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More than a third of the disease-linked genes (30/81) are involved in neurological and psychiatric disorders. This could potentially point to as laminopathies (1), including the misshapen nuclei and altered chromatin organia link between recent changes in regulation and accelerated-aging disease Hutchinson-Gilford zation (7). Deregulation might reflect cell fragility, many likely result from disease-linked genes. Guidelines for preventive activities in general practice, 9th edition Disclaimer the information set out in this publication is current at the date of frst publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates. Whilst the text is directed to health professionals possessing appropriate qualifcations and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices. The Royal Australian College of General Practitioners 100 Wellington Parade East Melbourne, Victoria 3002 Australia Tel 03 8699 0414 Fax 03 8699 0400 We recognise the traditional custodians of the land and sea on which we work and live. Contents Acknowledgements i Red Book Editorial Committee i Conficts of interest ii Contributors ii Reviewers ii Acronyms v I. Dutch Lipid Clinic Network Criteria for making a diagnosis of familial hypercholestrolaemia in adults 30 3. Preventive activities in middle age 42 References 44 Guidelines for preventive activities in general practice viii 9th edition 5. Screening tests of unproven beneft 147 References 153 Lifecycle chart 158 Guidelines for preventive activities in general practice 9th edition 1 I. Introduction General practice is at the forefront of healthcare in Australia and in a pivotal position to deliver preventive healthcare. It includes the prevention of illness, the early detection of specifc disease, and the promotion and maintenance of health. Preventive care is also critical in addressing the health disparities faced by disadvantaged and vulnerable population groups. The Red Book is now widely accepted as the main guide to the provision of preventive care in Australian general practice. Purpose the Red Book is designed to provide the general practice team with guidance on opportunistic and proactive preventive care. It provides a comprehensive and concise set of recommendations for patients in general practice with additional information about tailoring advice depending on risk and need. The Red Book provides the evidence and reasons for the effcient and effective use of healthcare resources in general practice. Scope the Red Book covers primary (preventing the initial occurrence of a disorder) and secondary (preventive early detection and intervention) activities. These guidelines focus on preventive activities applicable to substantial portions of the general practice population rather than specifc subgroups. However, there is an emphasis on equity, with recommendations aimed at major disadvantaged groups at higher risk of disease and those who are less likely to receive preventive care. This information can be obtained from the Centers for Disease Control and Prevention at nc. However, the leading causes of death and disability in Australia are preventable or able to be delayed by early treatment and intervention (Figure I. There were 32,919 potentially avoidable deaths in Australia in 2010; 62% were classifed as potentially preventable and 38% as potentially treatable. An Australian review10 concluded that lifestyle interventions could have a large impact on population health. Despite this evidence and wide acceptance of its importance, preventive interventions in general practice remain underused, being the primary reason for the consultation in only seven of every 100 clinical encounters. Much more needs to be done to support and improve proper evidencebased preventive strategies, and to minimise practices that are not benefcial or have been proven to be harmful. Yet there is evidence that some preventive activities are not effective, some are actually harmful. Therefore, it is crucial that evidence clearly demonstrates that benefts outweigh those harms for each preventive activity. Determining whether a preventive activity is benefcial, harmful or of indeterminate effect (ie there is not enough evidence on which to base a decision) requires a consistent, unbiased, evidence-based approach. Cancer screening, in particular, can polarise different sectors of the health profession and broader community. The objective interpretation of evidence, balancing harms and benefts, and considering overdiagnosis and overtreatment is a goal of the Red Book. Screening activities are only recommended where evidence demonstrates that benefts outweigh harms. Chapter 15 provides some guidance on common tests where this is not the case or where the evidence is either unclear or not available. Prevention in the practice population the risk of illness and disease is associated with a range of factors that operate on the individual across the lifecycle. For example, poor nutrition and lack of antenatal care during pregnancy are associated with later risk of chronic diseases in the child. Risk behaviours in childhood may become entrenched, leading to progressive physiological changes that can cause chronic diseases in later life. All these factors are in turn infuenced by the social determinants of health, which operate at the local community and broader societal levels; these are poverty, housing, education and economic development (Figure I. Thus, it is highly desirable for general practice to think beyond the preventive healthcare needs of the individual patient, towards a practice population approach to primary prevention. The determinants of health and illness9 Broad features of Socioeconomic Health Biomedical society characteristics behaviours factors Culture Education Tobacco use Birth weight Affuence Employment Alcohol Body weight Social cohesion Income and consumption Blood pressure Social inclusion wealth Physical activity Blood cholesterol Political Family, Dietary behaviour Glucose tolerance structures neighbourhood Use of illicit drugs Immune status Media Housing Sexual practices Language Access to Vaccination Environmental services Psychological factors Migration/ factors Health and wellbeing Natural refugee status Stress over time Built Food security Trauma, torture Life expectancy, mortality Geographical Knowledge, Safety factors Subjective health location attitudes and Risk taking, Functioning, disability beliefs Remoteness violence Illness, disease Health literacy Latitude Occupational Injury health and safety Individual physical and psychological make-up Genetics, antenatal environment, gender, ageing, life course and intergenerational infuences Note: Bold highlights selected social determinants of health Reproduced with permission from Australian Institute of Health and Welfare. Guidelines for preventive activities in general practice 6 9th edition General practice has a practical role to play in addressing these determinants and helping to break the cycle that may exist linking social and economic factors to illness and injury. This requires a systematic approach across the whole practice population, not just for those who seek out or are most receptive to preventive care. This may include auditing medical records to identify those who are missing out, using special strategies to support patients with low literacy, and being proactive in following up patients who are most at risk. It will usually require teamwork within the practice as well as links with other services. General practice also has a broader role in facilitating health improvement for vulnerable and disadvantaged groups in the local community, in association with other services and providers. Measures to improve access to preventive healthcare by Aboriginal and Torres Strait Islander peoples are especially important given their higher burden of disease and the barriers that exist to preventive healthcare. More information is available in the National guide to preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edn. Screening versus case fnding Many clinicians confuse screening and case-fnding tests.

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Recommend lifestyle changes, including reducing energy intake and sedentary behaviour, and increasing physical activity based on current Australian dietary and physical activity guidelines. Breastfeeding should be promoted as the most appropriate method for feeding infants (and one that offers protection against infection and some chronic diseases). Preventive activities in children and young people for nutrition-related recommendations. Nutrition-related complications: Preventive interventions Intervention Technique References Vitamin supplements Vitamin supplementation is not of established value in asymptomatic 85 individuals* (with the exception of folate and iodine in pregnancy). It is recommended that breastfeeding continue until 12 months of age and thereafter as long as is mutually desired *Prevalence of nutritional defciency is high in certain groups, such as people with alcohol dependence and the elderly living alone or in institutions. Preventive activities prior to pregnancy) Guidelines for preventive activities in general practice 76 9th edition Who is at riskfi The Australian guidelines, to be updated in 2016, represent the modal (or most common) recommendation. Such patients should be referred to a heavy drinking drug and alcohol service Implementation There is some evidence from earlier systematic reviews that for every 10 hazardous drinkers treated using brief interventions, one will reduce drinking to low-risk levels. Provide age-specifc advice on meeting recommended levels of sedentary behaviour and physical activity. If a patient does not already engage in regular physical activity, they can be encouraged to start by doing some, and then gradually build up to the recommended amount. Physical activity: Assessment, advice and referral Age and risk group What should be donefi Physical activity) Guidelines for preventive activities in general practice 9th edition 79 Age and risk group What should be donefi Those who have a chronic medical condition and complex needs may beneft from referral to an accredited exercise physiologist or physiotherapist. Australian of chronic disease to the gap in adult mortality between guidelines to reduce health risks from drinking alcohol. The process care model and the 5A services for treating tobacco of adapting the evidence-based treatment for tobacco use in urban primary care clinics. Robertson J, Stevenson L, Usher K, Devine S, Clough motivation and intention to lose weightfi Organisation and the Royal Australian College of General Socioeconomic inequalities in non-communicable Practitioners. National guide to a preventive health diseases and their risk factors: An overview of systematic assessment for Aboriginal and Torres Strait Islander reviews. Prevalences of overweight and obesity among Australian College of General Practitioners, 2012. The role of energy cost in counseling intervention for the family medicine provider. Health and enhancement therapy in obese patients: A promising nutrition economics: Diet costs are associated with diet application. Optimisation modelling to assess cost of dietary intervention on physical activity and predictors of improvement in remote Aboriginal Australia. Alcohol drinking effectiveness of interventions to change six health patterns and differences in alcohol-related harm: A behaviours: A review of reviews. Preventing differences in socioeconomic inequality of alcoholobesity among adolescent girls. Socioeconomic differences in the importance of ethnicity and culture in childhood alcoholrelated risk-taking behaviours. Engaging use disorder severity and reported reasons not to adolescent girls from linguistically diverse and low seek treatment: A cross-sectional study in European income backgrounds in school sport: A pilot randomised primary care practices. Melbourne: National Heart Foundation of Australia: Supporting smoking cessation: A guide for health 2009 professionals. Comparison of Interventions for smoking cessation in indigenous anthropometric characteristics in predicting the incidence populations. Final Effcacy of inteventions to combat tobacco addiction: recommendation statement: Obesity in adults: Screening Cochrane update of 2013 reviews. Tobacco cessation interventions Page/Document/RecommendationStatementFinal/ for young people. Nicotine replacement coaching service(R): Translational research with population therapy for smoking cessation. Increased systematic review and meta-analysis to compare consumption of fruit and vegetables for the primary advice to quit and offer of assistance. White A, Rampes H, Liu J, Stead L, Campbell activity-counseling-adults-with-high-risk-of-cvd J. Guidelines for the effectiveness of brief alcohol interventions in primary identifcation and management of substance use and care settings: A systematic review. Nutrition therapy with primary care populations: A systematic review and recommendations for the management of adults with meta-analysis. Infuence interviewing in medical care settings: A systematic review of alcohol on the progression of hepatitis C virus and meta-analysis of randomized controlled trials. Age-related effects of alcohol and impact of alcohol problems in major depression: A from adolescent, adult, and aged populations using systematic review. Risks of combined alcohol dependence with high density of family history is alcohol/medication use in older adults. Risk factors for falls in role of alcohol in drowning associated with recreational communitydwelling older people: A systematic review aquatic activity. National physical activity contexts and the acceptability of alcohol enquiry from 84 recommendations for older Australians: Discussion Guidelines for preventive activities in general practice 9th document. Melbourne: National Public and behavioral counseling interventions in primary care Health Partnership, 2002. Non face-to-face physical activity personalizedfeedback interventions: A meta-analysis. Telephone-delivered impact of brief alcohol interventions in primary healthcare: interventions for physical activity and dietary behavior A systematic review of reviews. Levels and predictors primary care: Absence of evidence for effcacy in people of exercise referral scheme uptake and adherence: with dependence or very heavy drinking.

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More complex organisms tend to have relatively more intron data and other non-functional data. However, genes, per se, are not the only data structures with obvious implications for the process of evolution. Repeats such as alu elements, introns, and other structural aspects also influence the evolutionary process. Evolvability Theories Evolvability theory refers to the idea that organism populations and species can vary in their capacity for evolution and that this factor needs to be considered and handled by any theory of evolutionary mechanics. In this context evolvability is essentially another proposed modification or adjustment to traditional evolution theory like group selection, kin selection, or the selfish gene theory. Evolvability considerations provide explanations for all of the discrepancies with traditional evolution theory including programmed aging, other lifespan limiting design features (biological suicide), sexual reproduction, elaborate evolved inheritance mechanisms, altruism, mating rituals, and excess male puberty age. Evolution of Evolvability It is generally accepted that organisms possess design features that enable the process of evolution. For example, all organisms possess the ability to pass information describing their designs to descendants, to store that information during the life of the organism, and to copy the information for distribution to multiple descendants, in addition to mechanisms that support accumulative adaptive modification of that information. The question here is whether it is possible for design properties that support or enhance the evolution process to vary between different organisms. If such was possible, then could not organisms evolve improvements in their ability to evolvefi Would not such enhancements represent an obvious benefit in that organisms possessing them would be able to adapt more rapidly or comprehensively to changes in their environmentsfi Would not any theory of evolution need to deal with variation in the capacity of organisms to evolvefi The first is that the capacity for evolution is a fundamental property of life that does not and cannot vary between populations or species, and that therefore evolvability is a constant that does not need to be considered in devising theories of evolutionary mechanics. The second is that evolvability is enclosed in traditional concepts of fitness and is therefore covered by traditional theory. Arguments are presented below to the effect that neither of these assumptions is correct. Darwin evidently and quite reasonably assumed that all living organisms had the capacity for evolution, that is, the capability for adapting by means of natural selection to changes in their external world of predators, food, habitat, etc. He also must have assumed that this capacity was a constant and not affected by other characteristics of organisms that might arise in the course of evolution. If all three statements are not true, then an organism could evolve characteristics that increased its ability to evolve. It could therefore adapt to its external conditions more rapidly than some competing species. Most people would readily agree that the first statement is true: all living organisms have the properties necessary for evolution. Is it really true that all properties that contribute to the ability to evolve are fundamental properties common to all organismsfi As suggested in previous sections, subsequent developments, including essentially the entire science of genetics (unknown to Darwin), have provided substantial evidence disproving these assumptions regarding evolutionary capacity (or evolvability). In fact, evolved traits of organisms can contribute to or detract from evolvability. The issues of evolvability have, since about 1994, resulted in development of a whole branch of theory. Evolvability has applications outside of biology such as the development of computer programs capable of progressive and cumulative adaptation. Species such as the cockroach and fern have apparently survived for a very long time without significant evolution. Evolvability is substantially different from and in conflict with traditional individual fitness. Many, possibly all, design features that increase evolvability decrease fitness or have no effect on fitness. Evolvability theory as defined here is the idea that a design feature that resulted in an increase in evolvability could evolve despite an individual fitness disadvantage. A belief that the evolution process is the same in all organisms appears to require one to ignore much of the science of genetics. However, a belief in evolvability appears to be incompatible with orthodox Darwinism in that evolvability features are adverse or neutral regarding individual benefit. Possession of the capacity for evolution does not necessarily mean that a species will evolve. The reader has no doubt by now correctly guessed that this is leading to an evolvability theory of aging[37]. One property that Darwin put forth as required by his theory of natural selection was genetically controlled natural variation in traits possessed by organisms in a population. While Darwin presumably thought that such local variation was a fundamental property of life itself, as it would be if inheritance was an analog process, we now know (see Digital Genetics) that complex evolved adaptations such as meiosis, gene crossover, paired chromosomes, and X inactivation support variation due to recombination in the actual digital inheritance scheme. Organisms that sexually reproduce evolved from organisms that did not and did not have the 122 the Evolution of Aging degree of and quality of local variation possessed by the more advanced organisms. Reproductive techniques of primitive organisms tend to be more nearly like cloning or simple copying of genetic code that do not involve the complex shuffling procedures associated with sexual reproduction and therefore do not deliver the degree of variation. It is actually far easier for nature to make an identical copy of the digital genetic instructions than to produce structured, organized, and genetically transmittable variation. It is therefore apparent that evolvability is affected by evolved traits at least in this one case of recombination. It is also apparent in this case that an increase in evolvability resulted in a decrease in individual fitness as suggested earlier. The logic for this is as follows: In a hypothetical fully adapted organism that was totally optimized by natural selection to its external world, every parameter would be optimum or at least as optimum as it was going to get. For example, if a certain height (to name one trait of an animal) were optimum, then we would expect that the average height of all the animals in the population would be the optimum height. However, recombination would cause some of the animals to be shorter than optimum and some to be taller than optimum. The more variation there is, the less fit the average animal will be and therefore the less fit the population as a whole will be. A population with more variation would be less able to compete with a rival population that had less variation. Variation presets a situation in which some of the animals will be instantaneously better adapted than others with regard to a change in the world. If the entire population consisted of genetically identical clones of an optimum animal, then all the animals would be the same optimum height and the average fitness of the population would be maximized. These animals would be completely incapable of adapting through natural selection to any changes in their world because there are no genetically transmittable differences between them for natural selection to select. Orthodox Darwinists would say that the occasional mutation would introduce changes and that therefore variation would never be zero. However, as indicated earlier, recombination creates much larger variation because of cascading the effects of individual mutational differences. So here we have a case of an evolved trait (the variation producing aspects of sexual reproduction and meiosis), which reduces fitness. Animals possessing this trait are less likely to survive and breed than animals not possessing the trait, a violation of the rules for Darwinian natural selection! Although we cannot say that all current species have evolvability, non-zero evolvability must have existed in all of their ancestor species. It is therefore clear that a tradeoff must exist between traits resulting in local variation, and fitness.

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Chronic disease management models such as state will often develop and present with geriatric syndromes that described by Wagner have been developed for optimal that pose serious risk of further functional decline and death. The Wagner Chronic Care model is As such, a strategy of preventing these syndromes or their built on creating a productive interaction between what is sequelae is warranted in frail older adults. Several features of the model foster the etiology of these syndromes is not confined to a single this type of productive interaction. Self-management support organ system or pathophysiologic process, but rather to mulextensively involves the patient in actively managing his or her tiple causes arising from both medical and non-medical conown illness, including participation in learning about the illditions and stressors. Preventive efforts for geriatric synness, care planning, goal setting, and monitoring of the target dromes can be primary, as in counseling older adults about condition. A team-oriented delivery system design, in which all accident prevention in the home; secondary, as in screening personnel taking part in care of the patient have well-defined older adults for gait disorders; or tertiary, as in enrolling a roles, includes planned proactive patient visits, care coordinapatient with an injurious fall in a comprehensive falls pretion, and regular follow-up. This proactive, team-care model is also supported by clinical information sysPrevention of Iatrogenic Illness tems capable of establishing patient registries to facilitate stanthe age-associated disregulation of homeostatic processes dardization of care processes and efficient measurement of described in the previous section render the older adult more outcomes. In Successful chronic disease management programs use general, the older a person becomes, the more he or she is case managers for coordination of all care associated with the likely to experience an adverse affect associated with medical target condition. Iatrogenic illness becomes particularly prominent in assessed for unmet needs, both medical and non-medical, and older adults who have multiple chronic illnesses or have the care manager is usually responsible for arranging services become frail. Group visits of patients logic predisposition to decompensate under the stress of medwith the same target condition have been shown to be successical care, but also invariably require more complex care ful for improving outcomes (11). During these sessions, involving greater numbers of providers across different care patients participate in educational activities designed to prosettings, leading to further problems arising from uncoordimote better self-care of their illness. Frequently the treatment prescribed by one Chronic disease management models have demonstrated provider for a single problem makes another problem worse. Acute care for the eldSyndrome Instruments/Methods erly wards are staffed by nursing and social work personnel Confusion/cognitive Mini-Cog (27), Mini-mental that have been specially trained in geriatrics and use protodecline status exam (28), Confusion cols for independent self-care, optimal skin integrity, proper Assessment Method (29) nutrition, and facilitation of a smooth discharge from the Falls Screening: inquiry about hospital. Pharmacist consultation, targeted at complicated hospitalized older adults and outpatients who are at high risk Functional decline Activities of daily living and for functional decline, has been demonstrated to minimize instrumental activities of adverse drug affects in both inpatient and outpatient settings daily living (19). Geriatric Evaluation and Management, when properly Gait and balance Semitandem stand, Get-Uptargeted to frail older inpatients or outpatients with multidisdisorders And-Go test (31) ciplinary needs, has been effective at reducing iatrogenic probIncontinence Inquiry if patient has lost lems such as adverse drug events or readmission to the hospiurine 5 times/previous year tal for relapses of chronic illnesses (20). Completion of a Physician Orders for LifeSustaining Treatment form, endorsed by some states and which treatments directed by multiple consultants clash, and being developed in many others, can potentially enhance to appropriately reconcile these treatments to minimize iatropatient-centered care at the end of life (23). Adverse drug affects are also quite common in the outpatient setting and have been associated with the following Table 7. In some instances, a preventive between providers at each end of the transition, resulting in service may represent more than one of these categories. For errors of overuse, underuse, and inappropriate use of medicaexample, detection and treatment of hypertension to prevent tions and treatments. Acute care for the elderly units vascular disease), or tertiary prevention (in those who have are modified hospital wards that are specifically designed for prior myocardial infarction or stroke). A rational approach to prevention in chronScreening Tests Not ically ill and older adults involves prioritizing the services in Condition Recommended Table 7. The disease in low risk treadmill test, electron beam most applicable preventive services for these patients center on patients computed tomography primary and secondary disease prevention. Colon cancer in Fecal occult blood testing, Any health promotive activities designed to stave off the people 75 years old colonoscopy development of chronic illness and frailty are also prioritized Chronic obstructive Spirometry in healthy older adults. Long-term observational studies show pulmonary disease that frailty can be primarily prevented through regular physical activity and proper nutrition (24). Young and middle-aged Ovarian cancer Transvaginal ultrasonography, adults who regularly exercise. Similarly, diets that include low saturated fats, low sodium, adequate calcium and vitamin D, high fiber, Prostate cancer in Prostate-specific antigen and moderate alcohol intake are also associated with robust men 74 years old measurement, digital rectal health in older adults. Even among older adults who lack a exam life-long pattern of exercise and good dietary habits, adoption *Strength of Recommendation D. Signs of frailty can be identified through clinical vigilance or regular screening of adults for conditions People with serious chronic diseases are likely to have comsuch as decreasing body mass index, worsening exercise tolplications related to those diseases. Although someone with erance, bradykinesia (for both fine and gross motor activity), osteoporosis and diabetes could still die of an unrelated canand especially immobility. Once identified as being frail, cer, it is more likely that she will become disabled or die from efforts focus more on prevention of geriatric syndromes (see a hip fracture or a complication of diabetes. For example, in a frail older woman will become frail and develop geriatric syndromes; thus, with atrial fibrillation who is also at high risk of falls and hip screening for these syndromes (see Table 7. List the most common symptoms and diagnoses seen in the family physician can come up with a treatment plan. Describe common decision-making approaches used these patients, the challenge is not making a diagnosis but by family physicians and give an example of when rather effective management over time. Apply the threshold model of decision-making to a include preventive visits, chronic illnesses such as diabetes common problem such as sore throat or deep vein and arthritis, and return visits for management of medicathrombosis. Explain how a family physician should approach the increasing emphasis in family medicine on prevention and following issues: dealing with clinical uncertainty, chronic disease management over the past two decades. Note that no psychological conditions are listed among the 20 most common reasons for visiting, although as many as half of family physician visits involve issues such as stress, adjustment problems, depression, and anxiety. Often, people who are in psychological distress either problems are approached quite differently. This chapter prothe broad training of family physicians allows multiple vides a brief overview of these problems and a general problems to be addressed during a single visit. We will begin by discussing that directly observed a large group of family physicians found what we mean by common problems. After the diagnosis is estabpatients visit family physicians, according to the National lished, a management plan can be developed. Providing an estimate of the majority of patients want help with specific medical prognosis. Many patients have hypertension, diabetes, chronic sinusitis, asthma) and acute problems that seem to defy classification, and the causes of illrespiratory problems. Decisions are made that care, strains/sprains, depression, and contact dermatitis. Yet outcomes these exemplify why family medicine training extends into of care are mostly good and the patients seem satisfied. The answer is, partly, because the physician is experiown so that making a specific diagnosis may be neither necesenced and well-trained and often knows his or her patients sary nor beneficial to the patient. However, just as important is that decision making in and decision-making styles learned in traditional inpatient primary care differs in certain respects from what students are care often are not appropriate in the outpatient primary care taught in hospital settings. In primary care, this concept is often findings, and test results), analyzing the information (the reversed.

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Intraocular foreign bodies and penetrating injuries are most often caused by being in close proximity to highvelocity projectiles such as windshield glass broken during a motor vehicle accident, metal ground without use of protective safety goggles, and improperly detonated fireworks. Clinical Findings Sudden ocular pain occurs; vision loss, as well as multiple organ trauma, may be present. B: Subconjunctival foreign body of ous signs of corneal perforation (shallow anterior chamber graphite. A blowout fracture must be suspected in a patient with symptoms of double vision, pain with eye movements, and restriction of extraocular muscle movements after blunt orbital trauma. Assessment of ocular motility, globe integrity, and intraocular pressure will determine the extent of the blunt orbital injury. Furthermore, nonradiopaque open the eyelids), proptosis, and possibly an acute traumatic materials such as glass will not be seen on x-ray film. Neuroimaging may reveal a retrobulbar including bony injury and foreign body wound. Treatment In cases of suspected intraocular foreign body or perforation Treatment of the globe, it may be best to keep the child at rest, gently Cold compresses or ice packs for brief periods (eg, 10 minutes shield the eye with a metal shield or cut-down paper cup, and at a time) are recommended in older children in the first 24 keep the extent of examination to a necessary minimum to hours after injury to reduce hemorrhage and swelling. In this setting, the Patients with clinical signs of muscle entrapment require child should be given nothing by mouth in case eye examiurgent surgical repair to help prevent permanent ischemic nation under anesthesia or surgical repair is required. Large fractures may need repair to prevent enophthalmos, a sunken appearAldakaf A et al: Intraocular foreign bodies associated with trauance to the orbit. Treatment should not be delayed in order to image the Blunt orbital and soft tissue trauma may produce so-called orbits. Inspection of the eyelids reveals the extent and severity of the traumatic laceration. Lacerations of the nasal third of the Clinical Findings eyelid and involving the eyelid margin are at risk for lacrimal system injury and subsequent chronic tearing. The orbital floor is a common location for a fracture (called a blowout fracture). A specific fracture that occurs mainly in Treatment children after blunt orbit trauma is called the white-eyed Except for superficial lacerations away from the globe, repair blowout fracture. A cycloplegic agent is added if corneal involvement is present, because pain from ciliary spasm and iritis may accompany the injury. This results in damage to the conjunctival vessels which give the eye a white or blanched appearance. Immediate treatment consists of copious irrigation and removal of precipitates as soon as possible after the injury. The patient should be referred to an ophthalmologist after immediate first aid has been given. Laceration involving right lower lid and Blunt trauma to the globe may cause a hyphema, or bleeding canaliculus. These injuries are best repaired by an ophthaledema or detachment, and glaucoma. In patients with sickle mologist and may require intubation of the nasolacrimal cell anemia or trait, even moderate elevations of intraocular system with silicone tubes. Therefore, all African Americans whose sickle cell status is unknown should be tested if hyphema is observed. Nontraumatic causes of hyphema include ectropion or entropion of the lid and scarring of the conjuvenile xanthogranuloma and blood dyscrasias. Clinical Findings Eyelid burns can occur in toddlers from contact with a lighted cigarette. Chemical burns with strong acidic and alkaline agents can be blinding and constitute a true ocular emergency. Examples are burns caused by exploding batteries, spilled drain cleaner, and bleach. Corneal epithelial defects can be diagnosed using fluorescein dye, which will stain areas of the cornea where the epithelium is absent. Other within several weeks may need surgical treatment by a retinal injuries to the globe and orbit are often present. Golf injuries can be very diagnosis of shaken baby syndrome is often vague and poorly severe. Bungee cords have been associated with multiple correlated with the extent of injury. Use of these items and associated Victims often have multiple organ system involvement that activities should be avoided or very closely supervised. Safety includes, but is not limited to, traumatic brain injury, bone goggles should be used in laboratories and industrial arts fractures and retinal hemorrhages. The presentation can vary classes and when operating snow blowers, power lawn mowfrom irritability to emesis, change in mental status, or ers, and power tools, or when using hammers and nails. Sports-related eye injuries can be prevented with protective Neuroimaging of the brain as well as a skeletal survey are eyewear. Sports goggles and visors of polycarbonate plastic tools used to diagnose shaken baby syndrome. Ophthalmic will prevent injuries in games using fast projectiles such as consultation and a dilated retinal examination are necessary tennis or racquet balls, or where opponents may swing to document retinal hemorrhages. Whereas retinal hemorrhages tend to resolve always wear polycarbonate eyeglasses and goggles for all fairly quickly, those in the vitreous do not. High-risk activities such as boxing and the martial over the macula, deprivation amblyopia may occur and may arts should be avoided by one-eyed children. Other ocular findings associated with nonaccidental trauma include American Academy of Pediatrics, Committee on Sports Medicine lid ecchymosis, subconjunctival hemorrhage, hyphema, retiand Fitness; American Academy of Ophthalmology, Eye Health nal folds, retinoschisis, and optic nerve edema. Acute-onset and Public Information Task Force: Protective eyewear for young athletes. Brophy M et al: Pediatric eye injury-related hospitalizations in the United States. Blepharitis is inflammation of the lid margin characterized by crusty debris at the base of the lashes; varying degrees of Treatment erythema at the lid margins; and in severe cases, secondary Management of any systemic injuries is required. Observacorneal changes such as punctate erosions, vascularization, tion by an ophthalmologist of retinal hemorrhages for resoand ulcers. When conjunctival injection accompanies blephlution is the usual course of treatment. Treatment includes lid scrubs with a nonburning baby shampoo several times a week and application of a topical antibiotic ointment such as erythromycin or bacitracin at bedtime. Rosacea Rosacea can also occur in the pediatric age group and cause chronic blepharoconjunctivitis with corneal changes that decrease vision. Pediculosis Pediculosis of the lids (phthiriasis palpebrarum) is caused by A Phthirus pubis. Nits and adult lice can be seen on the eyelashes when viewed with appropriate magnification. Mechanical removal and application to the lid margins of phospholine iodide or 1% mercuric oxide ointment can be effective. Treatment modalities include cryotherapy, cautery, carbon dioxide laser, and surgery.

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This subconscious transfer of feelings results in colleagues determining whether someone has a positive attitude about their work. Self-esteem impacts attitude: low self-esteem causes lack of confidence, and higher self-esteem leads to selfconfidence, improved relationships, self-respect, and a successful career. To listen effectively, be sure to understand the message instead of just hearing words. This active involvement in the communication process helps avoid miscommunication. It is equally important to remember that colleagues deserve the same respect and attention as patients. Ellison Diversity is defined as differences among people and includes demographics of age, education, ethnicity, gender, geographic location, income, language, marital status, occupation, parental status, physical and mental ability, race, religious beliefs, sexual orientation, and veteran status. Developing tolerance, which is the opposite of bigotry and prejudice, means dealing with personal attitudes, beliefs, and experiences. Embracing the differences that represent the demographics of our society is crucial to becoming a successful health professional. Kelly Leadership is the ability to motivate team members to complete a common organizational goal display. Leaders have earned the trust of their team, which is the reason the entire team is able to achieve its objective and set the standard for productivity, and even revenue goals. Leaders emerge from within the organization because they have demonstrated beliefs, ethics, and values with which team members identify. Managers who are not threatened by the natural emergence of leaders benefit from team harmony and increased productivity. They HealtH Insurance specIalIst career 11 receive credit for excellent management skills, and they begin the process to leadership when they begin to acknowledge the work ethic of the team and its leader. Pursuing professional certification and participating in continuing education helps ensure individual compliance with the latest coding rules and other updates. Increased knowledge leads to increased productivity and performance improvement on the job. The American Heritage Concise Dictionary defines ethics as the principles of right or good conduct, and rules that govern the conduct of members of a profession. This means colleagues provide help to and receive help is the initial point of contact for the office, all healthcare team from other members of the team. Sharing the leadership role and working members must effectively handle together to complete difficult tasks facilitates team-building. This requires sensitivity to patient concerns about healthcare Telephone Skills for the Healthcare Setting problems, and the healthcare professional must communicate the telephone can be an effective means of patient access to the healthcare a caring environment that leads system because a healthcare team member serves as an immediate contact for to patient satisfaction. When processes for handling all calls are developed and followed by healthcare team members, the result is greater office efficiency and less frustration for healthcare team members and patients. Avoid problems with telephone communication in your healthcare setting by implementing the following protocols: Establish a telephone-availability policy that works for patients and office staff. Telephone calls that are unanswered, result in a busy signal, and/or force patients to be placed on hold for long periods frustrate callers. Avoid such problems by increasing telephone availability so that the calls are answered outside of the typical 9 to 5 workday (which often includes not answering the telephone during lunch). Consider having employees (who have undergone telephone skills training) answer calls on a rotating basis one hour before the office opens, during the noon hour, and one hour after the office closes. This telephone protocol will result in satisfied patients (and other callers) and office employees (who do not have to return calls to individuals who otherwise leave messages on the answering machine). Another option is to install an interactive telephone response system that connects callers with appropriate staff. Inform callers who ask to speak with the physician (or another healthcare provider) that the physician (or provider) is with a patient. The receptionist will be able to tell callers an approximate time when calls will be returned (and patient records can be retrieved). Physically separate front desk check-in/check-out and receptionist/patient appointment scheduling offices. It is unlikely that an employee who manages the registration of patients as they arrive at the office (and the check-out of patients at the conclusion of an appointment) has time to answer telephone calls. Office receptionists and appointment schedulers who work in private offices will comply with federal and state patient privacy laws when talking with patients. In addition, appointment scheduling, telephone management, and patient check-in (registration) and check-out procedures will be performed with greater efficiency. Schedule professional telephone skills training as part of new employee orientation, and arrange for all employees to attend an annual workshop to improve skills. Training allows everyone to learn key aspects of successful telephone communication, which include developing an effective telephone voice that focuses on tone. During a telephone conversation, each person forms an opinion based on how something is said (rather than what is said). Therefore, speak clearly and distinctly, do not speak too fast or too slow, and vary your tone by letting your voice rise and fall naturally. The following rules apply to each telephone conversation: fi When answering the telephone, state the name of the office and your name. Professional Credentials the health insurance specialist who becomes affiliated with one or more professional associations (Table 1-4) receives useful information available in several formats, including professional journals and newsletters, access to members-only Web sites, notification of professional development, and so on. A key feature of membership is an awareness of the importance of professional certification. Once certified, the professional is responsible for maintaining that credential by fulfilling continuing education requirements established by the sponsoring association. National Electronic fi Created in 1996 to assist professionals entering the medical billing industry and those already working in Billers Alliance the field. A health insurance claim is submitted to a third-party payer or government program to request reimbursement for healthcare services provided. Many health insurance plans require preauthorization for treatment provided by specialists. While the requirements of health insurance specialist programs vary, successful specialists will develop skills that allow them to work independently and ethically, focus on attention to detail, and think critically. Medical practices and healthcare facilities employing health insurance specialists require them to perform various functions. Smaller practices and facilities require specialists to process claims for all types of payers, while larger practices and facilities expect specialists to process claims for a limited number of payers. Health insurance specialists are guided by a scope of practice, which defines the profession, delineates qualification and responsibilities, and clarifies supervision requirements.

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Athletes with mollusHead and neck injuries occur most commonly in contact cum contagiosum can compete if the affected areas are covered. The sports with the highest incidences Athletes with furuncles cannot be involved in contact sports or of brain injury are football, bicycling, baseball, horseback swimming until the lesions are healed. As a Universal precautions should be used with all athletes who have sustained injuries. Neuropsychology Symptoms appear on the same side as an injury to the testing is advocated for athletes with persistent symptoms. Recent findings related to multiple concussions in athletes Burning pain or numbness in the shoulder and arm. These types of cervical radiculopathies or play guidelines should be used in children. Second Impact Syndrome burning pain and paresthesias down one arm generally Second impact syndrome is a rare but potentially deadly lasting only minutes. The most important part of the workup is a thorough at risk for a loss of vascular autoregulation and subsequent neurologic assessment to differentiate this injury from a malignant cerebral edema. The athlete can return to play once symptoms have films including flexion, extension, and neutral position evalresolved, neck and shoulder range of motion is pain-free, reflexes and strength are normal, and the Spurling test is negative. Headache Dizziness Weinberg, J et al: Etiology, treatment and prevention of athletic Balance problems stingers. As children have become more competitive in Sleep abnormalities sports, the number of reported injuries has increased. Sports Memory problems with a fairly high incidence of back injuries include golf, Concentration difficulties gymnastics, football, dance, wrestling, and weightlifting. Irritability Pain lasting more than 2 weeks indicates a possible structural Behavioral changes problem and needs to be investigated. Patients present with focal tenderness of the thoracic letes with less than 30% slippage have no restrictions and are or thoracolumbar spine. Slippage of 50% or more phy that may demonstrate mild wedging of the thoracic requires interventions of stretching hip flexors and hamvertebra. When significant spinal tenderness or any neurostrings, working on core stability, along with bracing or logical abnormalities are present, radiographs are often folsurgery. Treatment of that he or she cannot return to activities for at least a year minor compression fractures includes pain control, bracing, and may not be able return to previous sporting activities. Discogenic back pain accounts for a small percentage of back injuries in children. Back pain can originate from disk herniation, apophyseal injury, and disk degeneration. Evaluation includes physical and neurologic examinations, including straight leg Usually presents as back pain with extension. The percentTreatment usually is conservative as most back injuries age of pars defects in athletes such as gymnasts, dancers, improve spontaneously. The athlete can rest the back for a divers, and wrestlers is significantly increased. Repetitive short period and then begin a structured exercise program of overload results in stress fractures. The athlete presents with back pain that symptoms persist, a short course of steroids may be indiis aggravated by extension, such as arching the back in cated. Evaluation includes anteroposterior Eddy D et al: A review of spine injuries and return to play. Shoulder injury is usually a result of acute trauma or chronic Treatment includes refraining from hyperextension and overuse. Acute injuries around the shoulder include contuhigh-impact sporting activities, stretching of the hamstrings, sions, fractures, sprains (or separations), and dislocations. Athletes can the age of the patient affects the injury pattern, as younger cross-train with low-impact activity and neutral or flexionpatients are more likely to sustain fractures instead of sprains. Return to play is often delayed 6 weeks or longer based on clinical signs of healing. Diagnosis is made by radiographs of the clavicle; the When a bilateral pars injury occurs, slippage of one vertebra fractures are most common in the middle third of the bone. These injuries are Initial treatment is focused on pain control and protecgraded from 1 to 4 based on the percentage of slippage: grade tion with a sling and swathe. Acromioclavicular Separation Follow-up treatment for a glenohumeral dislocation in young athletes is controversial. Initially, the shoulder is A fall on the point of the shoulder is the most common cause immobilized for comfort. Because of the high icular joint capsule and possibly the coracoclavicular ligarisk of recurrence, options for treatment should be individuments occurs. The injury is classified by the extent of the alized, with consideration given to both nonoperative and injuries to these ligaments. Fracture of the Humerus Numerous shoulder injuries are related to repetitive overuse and tissue failure. Rotator cuff injuries are common in sports Fractures of the humerus occur from a severe blow or fall on requiring require repetitive overhead motions. Pain and swelling are localized to the proximal imbalances and injury can cause the position of the humeral humeral region. The fractures can include the physes or may head to be abnormal, which may cause impingement of the be extraphyseal. Some amount of displacement and angulasupraspinatus tendon under the acromial arch. Careful assessment of the capsular laxity (also known as multidirectional instability) brachial plexus and radial nerves are needed to rule out are prone to overuse rotator cuff injury. Acute Traumatic Anterior the rehabilitation of this injury is geared toward reducShoulder Instability (Anterior tion of inflammation, improved flexibility, core stabilization, Shoulder Dislocation/Subluxation) and strengthening of the scapular stabilizers and rotator cuff muscles. Examination often shows tenderness Treatment of the acute injury includes rest from throwover the proximal humerus. It is not uncommon for a player to be benched for up office examination do not preclude this diagnosis. The key to treating this injury is prevenening, sclerosis, and irregularity of the proximal humeral tion. Comparison views are often helpful when considercoached in correct throwing biomechanics. Treatment consists of rest from throwing or other aggraLittle League limits 10to 12-year-old children to 6 innings vating activity. Physical therapy is initiated during the rest per week and 13to 15-year-old children to 9 innings per period. The child may have dull aching in the lateral Sciascia A et al: the pediatric overhead athlete: What is the problemfi Osteochondritis Dissecans dividing the examination into specific anatomic areas as discussed below.

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Just one final year optional module included undertaking a worksite analysis (Ross, 2006). A study undertaken by academics in occupational medicine showed evidence that the number of hours spent teaching occupational medicine to undergraduate doctors had dropped from the levels reported in 1989. As has been stressed throughout this book, gaining an understanding of the workplace is a core element of any successful rehabilitation for work programme. They highlight a concern regarding the numbers of practitioners in the field with no professional qualifications whatsoever. Importantly, they emphasise the need for education to extend beyond purely theoretical knowledge, to support the transfer of this knowledge into the workplace, and to provide the means to measure the effectiveness of the intervention which is delivered (Vocational Rehabilitation Association, 2006). There are a number of complex reasons for these difficulties, not least the rapid rate of change in this sector, which has outpaced education. Consequently, there is now a need for much creative thinking to develop innovative learning opportunities for therapists in this field, particularly at an undergraduate level. This is a positive shift and demonstrates that the work agenda is now filtering through to undergraduate students. Even in those countries where the infrastructure is already well-established, sufficient placements are not always available (James and Prigg, 2004). Furthermore, it has been suggested that the knowledge and skills learned in the undergraduate curriculum may not be sufficient for later needs when qualified (Strong et al. It is not unduly surprising that occupational therapists, or any other professional group, have been unable to hit the ground running. This workforce is often transient in nature, and therefore, perhaps too little investment is currently being made in creating a solid infrastructure for the future. We were also confronted about whether we were overly infiuenced by a traditional, Protestant work ethic and by political drives to reduce unemployment figures (Stewart, 2004). Running through these sentiments it seems there is a collective sense of frustration that may, perhaps, be shared by others as they read this book. A reality which has become increasingly apparent in recent years is the fact that occupational therapists are not well-deployed for them to be able to effectively deliver rehabilitation for work interventions (Alsop, 2004; Joss, 2002). It has been recognised that current practice has a very limited focus on rehabilitation of any form and even less on the vocational needs of clients. This small number of rehabilitation practitioners must be seen within the context of the present situation, where over 2. Many more will, of course, be absent or struggling to stay in work because of a health condition or a disability. Consequently, it seems that, in the foreseeable future at least, a major shake-up is unlikely. In education we need to shift away from an over-reliance on sociological perspectives of work (Ross, 2006) and begin to consider how we may be able to expand our understanding of human occupation to provide us with an occupation-focused perspective of work. Providing this theoretical knowledge is an important step forwards, but cannot replace the confidence and skill which are gained through experientially taking part in a worksite visit, for example. In a number of services, particularly within mental health, occupational therapists are acting as work champions, providing a focal point for others within the wider team. Returning to the literature, we can see that, in recent years, some demonstrable successes have been achieved, in spite of existing barriers. Forging new partnerships with other agencies such as education, training, volunteering and employment is a highly effective way to move forwards (Devlin et al. In this regard, an entrepreneurial approach towards service development is required. It is to be anticipated that, in the future, practitioners themselves will be expected to obtain some form of accreditation too. This question certainly needs to be a priority for debate and, hopefully, some consensus. In what ways may older people be actively supported to maintain a valued work role, if this is what they aspire to dofi Despite a recognition of the fact that outcomes are greatly enhanced with early intervention, many existing services which address work support needs are reactive and therefore seem to be delivered too late. While on this point, how do we help the person recovering from a life-changing illness, perhaps requiring lengthy medical rehabilitation or convalescence, to successfully retain a worker identityfi Clearly, it is wasteful of an expensive resource to think that every person who is absent from work will need a therapist to facilitate their return. But there will be instances where additional support to re-enter work will be needed, to prevent unnecessary long-term absence or job loss. On this note, not all individuals will need the same level of support to return either. There are some suggestions that men achieve better outcomes from rehabilitation for work than women (Ahlgren and Hammarstrom, 2000). Are we confident that our services are designed to meet the needs of all who might benefit from themfi How might we measure the potential contribution of the workplace itself to work, health and well-beingfi These, and many other questions, have raised themselves as worthy of research in the future. However, it is worth noting that finding the answers may not always be that straightforward. The researcher may have particular difficulty navigating his or her way around the electronic databases seeking out evidence on this subject, since search terms such as occupational health, are not particularly easy to locate. Furthermore, much of the literature on work is more likely to be found within sociological databases rather than health ones. It is now time to refiect on some of the things we have learned about vocational rehabilitation over the course of this book. Then, having done so, we need to step out into a world of work which is, perhaps, now a little more familiar, and take those ideas forward and integrate them into our work to benefit our clients. Gendered experiences of rehabilitation, Scandinavian Journal of Public Health, 28 (2), pp. Alcohol Concern (2006) Impact of alcohol problems in the workplace, Acquire, February. Presented at the 8th International Seminar on the Clubhouse Model, Salt Lake City. Ergonomics for therapists (second edition) Boston: Butterworth Heinemann, Chapter 1. An innovative work scheme for people with mental health problems, British Journal of Occupational Therapy, 58 (1), pp. Part two: National Activity Pacing Survey, British Journal of Occupational Therapy, 67 (11), pp. British Heart Foundation (2005) Returning to work with a heart condition, heart information series no. British Society of Rehabilitation Medicine (2000) Vocational rehabilitation: the way forward, London. British Society of Rehabilitation Medicine (2003) Vocational rehabilitation: the way forward (second edition). British Society of Rehabilitation Medicine, Jobcentre Plus and Royal College of Physicians (2004) Inter-agency guidelines for vocational assessment and rehabilitation after aquired brain injury, London: Royal College of Physicians.

References:

  • https://stanfordhealthcare.org/content/dam/SHC/for-patients-component/programs-services/clinical-nutrition-services/docs/pdf-therapyforchronicpancreatitis.pdf
  • https://www.ncjrs.gov/pdffiles1/nij/grants/251932.pdf
  • http://www.bccancer.bc.ca/chemotherapy-protocols-site/Documents/Lymphoma-Myeloma/LYCDA_Protocol.pdf
  • https://www.landsaga.com/uploads/1/2/7/6/127674913/characterization_of_fungal_communities_associated_to_willow.pdf

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