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Hallfrisch and colleagues (1995) studied glucose responses in 16 women and 7 men with moderately high cholesterol concentrations who supplemented their normal diets with oat extracts in which either 1 or 10 percent viscous β-glucans were added cheap phenergan 25 mg fast delivery i have anxiety symptoms 247. Glucose responses were reduced at both the 1 and 10 percent β-glucan supplementation level phenergan 25mg on-line anxiety symptoms heavy arms. In a meta-analysis of approximately 100 studies on stool weight changes with various fiber sources, investigators were able to calcu- late the increase in fecal weight due to fiber ingestion (Cummings, 1993). This meta-analysis concluded that pectin ingestion leads to an increase of about 1. In a randomized crossover study designed to compare the effects of pectin (12 g/d), cellulose (15 g/d), and lignin (12 g/d) on stool characteristics in healthy volunteers, pectin did not alter transit time or increase 24-hour stool wet weight, whereas cellulose decreased mean stool transit time and increased mean wet stool weight (Hillman et al. For example, in a 16-week, double-blind crossover study, grapefruit pectin supplementa- tion decreased plasma cholesterol concentration by 7. When 12 g/d of pectin was taken with meals for 3 weeks, there was a mean decrease in total serum cholesterol concentration of 0. When 15 g/d of citrus pectin was provided in metabolically controlled diets for 3 weeks, plasma cholesterol concentrations were reduced by 13 percent and fecal fat excretion increased by 44 percent; however, plasma triacylglycerol concentrations did not change (Kay and Truswell, 1977). Gold and coworkers (1980) did not observe reductions in serum cholesterol concentrations following the consumption of 10 g of pectin with 100 g of glucose. However, total cholesterol and triacylglycerol concentrations were significantly decreased (Jenkins et al. Supple- mentation with 15 g of pectin increased bile acid excretion by 35 percent and net cholesterol excretion by 14 percent in ileostomy patients, whereas 16 g of wheat bran produced no significant changes (Bosaeus et al. Viscous fibers such as pectin have been found to produce a significant reduction in glycemic response in 33 of 50 studies (66 percent) (Wolever and Jenkins, 1993). Tomlin and Read (1988) showed that 30 g/d of polydextrose increased fecal mass without affecting transit time and stool frequency. Achour and coworkers (1994) observed no significant changes in fecal weight or transit time when seven men consumed 30 g/d of polydextrose. When 4, 8, or 12 g/d of polydextrose was provided, fecal weight increased and ease and frequency of defecation improved in a dose–response manner (Jie et al. Findings on the effect of polydextrose intake on fecal bacterial pro- duction are mixed. Achour and colleagues (1994) reported no changes in bacterial mass in the feces of individuals who consumed 30 g/d of poly- dextrose. This lack of difference may be explained, in part, by the findings of Jie and coworkers (2000). Following the ingestion of 4, 8, or 12 g/d of polydextrose (n = 30 treatment), there was a dose-dependent decrease in Bacteriodes, whereas the beneficial Lactobacillus and Bifidobacteria species increased. Psyllium is the active ingredient in laxatives, and thus from an over-the-counter drug viewpoint, there is extensive literature on its effi- cacy in this regard. The authors concluded that the beneficial effects of psyllium with regard to constipation are largely related to a facili- tation of the defecatory process (Ashraf et al. Similarly, psyllium was tested in a multisite study of 170 individuals with chronic idiopathic constipation for 2 weeks (McRorie et al. Psyllium increased stool water content, stool water weight, total stool output, bowel movement fre- quency, and a score combining objective measures of constipation. Four months of psyllium treatment significantly improved bowel function and fecal output in 12 elderly patients (Burton and Manninen, 1982). In a multicenter trial with 394 individuals, psyllium improved bowel function better than other laxatives (mainly lactulose), with superior stool con- sistency and decreased incidence of adverse events (Dettmar and Sykes, 1998). Prior and Whorwell (1987) tested psyllium (ispaghula husk) in 80 patients with irritable bowel syndrome and found that constipation was significantly improved and transit time decreased in patients taking psyllium. A number of studies have been conducted to ascertain the beneficial effects of psyllium on blood lipid concentrations. Serum cholesterol concentration was reduced by 20 percent in 12 elderly patients receiving psyllium supplementation (Burton and Manninen, 1982). Danielsson and coworkers (1979) treated 13 patients with essential hyper- lipoproteinemia over 2 to 29 months with psyllium hydrophilic colloid. Serum cholesterol and triacylglycerol concentrations were reduced an average of 16. If blood lipid concentra- tions were normal at baseline, no reductions were observed when indi- viduals consumed psyllium colloid (Danielsson et al.

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All children between the ages of 2 months and 5 years who are in a licensed childcare setting are required to have Hib vaccine or they must have a legal exemption buy phenergan 25mg low price anxiety kit. Type b If you think your child Symptoms has Hib: Your child may have a fever with any of these conditions best phenergan 25mg anxiety symptoms definition. The infection occurs most commonly in children less than 10 years of age and most often in the summer and fall months. Blister-like rash occurs in the mouth, on the sides of the tongue, inside the cheeks, and on the gums. Blister-like rash may occur on the palms and fingers of the hands and on the soles of the feet. The disease is usually self- limited, but in rare cases has been fatal in infants. It also is spread through droplets that are expelled from the nose and mouth of an infected person during sneezing and coughing and by direct contact with respiratory secretions. Wash hands thoroughly with soap and warm running water after using the bathroom, after changing diapers, after handling anything soiled with feces or secretions from the nose or mouth, and before preparing food or eating. Staff should closely monitor or assist all children, as appropriate, with handwashing after children have used the bathroom or been diapered. Disease If you think your child Symptoms has Hand, Foot, and Mouth Disease: Your child may have a runny nose, low-grade fever, and sometimes a sore throat. Childcare and School: If your child is infected, it may take 3 to 6 days for symptoms Yes, until fever is gone to start. This includes toilets (potty chairs), sinks, mouthed toys, and diaper changing areas. There are two other kinds of lice that infest people, but they do not live on the head. Head lice are very small (less than 1/8" long, about this size [--]), brownish-colored insects that live on human heads and lay their eggs (nits) close to the scalp. The eggs are tiny (about the size of the eye of a small needle) and gray or white in color. Look for: 1) crawling lice in the hair, usually few in number; 2) eggs (nits) glued to the hair, often found behind the ears and at the back of the neck; and 3) scratch marks on the head or back of the neck at the hairline. Children do not need to be sent home immediately if lice are detected; however they should not return until effective treatment is given. Removing the nits (nitpicking) is an essential part of the treatment for controlling the spread of head lice. The nits are glued onto the hair shaft as they are laid and require effort to remove. To remove the nits, use a metal nit comb, cat flea comb, or your fingernails to slide eggs off the hair shafts, or use scissors to cut the hair shafts that have nits glued to them. If all nits within ½" of the scalp are not removed, some may hatch and the child will be infested again. Bedding, when not in use for naptime, can be stored in individual plastic bags or storage boxes. When a child returns from a sleepover, check the child’s head and launder any bedding that they brought home. Clothing or backpacks that cannot be washed or dried, linens, and stuffed toys can be dry cleaned or sealed in plastic bags for 2 weeks. More information about head lice can be found on the Centers for Disease Control and Prevention website at: http://www. Look for: 1) crawling lice in the  Tell your childcare hair, usually there aren’t very many; 2) eggs (nits) glued to provider or call the the hair, often found behind the ears and at the back of the school. If all nits within ½" of the Lice do not jump or fly; they crawl and can fall off the head. With certain Childcare and School: products a second treatment is recommended 7 to 10 days later. Lice treatment products are not 100% Yes, until first treatment effective in killing lice, especially nits. To remove the nits, use a metal nit comb, cat flea comb, or your fingernails to slide eggs off the hair shafts, or use scissors to cut the hair shafts that have nits glued to them. If all nits within ½” of the scalp are not removed, some may hatch and your child will get head lice again.

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It makes powerful intuitive sense that individuals will spend their own money more carefully than Health Plans 137 they will spend the employer’s money buy phenergan 25 mg visa anxiety symptoms depression. It is clear that without a greater economic stake in conservative health use by consumers phenergan 25mg discount anxiety while pregnant, health costs will not come under control. Notably, it fell even during the period of the managed care revolution (the 1980s and 1990s), because employers used reduced cost sharing as a way of encouraging people to enroll in health plans. Another way of viewing this is that economic risk steadily shifted toward the employer and private health insurance during the man- aged care explosion, and away from consumers. Moreover, the struc- ture of that cost sharing—a nominal copayment of the insurance premium, variable amounts of “first dollar” deductibles for various forms of healthcare use (focused primarily on the hospitalization), and a maximum annual cap on the consumer’s cost exposure—had not changed materially in 30 years. Health plans are already experimenting with the use of economic incentives as a way of encouraging consumers to use less expensive providers of service by varying the cost share depending on the “tier” of hospital they visit. People who use their community hospitals for most of their care will pay less out of pocket than people who rely entirely on expensive academic health centers for all their care. So far, the anecdotal evidence suggests that consumers are willing to pay more out of pocket to use expensive institutions and that the incentives have not encouraged much switching. Health plans have had some success containing pharmacy expense through so-called “three-tier” pharmacy coverage. Under three-tier coverage, the managed care plan or the pharmacy benefits manager negotiates a list of approved drugs for which subscribers 138 Digital Medicine Figure 6. Centers for Medicaid & Medicare Services, National Health Expenditure Projections, 2002. Under this plan, consumers who use generic drugs on the formu- lary have nominal or no cost share. Consumers who use approved “branded drugs” on the formulary pay a modest cost share. Con- sumers who want to use a branded drug not on the formulary may pay as much as half of the cost out of pocket. Not surprisingly, measures to outlaw the three-tier approach were slipped into patient-protection legislation in many states by aggres- sive pharmaceutical company lobbying. Increased trans- parency of clinical results and cost will mean that high cost and high-risk hospitals and physicians could lose market share as con- sumers move to safer or higher-value alternatives. This risk em- bodies powerful reasons for hospitals and physicians to collaborate in improving patient safety, as well as to increase efficiency and customer service. Increased cost sharing will probably increase bad debts for pro- viders of all types and friction with patients in collecting those debts. Hospitals and physicians will become increasingly visible as a source of health cost increases as the veil of third-party insurance is partially stripped away. Interactive claims management between hospitals, doctors, and health plans could lead to instantaneous electronic payment for health services, markedly reducing not only accounts receivable, but also clerical expense on both ends of the transaction. Hospitals and physicians must be prepared to digitize their back offices and connect their claims systems to health insurers via the Internet. As suggested earlier, nurses and hospital personnel presently wrestling the paperwork monster of antiquated healthcare pay- ment schemes could be reassigned to supporting continuity of care and communication with patients. Health plans have been strangled by the sheer magnitude of their back-office problems. Just as with hospitals, health plans must have modern enterprise information systems before they can fix the customer service problems that have plagued them. Health plans certainly have as much incentive to change their business model as any actor in the healthcare system. If physicians face the crippling inability to take collective action and hospitals struggle with an anarchic clash of professional interests and cultures, then health plans will struggle with a legacy of paternalism and insensitivity to the needs of the consumer and family. Humana not only has invested $1 billion in the last four years to renovate and computerize its back office, but it has also invested in a suite of consumer applications to bring “consumer directed” health plan options to its members. Blending web-enabled health plan customization with sharp increases in cost sharing for hospital services, Humana was able to reduce its own employees’ health benefits cost escalation from 19 percent per year to under 5 percent in the first two years of its new plan. Delivering promised improvements in service is the true test of good intentions by health plans. If, as it is said in architecture, God is in the details, in e-commerce, God is in the back end. Adminis- trative systems in health plans need to be completely renovated and digitized for any of the promising Internet tools discussed above to make any difference. Properly executed, Internet applications can help health Health Plans 141 plans rebuild their relationships with hospitals and physicians by reducing or eliminating paperwork and bureaucratic interference with medical practice.

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With the exception of quinine bisulfate quality phenergan 25mg anxiety symptoms journal, the dosage is the same for all quinine salts (sulfate generic phenergan 25mg with mastercard anxiety books, hydrochloride, dihydrochloride): Child and adult < 50 kg: 30 mg/kg/day in 3 divided doses at 8-hour intervals for 7 days Adult ≥ 50 kg: 1800 mg/day in 3 divided doses at 8-hour intervals for 7 days age Weight 300 mg tablet 5 months to < 2 years 7 to < 12 kg ¼ tab x 3 2 to < 8 years 12 to < 25 kg ½ tab x 3 8 to < 11 years 25 to < 35 kg 1 tab x 3 11 to < 14 years 35 to < 50 kg 1½ tab x 3 ≥ 14 years ≥ 50 kg 2 tab x 3 Contra-indications, adverse effects, precautions – May cause: headache, skin rash; visual, auditory and gastrointestinal disturbances. During treatment, closely monitor the rate of administration in order to avoid overhydration. Increase in respiratory and pulse rates and appearance or increase of oedema are signs of over rapid rehydration. Risk of maternal and neonatal bleeding disorders when the mother receives rifampicin in late pregnancy: administer phytomenadione (vitamin K) to the mother and the newborn to reduce the risk. Duration – Acute psychosis: minimum 3 months; chronic psychosis: minimum one year. However, if it is difficult to change treatment at the beginning of pregnancy or if pregnancy is already in second trimester, risperidone can be maintained. Observe the newborn infant the first few days (risk of hypertonia, tremors, sedation). Presentation – 50 mg and 100 mg tablets – 80 mg/ml oral solution, containing 43% alcohol (v/v) Dosage – Adult: • Tablet: 100 mg once daily or 200 mg/day in 2 divided doses, depending on the protease inhibitor co-administered • Oral solution: 1. Contra-indications, adverse effects, precautions – Do not administer to patients with severe hepatic impairment. For information : – 2 to 4 puffs (up to 10 puffs depending on severity) every 10 to 30 minutes administration technique – Shake the inhaler. Contra-indications, adverse effects, precautions – May cause: headache, tremor and tachycardia. Contra-indications, adverse effects, precautions – May cause: headache, tremor, tachycardia; hyperglycaemia and hypokalaemia (after large doses); worsening hypoxia if administered without oxygen. Otherwise, salbutamol should be delivered via a metered-dose inhaler with a spacer: administration is easier and faster, the treatment is as effective, or even more effective, than with a nebuliser and causes fewer adverse effects. The diluted solution is dispersed with oxygen at a flow rate of 5 to 8 litres/min. When weight is stable, administer the lowest possible maintenance dose, in order to prevent adverse effects. Contra-indications, adverse effects, precautions – Do not administer to patients with severe renal impairment, anuria, hyperkalaemia > 5 mmol/l, hyponatraemia. However, avoid using during the last month of pregnancy (risk of jaundice and haemolytic anaemia in the newborn infant). Dosage and duration – Infantile beriberi 10 mg once daily, until complete recovery (3 to 4 weeks) – Acute beriberi 150 mg/day in 3 divided doses for a few days, until symptoms improve, then 10 mg/day until complete recovery (several weeks) – Mild chronic deficiency 10 to 25 mg once daily Contra-indications, adverse effects, precautions – No contra-indication, or adverse effects with oral thiamine. Clostridium sp, Bacteroides sp) Presentation – 500 mg tablet Dosage and duration – Amoebiasis Child: 50 mg/kg once daily, without exceeding 2 g/day Adult: 2 g once daily The treatment lasts 3 days in intestinal amoebiasis; 5 days in hepatic amoebiasis. Contra-indications, adverse effects, precautions – Do not administer to patients with allergy to tinidazole or another nitroimidazole (metronidazole, secnidazole, etc. In the event of prolonged treatment, do not stop abruptly, reduce doses progressively. Contra-indications, adverse effects, precautions – Do not administer in the event of severe respiratory depression and to patients that risk seizures (e. The neonate may develop withdrawal symptoms, respiratory depression and drowsiness in the event of prolonged administration of large doses at the end of the 3rd trimester. Monitor the mother and the neonate: in the event of excessive drowsiness, stop treatment. In situations of repeated bleeding, it may be helpful to combine tranexamic acid with a non-steroidal anti-inflammatory drug (oral ibuprofen, 1200 to 2400 mg/daily maximum, to be divided in 3 doses for 3 to 5 days) and/or a long-term treatment with oral estroprogestogens or injectable progestogens. Therapeutic action – Antiepileptic Indications – Generalised and partial epilepsy Presentation – 200 mg and 500 mg enteric coated tablets Dosage – Child under 20 kg: 20 mg/kg/day in 2 divided doses – Child over 20 kg: start with 400 mg (irrespective of weight) in 2 divided doses, then increase gradually until the individual optimal dose is reached, usually 20 to 30 mg/kg/day in 2 divided doses – Adult: start with 600 mg/day in 2 divided doses, then increase by 200 mg every 3 days until the individual optimal dose is reached, usually 1 to 2 g/day in 2 divided doses Duration – Lifetime treatment Contra-indications, adverse effects, precautions – Do not administer: • to women of childbearing age. If the treatment is absolutely necessary and if there is no alternative, an effective contraception is required (intrauterine device); • to patients with pancreatitis, hepatic disease or history of hepatic disease. If treatment was started before pregnancy: replace valporic acid with a safer antiepileptic if possible. If there is no other alternative, do not stop valporic acid however administer the minimal effective dose and divide the daily dose. Monitor the newborn (risk of withdrawal syndrome and haemorrhagic disease, not related to vitamin K deficiency).

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