common mechanisms of injury include sudden deceleration, landing from a jump, and twisting or changing direction. Surgical reconstruction is preferred for athletes who wish to return to sports involving jumping or direction change. The surgical technique for skeletally mature individuals involves drilling through the bone in the area where the physis is located. Exercise programs emphasizing balance, strength, and landing mechanics have been shown to reduce rates of injury. Athletes in sports with high injury rates, for example, soccer and basketball, appear to derive the largest benefits from neuromuscular training programs. For the athlete in the vignette, a return to sports is inappropriate because her history and physical examination are suggestive of intra-articular injury. Aspiration of the knee would not be helpful in this case, because the fluid would likely reaccumulate and there is a risk of infection. A patella-stabilizing brace would be an appropriate initial treatment for a patella subluxation or dislocation, without associated osteochondral fracture. The girl has second degree burns involving her neck, posterior trunk, and buttocks, estimated to cover approximately 20% of her total body surface area. On auscultation, her heart has a regular rate and rhythm with no murmurs, and her lungs are clear bilaterally. Her extremities are warm and well-perfused, with a capillary refill time of 2 seconds. First-degree burns are limited to the epidermis, second-degree burns extend to part of the dermis, third-degree burns involve the entire dermis, and fourth-degree burns extend to the muscle or bone. Patients who have suffered burns have a high fluid requirement because of increased evaporative insensible losses from skin damage and extravasation of fluids from increased capillary permeability due to a systemic inflammatory state. Failure to adequately restore or maintain intravascular volume can adversely affect hemodynamics and lead to lactic acidosis and multiple organ failure. Because the purpose of fluid administration is to maintain intravascular volume, the choice should be isotonic, such as normal saline or lactated Ringer solution.

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These defining this outcome make this a controverlatefilife effects are usually suggested to sial result (10). It should be noted that some national surveys As a further development, it is suggested have shown an increase (33), perhaps not only that clinical outcomes should be explained by the effects of undiagnosed prefi improved by detection and treatment of gestational diabetes. By condeliveries) but no overall difference in birthtrast, other groups have suggested that the weight in those screened earlier (49). Taken together, these data give a sense that earlier A further important area is the potential for diagnosis of hyperglycemic states in early treatment may be advantageous, but they are far from determining what the best marker pregnancy. Systematic review of expected that existing data from women with the literature around the same time (2008) type 1 and type 2 diabetes regarding early found no randomized controlled trials risk of congenital anomaly and miscarriage, of screening and treatment earlier than along with management plans and coun24 weeks (46). The dramatic later (48), with a suggestion of increases in secular increase in type 2 diabetes and obeneonatal hypoglycemia and perinatal mortalsity should not be forgotten, and it seems ity although based on very small numbers clear that it will be necessary to define a (48). Below this categrowth and indeed preeclampsia from a gory is a much larger group of women who fairly unintrusive healthcare intervention in benefit in terms of fetal growth from the many women should also be emphasized. This will be diabetes is possibly unhelpful (28) if these refined and may become different in differwomen are viewed not as having a defined ent healthcare settings (26). Particularly for disease in pregnancy but rather as a group those with the mildest abnormalities of gluwith one of several risk factors. MultiplefiChoice Questions 1 Overt diabetes in pregnancy or diabetes 2 In the second trimester, HbA1c at or mellitus in pregnancy can be diagnosed above the following is an accepted at or above a fasting plasma glucose diagnostic criterion (World Health level of: Organization) for gestational diabetes. Criteria for the 17 Waugh N, Royle P, Clar C, Henderson R, oral glucose tolerance test in pregnancy. Diabetes in Pregnancy: Diagnosis and Classification of Diabetes Management of Diabetes and Its Mellitus and its Complications. The diabetes and type 2 diabetes diagnostic International Federation of Gynecology criteria. At gestational week 28, an oral glucose tolerance test is performed with a 2 h glucose level of 8. Due to glucosuria, an oral glucose tolerance test is done at gestational week 24, and Linda is now diagnosed with gestational diabetes and referred to a program with a diabetes nurse, a dietician, obstetricians, and endocrinologists. By the time of diagnosis, she has gained 5 kg, and with the intervention initiated she restricts the total gestational weight gain to 8 kg. From gestational week 35, insulin treatment is added, and the delivery is induced 4 weeks later due to rapid increase in abdominal circumference of the baby. Birthweight is 4650 g, and the delivery is complicated with a grade 3 anal sphincter injury. A few studies have also looked at maternal easily reached because of frequent contacts metabolic parameters such as hyperglycewith healthcare professionals during pregmia, insulin, and lipid profile (10,11). Despite a large number of recent clinone study so far has published detailed childical trials on lifestyle interventions during hood followfiup data in the offspring (12). Participants were included between 10 and Pregnancy offers the opportunity to manage 20 weeks gestation (16). Lifestyle intervenor prevent obesity as many women are contion comprised dietary advice, individual cerned with the health of their babies during diet plans, and encouragement to exercise. Lifestyle Treatment 75 the behavioral strategies were provided by a had a significantly lower energy intake and a research dietician during a facefitofiface visit reduced intake of food with high glycemic after inclusion and in gestational weeks 28 index.

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An in-depth understanding of the psychological impact of diabetes, at diagnosis and in the long term Sources of information and support K8. An in-depth understanding of how to gather information from patients about their health K33. A working knowledge of sources of practitioner and patient information on diabetes and on pregnancy K9. A critical understanding of how to work in partnership with patients and carers K34. An in-depth understanding of the social, cultural and economic background of the patient/carer group K35. A working knowledge of how individuals can access facilities for exercise and physical activity Managing diabetes K11. An in-depth understanding of the impact of nutrition, particularly carbohydrates, on diabetes K12. An in-depth understanding of the effects of, and how to manage, intercurrent illness K15. An in-depth understanding of the long term complications of diabetes and when they are likely to occur Pregnancy and diabetes K19. An in-depth understanding of the effects of pre-existing long term complications on the risks K21. An in-depth understanding of the medications used to manage diabetes during pregnancy and the medications that are contra-indicated K22. An in-depth understanding of how to manage high blood pressure during pregnancy K23. An in-depth understanding of the priorities for managing diabetes during each trimester of pregnancy, during labour, and following delivery 19 20 Appendix 2 Competence performance criteria Performance criteria Factual Working In-depth Critical Action plan In the following table is an example of a competence set out with the expected performance criteria. This can You need to: knowledge knowledge knowledge Education/training requirement act as an assessment tool for individual practitioners, managers etc. Discuss and agree continuing Competence: targets for blood glucose and Agree continuing care plans for women with diabetes who are pregnant HbA1c levels that are realistic and safe, and support women and their partners in continuing to monitor Performance criteria Factual Working In-depth Critical Action plan and manage blood glucose levels You need to: knowledge knowledge knowledge Education/training requirement Activities to be undertaken 6. Include women with diabetes and treating hypoglycemia during their partners as members of the each trimester of the care team, involve them in decisions pregnancy about their care, and provide them with sufficient appropriate 7. Where a woman with Type information for them to participate 1 diabetes is not already using fully in making decisions ketone strips, arrange for supply and, if necessary, help 2. Work in full partnership with her learn how to use and other members of the interpret them multi-disciplinary team involved in providing care and support for 8. Where the woman is using diabetes and for pregnancy to insulin to manage her ensure that holistic care is provided diabetes, discuss and provide information in suitable forms 3. Continue to assess the on how to adjust dosages understanding of the woman and throughout pregnancy, and her partner of what they can do to support the woman and her support a safe and healthy partner in learning to pregnancy, and provide information self-manage dose adjustment at appropriate times to reinforce and develop this understanding 9. Arrange or carry out a dietetic to other long term review to help to optimise blood complications, at appropriate glucose control and ensure total intervals during pregnancy nutritional adequacy during pregnancy 21 22 Appendix 3 Performance criteria Factual Working In-depth Critical Action plan Lead Midwife in Diabetes role specification guidance You need to: knowledge knowledge knowledge Education/training requirement this section covers essential or developmental attributes within the Lead Midwife in Diabetes role and can be Activities to be undertaken built into the development of a job description for this role. This cannot be read as a comprehensive of all attributes as there are associated competencies. This has been occasioned by changes in social and demographic situation in the country. The life expectancy in the country is improving, while the country is developing at a rapid pace. This has resulted in people living more years and at the time adopting lifestyles that have negative impacts on their health. This increase in diabetes and other noncommunicable diseases has given rise to a double burden of communicable and non-communicable diseases in Kenya. Diabetes and other non-communicable disease are now a threat to national development as they ofen result in long standing complications that are usually very costly to treat. They progressively drain the strength and resources of an individual rendering them unproductive and poor. This burden is in most cases passed on to families and the community with untold retardation of economic progress and eventually exacerbating poverty. In response to this crisis, the Ministries of Health in collaboration with Non-Governmental Organizations, Regional and International Diabetes Support Bodies spearheaded the National Guidelines for the Management of Diabetes Mellitus in order to provide a standardized way of managing diabetes in the country.

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The gene for thalassemia major is relatively sphere) that forms part of the walls of the third venfrequent in people of Mediterranean origin. The thalamus contains a number Children with thalassemia major inherit one thaof distinct groups of cells, or nuclei, that function as lassemia gene from each parent. Treatment based relay centers for sensory and other impulses on blood transfusions is helpful but not curative. People who thalassemia A group of genetic disorders that are carriers have just one beta thalassemia gene and involve underproduction of hemoglobin, the indisare essentially normal, although they can transmit pensable molecule in red blood cells that transports the gene to their offspring. The thalidomide A drug (brand name: Thalomid) globin part of hemoglobin is made up of four polypepthat was used in the 1950s and early 1960s to treat tide chains. The use of thalidopredominant type of hemoglobin after the first year of mide had tragic results: When taken during preglife, two of the globin chains are identical to each nancy, it can cause a syndrome of congenital other and are called the alpha chains. Thalidomide appears to modtherapeutic abortion An abortion that is ify the reaction of the immune system to the leprosy brought about intentionally. In therapeutic cloning, the Thalidomide is a potent teratogen and should never nucleus of a cell, typically a skin cell, is inserted into be taken by women who are or could become prega fertilized egg whose nucleus has been removed. See also thalidomide baby; thalidomide synthe nucleated egg begins to divide repeatedly to drome, teratogen. Scientists then extract stem cells from the blastocyst and use them to grow cells that thalidomide baby An infant who is affected by are a perfect genetic match for the patient. In 1998, created via therapeutic cloning can then be transthalidomide again became available to treat certain planted into the patient to treat a disease from conditions, and there is concern that babies may be which the patient suffers. In contrast to the goal of born with the thalidomide syndrome as they were in therapeutic cloning, the goal of reproductive the 1950s and early 1960s. Therapy is synepitomized by the flipper-like limbs (phocomelia), onymous with treatment. There are hypoplasia (underdevelopment) of the arms, espemany types of medical thermometers, including oral cially affecting the radius and the thumb; thumbs thermometers (placed under the tongue), rectal with three joints; defects of the femur and of the thermometers (placed within the rectum), multipurtibia; and malformations of the heart, bowel, uterus, pose thermometers (placed under the tongue, in the and gallbladder. The pattern of malformations rectum, or under the armpit), eardrum thermomedepends on the time of intake of the drug. During the sensitive period, ture changes indicating that ovulation has taken place taking thalidomide causes the following sequence of in a woman). The thigh has only arms, legs, and internal organs, and the baby may one bone, the femur, which is the largest bone in the die. The thoracic vertebrae third ventricle One cavity in a system of four are represented by the symbols T1 through T12. The third ventricle is a median (midthoracotomy An operation to open the chest, line) cavity in the brain and is bounded by the thalusually in order to gain access to the lungs or heart. It communicates anteriorly (in front) with the lateral thorax the area of the body that is located ventricles, and posteriorly (in back) with the aquebetween the abdomen and the neck. Within the thoduct of the midbrain, also known as the aqueduct of rax are the lungs, the heart, and the first section of Sylvius. For example, the version of a substance called fibrinogen to fibrin, thoracic aorta is the part of the aorta that lies within which promotes blood clotting. The clot lates lymph from the lymphatic circulation into the may plug a vessel in the lungs (pulmonary bloodstream. The thoracic duct begins in the embolism), brain (stroke), gastrointestinal tract, abdomen, tracks alongside the aorta and esophakidneys, or leg. Thromboembolism is a significant gus, and eventually joins with the left brachiocause of morbidity (disease) and mortality (death), cephalic vein. Treatment may involve anticoagulants (blood thinners), aspirin, or vasodilators thoracic outlet syndrome A condition that is (drugs that relax and widen vessels). Thoracic outlet synthrombophilia the tendency to form thromdrome can be caused by muscle development from boses (blood clots in arteries and veins).

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Later in the derivative, may improve anaemia in approximately disease leucopenia and thrombocytopenia are 30% of patients. In 10% of cases Allopurinol is indicated in virtually all patients to there is increased bone formation with increased prevent gout and urate nephropathy from hyperubone density on X ray. Systemic mastocytosis is a clonal myeloproliferative disorder involving usually the bone marrow, heart, spleen, lymph nodes and skin. Symptoms are related to histamine and prostaglandin release and include fushing, pruritus, abdominal pain and bronchospasm. In others an aggressive course may be associated with acute myeloid leukaemia, mast cell Figure 15. It occurs in older patients and Chapter 15 Myeloproliferative neoplasms / 213 the increase in blood viscosity leads to the predominant feature of primary headaches, plethoric appearance and myelofibrosis is a progressive generalized splenomegaly. Survival is usually over 10 shows a leucoerythroblastic appearance, years but there may be progression to together with bone marrow biopsy and leukaemia or myelofibrosis. A hallmark of the disease is simultaneous syndromes) proliferation and apoptosis of haemopoietic cells (inefective haemopoiesis) leading to the paradox of a this is a group of clonal disorders of haemopoietic hypercellular bone marrow but pancytopenia in stem cells characterized by increasing bone marrow peripheral blood. The immune system may have a minor abnormalities role in suppressing bone marrow function and immunosuppression is sometimes used in treatment (see below). It has a particumutation is often present, is classifed with larly good prognosis (Table 16. The symptoms, if in women and typically there is anaemia with present, are those of anaemia, infections or of easy Chapter 16 Myelodysplasia / 217 bruising or bleeding (Fig. The function of the neutrophils, monotransfusion-dependent anaemia dominates the cytes and platelets is often impaired so that infeccourse, while in others recurring infections or spontions and bleeding may occur out of proportion to taneous bruising and bleeding are the major clinical the severity of the cytopenia. The red cells are usually macrocytic or dimorphic but occasionally hypochromic; normoblasts may be present. Granulocytes are often reduced in number and frequently show lack of granulation (Fig. The platelets may be unduly large or small and are usually decreased in number but in 10% of cases are elevated. The appearance of ring sideroblasts is (b) caused by iron deposition in the mitochondria of erythroblasts. Megakaryocytes are infections of the face and maxillary sinuses associated abnormal with micronuclear, small binuclear or with neutropenia (haemoglobin 9. Myelosuppression is a common constitute partial or total loss of chromosomes 5 or sideefect. Mutations may also be found with molecular High-risk myelodysplastic syndromes testing. A key subdivision is into patients with with some beneft to patients with refractory low risk or high risk disease. Azacitidine is given for 7 days every month and improves surLow-risk myelodysplastic syndromes vival by approximately 9 months. Although the majority Instead they are not treated or, if necessary, attempts of patients may obtain a remission, relapse is almost may be made to improve marrow function with inevitable and frequently occurs within a few haemopoietic growth factors, either singly or in months. Erythropoietin may improve anaemia great because prolonged pancytopenia may occur in although the haemoglobin should not be raised some cases without normal haemopoietic regeneraabove 12g/dL. Ciclosporin or antilymphocyte globulin occasionally help, particularly for those with a hypocellular Stem cell transplantation bone marrow. The total white cell count is 9 chemotherapy may be tried to reduce the blast prousually raised and may exceed 100 fi 1 0 /L. Bruising is frequent and gum hyperGeneral support care only trophy and lymphadenopathy may also be present. Transfusions of red cells cult although oral hydroxyurea or etoposide may be and platelets, and therapy with antibiotics and antiuseful. Median survival is approximately 2 years, with increased marrow blasts a predictor of poor outcome.

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