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Laura M Caputo, MD

• Assistant Professor of Medicine

https://medicine.duke.edu/faculty/laura-m-caputo-md

Diagnosis and management of asthma in children 5 years and younger 159 the emergency department antibiotic resistance review 2015 order minomycin us, or antibiotics for sinus fungal infection 50 mg minomycin amex, if at home antibiotic nausea order cheap minomycin, should be observed by the family/carer and have ready access to emergency care antibiotics simplified pdf buy 50 mg minomycin mastercard. The child should be closely monitored antibiotics for acne yes or no generic 100 mg minomycin fast delivery, and the dose should be adjusted according to clinical improvement and side effects hm 4100 antimicrobial generic 50mg minomycin overnight delivery. This approach should be reserved mainly for individual cases, and should always involve regular follow up and monitoring of adverse effects (Evidence D). Discharge and follow up after an exacerbation Before discharge, the condition of the child should be stable. Children who have recently had an asthma exacerbation are at risk of further exacerbations and require follow up. The most important of these interactions may occur in early life and even in utero. Multiple environmental factors, both biological and sociological, may be important in the development of asthma. Additional information about factors contributing to the development of asthma, including occupational asthma, is found in Appendix Chapter 2. However, a recent study of a pre-birth cohort observed that maternal intake of foods commonly considered allergenic (peanut and milk) was associated with a decrease in allergy and asthma in the offspring. High gestational weight gain was associated with higher odds of ever asthma or wheeze. Primary prevention of asthma Breastfeeding Despite the existence of many studies reporting a beneficial effect of breastfeeding on asthma prevention, results are conflicting,432 and caution should be taken in advising families that breastfeeding will prevent asthma. Regardless of its effect on development of asthma, breastfeeding should be encouraged for all of its other positive benefits (Evidence A). Timing of introduction of solids Beginning in the 1990s, many national pediatric agencies and societies recommended delay of introduction of solid food, especially for children at a high risk for developing allergy. However, meta-analyses have found no evidence that this practice reduces the risk of allergic disease (including asthma). A systematic review of cohort, case control and cross-sectional studies concluded that maternal dietary intake of vitamin D, and of vitamin E, was associated with lower risk of wheezing illnesses in children. Probiotics A meta-analysis provided insufficient evidence to recommend probiotics for the prevention of allergic disease (asthma, rhinitis, eczema or food allergy). While there appears to be a linear relationship between exposure and sensitization to house dust mite,718,719 the relationship for animal allergen appears to be more complex. Primary prevention of asthma 165 Birth cohort studies provide some evidence for consideration. A meta-analysis found that studies of interventions focused on reducing exposure to a single allergen did not significantly affect asthma development, but that multifaceted interventions such as in the Isle of Wight study,728 the Canadian Asthma Primary Prevention Study,729 and the Prevention of Asthma in Children study730 were associated with lower risk of asthma diagnosis in children younger than 5 years. Pollutants Maternal smoking during pregnancy is the most direct route of pre-natal environmental tobacco smoke exposure. For example, there is a lower risk of asthma among children raised on farms with exposure to stables and consumption of raw farm milk than among children of non-farmers. Although the risk of parent-reported asthma with infrequent wheeze was reduced at 6 years, there was no impact on doctor-diagnosed asthma or lung function. Medications and other factors Antibiotic use during pregnancy and in infants and toddlers has been associated with the development of asthma later in life,750-752 although not all studies have shown this association. Primary prevention of asthma Psychosocial factors the social environment to which children are exposed may also contribute to the development and severity of asthma. Obesity A meta-analysis of 18 studies found that being either overweight or obese was a risk factor for childhood asthma and wheeze, particularly in girls. Possibly the most important factor is the need to provide a positive, supportive environment for discussion that decreases stress, and which encourages families to make choices with which they feel comfortable. When asthma care is consistent with evidence-based recommendations, outcomes improve. Specific steps need to be followed before clinical practice recommendations can be embedded into local clinical practice and become the standard of care, particularly in low resource settings. Approach to implementation of the Global Strategy for Asthma Management and Prevention Box 8-2. Select the material to be implemented, agree on main goals, identify key recommendations for diagnosis and treatment, and adapt them to the local context or environment. Develop a step-by-step implementation plan: o Select target populations and evaluable outcomes. Continuously review progress and results to determine if the strategy requires modification. Cultural and economic barriers can particularly affect the application of recommendations. Each country should determine its own minimum sets of data to audit health outcomes. Calling time on asthma deaths in tropical regions-how much longer must people wait for essential medicines Management of asthma in resource-limited settings: role of low cost corticosteroid/beta-agonist combination inhaler. Identification of asthma phenotypes using cluster analysis in the Severe Asthma Research Program. An official American Thoracic Society and European Respiratory Society technical statement. Worldwide patterns of bronchodilator responsiveness: results from the Burden of Obstructive Lung Disease study. An official American Thoracic Society clinical practice guideline: exercise-induced bronchoconstriction. The effects of the inhaled corticosteroid budesonide on lung function and bronchial hyperresponsiveness in adult patients with cystic fibrosis. Bronchial responsiveness to methacholine in chronic bronchitis: relationship to airflow obstruction and cold air responsiveness. In vitro diagnosis of allergy: how to interpret IgE antibody results in clinical practice. Exhaled nitric oxide: a biomarker integrating both lung function and airway inflammation changes. Overtreatment with inhaled corticosteroids and diagnostic problems in primary care patients, an exploratory study. Inducible laryngeal obstruction: an official joint European Respiratory Society and European Laryngological Society statement. An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea. Diagnostic accuracy of an integrated respiratory guideline in identifying patients with respiratory symptoms requiring screening for pulmonary tuberculosis: a cross-sectional study. Burney P, Jithoo A, Kato B, Janson C, Mannino D, Nizankowska-Mogilnicka E, Studnicka M, et al. The relationship of asthma impairment determined by psychometric tools to future asthma exacerbations. Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis. Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study. Patient-reported outcomes with initiation of fluticasone furoate/vilanterol versus continuing usual care in the Asthma Salford Lung Study. Measurement properties and interpretation of three shortened versions of the asthma control questionnaire. Longitudinal validation of the Test for Respiratory and Asthma Control in Kids in pediatric practices. Development and validation of the Composite Asthma Severity Index-an outcome measure for use in children and adolescents. Inflammatory and comorbid features of patients with severe asthma and frequent exacerbations. Association between air pollutants and asthma emergency room visits and hospital admissions in time series studies: A systematic review and meta-analysis. City housing atmospheric pollutant impact on emergency visit for asthma: A classification and regression tree approach. Psychological, social and health behaviour risk factors for deaths certified as asthma: a national case-control study. Mild exacerbations and eosinophilic inflammation in patients with stable, well-controlled asthma after 1 year of follow-up. Higher patient perceived side effects related to higher daily doses of inhaled corticosteroids in the community: a cross-sectional analysis. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Long-acting beta2 agonist monotherapy vs continued therapy with inhaled corticosteroids in patients with persistent asthma: a randomized controlled trial. Significant variability in response to inhaled corticosteroids for persistent asthma. Risk of severe asthma episodes predicted from fluctuation analysis of airway function. The risk of hospitalization and near-fatal and fatal asthma in relation to the perception of dyspnea. Perception of bronchoconstriction: a complementary disease marker in children with asthma. Impact of shared decision making on asthma quality of life and asthma control among children. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. The association of health literacy with adherence and outcomes in moderate-severe asthma. Effectiveness of educational interventions on asthma self-management in Punjabi and Chinese asthma patients: a randomized controlled trial. Implementation of asthma guidelines in health centres of several developing countries. Increasing doses of inhaled corticosteroids compared to adding long-acting inhaled beta2-agonists in achieving asthma control. Tailored interventions based on sputum eosinophils versus clinical symptoms for asthma in children and adults. Fractional exhaled nitric oxide as a predictor of response to inhaled corticosteroids in patients with non-specific respiratory symptoms and insignificant bronchodilator reversibility: a randomised controlled trial. Effect of inhaled corticosteroid particle size on asthma efficacy and safety outcomes: a systematic literature review and meta analysis. Dusser D, Montani D, Chanez P, de Blic J, Delacourt C, Deschildre A, Devillier P, et al. Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations. Asthma and adherence to inhaled corticosteroids: current status and future perspectives. Association of inhaled corticosteroids and long-acting beta-agonists as controller and quick relief therapy with exacerbations and symptom control in persistent asthma: A systematic review and meta-analysis. Lazarinis N, Jorgensen L, Ekstrom T, Bjermer L, Dahlen B, Pullerits T, Hedlin G, et al. Combination of budesonide/formoterol on demand improves asthma control by reducing exercise-induced bronchoconstriction. Early intervention with budesonide in mild persistent asthma: a randomised, double-blind trial. Regular use of inhaled corticosteroids and the long term prevention of hospitalisation for asthma. Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey. Haahtela T, Jarvinen M, Kava T, Kiviranta K, Koskinen S, Selroos O, Sovijarvi A, et al. Comparison of a b2-agonist, terbutaline, with an inhaled corticosteroid, budesonide, in newly detected asthma. Comparison of formoterol and terbutaline for as-needed treatment of asthma: a randomised trial.

Expecting clinical excellence that improves quality of care antibiotics used for strep throat order minomycin 100 mg with amex, expands services and access to services antibiotics for lactobacillus uti order minomycin 100 mg without a prescription, and achieves outcomes that are recovery oriented virus 78 order minomycin on line, with an emphasis and support to train clinical staff in evidence-based approaches and interventions antimicrobial resistance 5 year plan minomycin 50 mg amex. All operations are conducted in an honest infection 68 minomycin 100 mg online, fiscally responsible antibiotic abuse buy minomycin 100 mg visa, ethical manner with dedication to quality that meets and exceeds customer expectations. These partnerships are diverse, creative, supportive, and are always focused on supporting our quality improvement mission. Our missions are to improve access to quality behavioral health care for New Mexicans and to reduce barriers that prevent access. This will include, but is not limited to: participating in meetings, providing information requested by the State to assess ongoing parity compliance, working with the State to resolve any non-compliance, and notifying the State of any changes to benefits or limitations that might impact parity compliance. Respite services are limited to a maximum of 100 hours annually per care plan year provided there is a primary caretaker. For children and youth up to 21 years of age diagnosed with a serious emotional or behavioral health disorder, respite services are limited to 720 hours a year or 30 days. Critical incident reporting responsibilities and reporting requirements include: A. Only sentinel events are reported directly to the Human Services Department/Behavioral Services Division. Refer to the Critical Incident Reporting Protocol (2018) for additional information and reporting resources. This process does not supplant any reporting requirements that are mandated by another agency such as the Children Youth and Families Department, Aging and Long-Term Services Department or the Department of Health. This template features drop-down menu options, and can be filled out, saved, and sent without printing. Training dates and sites should be considered in conjunction with other events that are relevant to the same professional within the behavioral health service model. Purpose the purpose of telemedicine is to extend access to assessment, evaluation and therapeutic services. Definitions Telemedicine the use of interactive simultaneous audio and video, or video only if client is deaf or has other individualized needs. Forwarding an image or information to a different provider for interpretation is not considered store-and-forward technology eligible for reimbursement unless it is to obtain information necessary for treating the recipient during the telemedicine session. An interactive telehealth communication system must include both interactive audio and video and be delivered on a real-time basis at both the originating and distant sites. Originating site the location of an eligible Medicaid recipient at the time the service is furnished via a telecommunications system. Distant site sometimes called the remote site, the telemedicine site where the medical provider or specialist is located while using telemedicine connections to treat the recipient who is at the originating site. The terms telehealth and telemedicine are used interchangeably in the Medicaid program. Prescribing Medications via Telehealth All prescribing via telehealth must be compliant with the Ryan Haight Act. Prescribers are prohibited from prescribing, dispensing or administering drugs or medical supplies to a patient when there is no established prescriber-patient relationship. This includes prescribing over the Internet, or via other electronic means, based solely on an online questionnaire. Physicians, psychologists with prescriptive authority, physician assistants and advanced practice nurses may prescribe online during a live video exam. The prescribing clinician must: obtain a medical history, obtain informed consent and generate a medical record. A physical exam is recorded as appropriate by the telehealth practitioner or an on-site practitioner such as a physician, advanced practice nurse, or physician assistant; or the exam is waived when a physical exam would not normally be part of a typical physical face-to-face encounter with the patient for the services being provided (see 16. Additional Requirements When the originating site is in New Mexico and the distant site is outside New Mexico, a physician at the distant site must be licensed in New Mexico for telemedicine or meet federal requirements for Indian Health Service or tribal contract facilities, (8. Non-physician practitioners at distant sites must be licensed in New Mexico to the extent required by their practicing boards. These may be on the header level if a single provider is the rendering or on the line level if there are several services on the same claim. The encounter is billed when a practitioner sees a patient at the clinic or in a hospital or nursing facility. Purpose To clarify and define interdisciplinary teaming requirements for specialized behavioral health services as used throughout 8. Centennial Care emphasizes the importance of integrated care to achieve positive health outcomes for individuals and populations. The opportunity for physical health and behavioral health practitioners to collaborate to achieve whole person health outcomes for an individual can be achieved by allowing a small number of providers (three) to bill for a meeting of the team where the member is included, and an interdisciplinary teaming approach is used. There may be more than three different providers, community, or family members at the session, but only three may bill concurrently. Policy Interdisciplinary teaming is a set of case-level learning, reasoning, and decision processes involving appropriate service providers joining together with the individual to achieve agreed upon goals for an individual receiving service. It is a dynamic process, not a static group or a discrete event, and involves coordinating and collaborating without a prescribed or rigid team structure. From a person-centered point of view, case-level interdisciplinary teaming happens only when the individual whose needs and services are being discussed is present at the team meeting. Any meeting at which the individual is absent when their needs and services are discussed is an agency staffing. Such a meeting must include the individual, as well as an interdisciplinary team of health professionals, and may include representatives of community agencies. Core Elements of Teaming: Teaming involves ongoing group-based processes that build and sustain: 1) Communication ongoing exchange of essential information among team members (supporting individual receiving services) that is necessary for achieving and maintaining situational awareness in case practice. Only the last element, conducting face-to face meetings with the person present when key decisions are made, is a billable event. Definitions Interdisciplinary Teaming a dynamic activity, not a static group or structure. Interdisciplinary teaming involves coordinating and collaborating without a prescribed or rigid team structure. A team is composed of professionals who are specialists in different areas and who work together with an individual to coordinate the care of an individual whose medical and/or behavioral health conditions have complexities that require more than one focus of care from different or related disciplines. The Lead Agency has a designated and qualified Team Lead who prepares team members, convenes and organizes meetings, facilitates team decision-making processes, and follows up on commitments made. This agency may already be providing service to this individual or may be new to the case. Procedures Interdisciplinary teaming provides the central learning, decision-making, and service integrating elements that weave practice functions together into a coherent effort for helping an individual meet needs and achieve life goals. Documentation the Lead Agency, Participating Agencies and any other team members attending the interdisciplinary team meeting, must be identified in the treatment record. Capturing the signature (written or electronic) of those attending, along with the date and time of the meeting, fulfills this requirement. Exhibits/Appendices/Forms Appendix M: Tip Sheet for Practitioners in Integrated Care Settings: Practice Principles and Functions for use in behavioral health center Appendix N: Interdisciplinary Teaming in Behavioral HealthCare Appendix O: Practice Standards for Family Teaming G. Only 3 agencies may bill for a single session; if more than 3 attend the group decides, based on level of change for their discipline, which will bill. The lead agency (i) any provider type; (ii) for a 30-minute conference, bill S0220, U1 (iii) for a conference of 60 minutes or more, bill S0221, U1 b. The participating agency (i) any provider type; (ii) for a 30-minute conference, bill S0220, U2 (iii) for a 60 minute or greater conference bill S0221, U2 c. Purpose To clarify and define Treat First Clinical Model for specialized behavioral health services as used throughout 8. This section will describe the Treat First Clinical Model, participation in the Treat First Learning community, data collection requirements and training expectations. The Treat First Approach corrects the problem of delay by emphasizing the initial clinical practice functions of establishing rapport, building trust, screening to detect possible urgencies, and providing a quick response for any urgent matters when a new person presents with a problem and requests help from the agency. This policy provides an overview of a Treat First Approach and describes service elements and activities associated with the first four visits or sessions provided to a person requesting services. It is intended to provide guidance for practitioners who are implementing the practice concepts and steps. Use of a Treat First Approach overcomes historic difficulties encountered by a person requesting services and having to wait until many required data collection tasks are completed before getting help. Self Check-In Instrument A four question Self Check-In is conducted with the person to assess how well he/she is doing at the beginning of the session and to determine what has changed since the last session. Participating agencies shall enter the data from the instruments into the Treat First web-based data collection program on a timely basis. Procedures the Clinical Model A segment of the population of persons requesting behavioral health services may be served successfully using a short intervention approach. For others who may require longer, more extensive or specialized interventions, the early steps in the Treat First Approach would enable the service provider to gather sufficient assessment information in order to develop a clinical case formulation and comprehensive service plan by the fourth visit. The concepts, principles, and processes used in the Treat First Approach provide a responsive way of initiating a service process for a person requesting help. Brief intervention techniques such as a Treat First Approach are part of a full continuum of behavioral health care services provided in community-based services. Tip sheets are provided in Appendix Q for the practice functions used in the first four interactions of a Treat First Approach. Documentation the use of the Treat First Clinical Model may be billed with a provisional diagnosis for up to four encounters. After four encounters, if continuing treatment is required, a diagnostic evaluation must be performed, and subsequent reimbursement is based on the diagnosis and resulting service and treatment plan. Exhibits/Appendices/Forms st Appendix P: Highlights of the 1 Four Encounters Appendix Q: Treat First Approach and Tip Sheet Appendix R: Adult and Child Self Check-In and Session Check-Out Instruments Appendix S: Treat First Talks an educational website (in development) G. The collection of information and data is used to guide and shape the initial service plan and can be used to highlight elements that need to be addressed in a service plan. The Comprehensive Assessment should be completed not only with the individual in service, but it may also require collection of collateral information from other supports, natural or paid. It is not a diagnostic evaluation (90791-92) to determine eligibility; it is a screening and assessment tool to establish service needs. If no diagnosis from previous records is available, a diagnostic evaluation must also be completed. The Comprehensive Assessment can be completed over the course of four appointments; when completed, the level of care or intensity of intervention must be defined. The Service Plan is a document intended to be updated frequently to reflect identified needs and to communicate services an individual will receive. It serves as a shared plan for the individual, their family or representatives, and service providers. The plan is intended to be supplemented by treatment plans, discharge plans, safety plans and/or crisis plans developed by practitioners when appropriate and indicated by service type. Exhibits/Appendices/Forms Appendix U: Comprehensive Assessment & Service Plan Adult Form Appendix V: Comprehensive Assessment & Service Plan Child/Adolescent Form D. Billing Instructions 1) Only the following agency types are reimbursed for these services: a. This code involves the collection of data from multiple sources: the recipient; providers already interacting with the recipient; other community supports; and natural supports. If taking multiple encounters to develop the assessment and service plan, bill only the last encounter when it is completed. Always place the lead author in the rendering field if more than one provider had input. Generally, individuals define what qualifies as a crisis for them, while entities (state or federal government, providers, schools, etc. Crises may create a sense of disequilibrium or a sense of helplessness but may or may not require immediate action or reaction. A safety situation is a time when basic health is compromised, and risk is high, and it requires immediate action or reaction to keep an individual or family safe. Crisis planning can help people feel better and provide suggestions on how to manage, while safety planning is intended to mitigate or reduce severe or imminent risk. For many individuals seeking behavioral health services, crisis should be: expected and anticipated; defined by the person having it; an opportunity to practice strength-based and creative interventions; and a gateway to develop a range of self-care and/or support activities. Safety Plan A Safety Plan is an in-community, in-the-moment tool used by an individual to reduce or manage worsening symptoms, promote wanted behaviors, prevent or reduce the risk of harm or diffuse dangerous situations. The specifics of the Safety Plan must be meaningful to , and actionable by, the individual. For many individuals, such as those experiencing a first or infrequent crisis episode or who are addressing behaviors in the home that are unlikely to rise to the level of emergency services, this will often be the one and only crisis planning tool that is used. Crisis Plan A Crisis Plan provides a method for individuals to communicate in advance and in writing to providers of crisis support or intervention.

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Acting Finding physical ways to show Making eye contact; touching care infection on x ray buy minomycin 100mg overnight delivery, concern antimicrobial gym bag for men cheap minomycin, and attention when appropriate; hugging; staying near the person 137 Understanding Sexuality and Gender Step 3 To be a Man or Woman: What Defines Us Once the chart is completed antibiotic resistance meat discount 100 mg minomycin overnight delivery, cross out Women and replace it with Men bacterial vagainal infection generic 100mg minomycin otc, and cross out Men and replace it with Women bacteria 5 facts cheap minomycin online mastercard. Only childbearing antibiotics for uti intravenous buy generic minomycin on-line, breast-feeding and fathering a child should be underlined, as those are biologically driven. Lead a brief discussion of roles that society expects of men and women (gender roles), elaborating on the difference between sex and gender. Ask participants what the gender roles have in common (they are not biologically determined, but culturally determined). Assist the group in identifying how gender roles have changed over time in their family/community/culture/ country. Emphasize to parents that the concepts of changing gender roles will be addressed in My Changing Body to help prepare their daughters and sons for the changing world that they are growing up in. In large group, explain to participants that in the My Changing Body curriculum we discuss sexuality as broadly defined, meaning much more than just sex. Explain that they will be participating in an exercise to look at the broad meaning of sexuality. Ask participants to call out all the terms/words that they can think of which are associated with sexuality. You as the facilitator, or two volunteers, record all words without editing on chart paper, probing for areas that may be overlooked. Break into small groups of 4-6 participants and give each group a blank Circles of Sexuality flip chart paper. On a paper that ParentsParents is empty of words, ask the group to record words from the brainstorm session in the appropriate circle, pointing out that some words may fit in more than one place. Are there any Circles that participants feel should not be discussed with 10-14 year old children Are there any Circles that participants feel are especially important to discuss with 10-14 year old children Ask participants to think of a time when they have talked with their child about becoming a teenager/young man/young woman. Start by giving the following example (feel free to use an example that comes from your own experience or is particularly 140 appropriate to the context/culture/community you are working with): My daughter put on a sweater that was covered with dust. Now go around the circle and ask each participant share an example, giving the circumstance and content they discussed with their child. When each has given an example, ask the group for other changes that they have observed in their child or remember from their older children or from their own puberty. Once the lists are completed, pass out the Puberty Handouts Q and R to reinforce the information covered in the exercise. Ask parents to review the handouts and invite them to ask any questions they have about the content. Once this discussion is over, ask parents to share ways that they encourage their children to ask them questions. Parents Parents Introduction to Fertility Awareness Step 5 Group Activity (60 minutes) You will be using some of the activities from My Changing Body for young people to introduce fertility awareness to the parents. Follow the instructions in the My Changing Body manual for Session 2, Steps 1, 2 & 3 and Session 3, Steps 3 & 4. Follow the instructions in the My Changing Body manual for materials, preparation and directions for activities. Explain to the parents that fertility awareness is the cornerstone of fertility control. As their children grow and mature it is important that they understand their own body processes as well 141 as those of the opposite sex. By developing this understanding parents can assist their children to better understand these issues. Summary and Closing Step 6 (30 minutes) Review briefly the main themes of the parent session. Ask participants to reflect on the training they just received and to share their thoughts. Once this discussion is over, ask parents what are their concerns going forward in terms of communicating with and supporting their children through puberty. Ask people to share things that they plan to do to encourage their children to ask them questions. Intimacy Sexualization the ability and need to the use of sexuality to experience emotional influence, control, or closeness to other human manipulate others. Sexual Health and Reproduction Sexual Identity Attitudes and behaviors related A sense of who one is sexually, to producing children, care and including a sense of maleness maintenance of the sex and or femaleness. Boys usually start to show the physical changes of puberty between the ages of 11 and 14, which is slightly older than when girls start puberty. The male sex hormone called testosterone and other hormones cause the physical changes. Here are the 5 stages and what happens: Stage 1 Stage 2 May begin as early as age May begin anywhere from 9 and continue until 14. Girls usually start to show the physical changes of puberty between the ages of 9 and 13, which is slightly sooner than boys. The female sex hormone called estrogen and other hormones cause the physical changes. Here are the five stages and what happens: Stage 1 Stage 2 Age: Between ages 8 and 12. Please note that the red bead is represented by a 147 striped bead throughout the manual. To be askable means that young people see you as approachable and open to questions. Being askable about sexuality is something that most parents and caregivers want but that many find very difficult. Adults may have received little or no information about sex when they were children. Sex may not have been discussed in their childhood home, whether from fear or out of embarrassment. Research shows that youth with the least accurate information about sexuality and sexual risk behaviors may experiment more and at earlier ages compared to youth who have more information1,2,3,4,5. Because being askable is so important and because so many adults have difficulty initiating discussions about sex with their children, adults may need to learn new skills and become more confident about their ability to discuss sexuality. It includes biology and gender, of course, but it also includes emotions, intimacy, caring, 148 sharing, and loving, attitudes, flirtation, and sexual orientation as well as reproduction and sexual intercourse. If you have difficulty saying some words without embarrassment, practice saying these words, in private and with a mirror, until you are as comfortable with them as with non-sexual words. Include your childhood memories, your first infatuation, your values, and how you feel about current sex related issues, such as contraceptives, reproductive rights, and equality with regard to sex, gender, and sexual orientation. Only by listening to each other can you understand one another, especially regarding love and sexuality, for adults and youth often perceive these things differently. Any loving parent or caregiver can be an effective sex educator for his/ her children. Just follow up by offering to find the answer or to work with your child to find the answer. Remember that if someone is old enough to ask, she/he is old enough to hear the correct answer and to learn the correct word(s). It is usually better to risk embarrassing a few adults (at the supermarket, for example) than to embarrass your child or to waste a teachable moment. If you cannot answer at the time, assure the child that you are glad he/she asked and set a time when you will answer fully. Answer slightly above the level you think your child will understand, both because you may be underestimating him/ her and because it will create an opening for future questions. For example, if a child asks whether it is bad to masturbate, you could say, Masturbation is not bad; however, we never masturbate in public. Teens have values, and they are capable of making mature, responsible decisions, especially when they have all the needed facts and the opportunity to discuss options with a supportive adult. If you give your teen misinformation she/he may lose trust in you, just as he/she will trust you if you are a consistent source of clear and accurate information. Patterns of condom use among adolescents: the impact of mother title be in italics Family structure, parental strictness, and sexual behavior 151 among inner-city black male adolescents. Parenting processes related to sexual risk-taking behaviors of adolescent males and females. Over half of this curriculum involves facilitator-trainee practice sessions, using activities from My Changing Body, allowing participants to reinforce their knowledge and gain comfort in talking about feelings, fertility, and other sensitive subjects. Facilitators new to the subjects of gender and sexuality may also want to practice facilitating activities relating to these themes, found in the My Changing Body: Instructions for Parents curriculum. Objective By the end of this session, the facilitators will be comfortable as facilitators (versus trainers), and approach their work based on youth-adult partnership, the consent and interest of participants. Facilitation Step 1 Group Discussion (20 minutes) this is a group reflection on the meaning of facilitation. Divide the group into pairs to discuss and write down their different interpretations of facilitation on different cards (one per card). After a few minutes, the facilitator should collect all the cards and subsequently read each out loud and discuss with the larger group. Complete the above exercise by sharing the below Basic Principles of Facilitation. Participatory Approaches Step 2 Group Discussion (25 minutes) Facilitator Note the definition below should be written out on a flip-chart in advance and then put up on the wall for the group discussion. Concept of Participatory Training Approaches: Participation = Ownership = Empowerment and Development Ask participants to explain how they understand the above. Learning sessions are structured in the form of problem solving activities or tasks requiring teamwork and open peer discussion. While the facilitator provides the simple structure of the problem solving activity or task, the content comes mainly from the learners (youth or parent participants). This increases the relevance of the learning and gives them self-assurance in practicing problem-solving skills. Facilitators need to have the 156 patience for a lot of dialogue and consultation, and ensure that all participants are sufficiently involved. Game FacilitatorsFacilitators Opinion Scales: Below is a list of statements regarding the lives of young people and their role in society. Ask the participants to imagine a line between the two sheets and show where the middle is. When asking participants to explain their opinions and why they have placed themselves the way they have, make sure that no discussion develops over the opinions. Each participant should be given the opportunity to explain him/herself without being interrupted, laughed at, or contradicted. If you feel that there are important issues to be discussed, note them down and use them for the discussion in Step 2 of the My Changing Body: A Puberty and Fertility Awareness Manual for Young People.

In each case antibiotic resistance washington post buy minomycin online, the taxable payroll will be the same as assumed for the intermediate assumptions infection during pregnancy minomycin 100mg cheap. On the other hand antibiotic resistance powerpoint 100 mg minomycin free shipping, if the ultimate growth rate assumption is 1 percentage point higher than the intermediate assumptions bacteria zone of inhibition discount generic minomycin canada, the deficit increases substantially virus removal programs buy minomycin 100 mg online, by $9 infection klebsiella generic 100mg minomycin mastercard,407 billion. Chart 5 shows projections of the present value of the estimated net cash flow under the three alternative annual growth rate assumptions presented in Table 1. Several factors, such as the utilization of services by beneficiaries or the relative complexity of services provided, can affect costs without affecting tax income. Real-Wage Differential Table 2 shows the net present value of cash flow during the 75-year projection period under three alternative 20 ultimate real-wage differential assumptions: 0. Conversely, for a half-point decrease in the ultimate real-wage differential assumption, the deficit increases by about $980 billion. Chart 6 shows projections of the present value of the estimated net cash flow under the three alternative real-wage differential assumptions presented in Table 2. There is a full effect on wages and payroll taxes, but the effect on benefits is only partial, since not all health care costs are wage-related. There is a strong possibility that certain payment changes will not be viable in the long range. Since the thresholds are not indexed, additional workers become subject to the additional tax more quickly under conditions of faster inflation, and vice versa. Real-Interest Rate Table 4 shows the net present value of cash flow during the 75-year projection period under three alternative ultimate annual real-interest assumptions: 2. Chart 8 shows projections of the present value of the estimated net cash flow under the three alternative real-interest assumptions presented in Table 4. These results illustrate the substantial sensitivity of present value measures to different interest rate assumptions. With higher assumed interest, the very large deficits in the more distant future are discounted more heavily (that is, are given less weight), resulting in a smaller overall net present value. Fertility Rate Table 5 shows the net present value of cash flow during the 75-year projection period under three alternative ultimate fertility rate assumptions: 1. Chart 9 shows projections of the present value of the net cash flow under the three alternative fertility rate assumptions presented in Table 5. It is important to point out that if a longer projection period were used, the impact of a fertility rate change would be more pronounced. Conversely, if the assumption is 1,465,000 persons, the deficit decreases by $206 billion. Chart 10 shows projections of the present value of net cash flow under the three alternative average annual net immigration assumptions presented in Table 6. However, the impact on expenditures occurs later as those individuals age and become beneficiaries. As in past years, the Trustees have determined that the fund is not adequately financed over the next 10 years. However, the Trustees project slight surpluses in 2015 through 2023, with a return to deficits thereafter until the trust fund becomes depleted in 2030. Bringing the fund into actuarial balance over the next 75 years under the intermediate assumptions would require significant increases in revenues and/or reductions in benefits. The financing established for the Part B account for calendar year 2015 is adequate to cover 2015 expected expenditures but would need to be increased in future years in order to restore the financial status of the Part B 22 account to a satisfactory level. Similarly, Part D income and outgo would remain in balance as a result of the annual adjustment of premium and general revenue income to cover costs. The appropriation for Part D general revenues has generally been set such that amounts can be transferred to the Part D account on an as-needed basis. Such financing, however, would have to increase faster than the economy to cover expected expenditure growth. If this level is attained within the seven year timeframe, federal law requires a determination of projected excess general revenue Medicare funding. For the 2015 Medicare Trustees Report, this difference is not expected to exceed 45 percent of total expenditures in fiscal years 2015-2021 (the first seven years of the projection), and therefore the Trustees are not issuing this determination. Furthermore, if the growth in Medicare costs is comparable to growth under the illustrative alternative projections, then these further policy reforms will have to address much larger financial challenges than those assumed under current law. Grants, Financial Other Personnel Subsidies, & Assistance Direct Contractual Compensation How was the Money Spent/Issued Medicare Part C A federal health insurance program that allows beneficiaries to receive their Medicare benefits through a private health plan. Medicare Part D A federal prescription drug benefit program for Medicare beneficiaries. Medicaid A joint federal/state program, administered by the states, that provides health insurance to certain low income individuals. Foster Care A joint federal/state program, administered by the states, for children who need placement outside their homes in a foster family home or a child care facility. The complexity of the program reviewed, particularly with respect to determining correct payment amounts; 3. Whether payments or payment eligibility decisions are made outside of the agency, for example, by a state or local government, or a regional federal office; 5. Recent major changes in program funding, authorities, practices, or procedures; 6. The level, experience, and quality of training for personnel responsible for making program eligibility determinations or certifying that payments are accurate; 7. Inherent risks of improper payments due to the nature of agency programs or operations; 8. In addition to these risk factors, the improper payment risk assessment questionnaire includes information on specific risks identified by the program that may lead to improper payments, as well as controls that may help mitigate those risks. Performing comprehensive risk assessments is critical to establishing an effective program for achieving payment accuracy in future years. In addition, both Departments have established internal controls to provide for effective program operations, reliable financial reporting, and compliance with laws and regulations. As evidence of this focus, beginning with senior leadership and cascading down, performance plans contain strategic goals that are related to strengthening program integrity, protecting taxpayer resources, and reducing improper payments. Senior Executives and programs officials are evaluated as part of their semi-annual and annual performance evaluations on their progress toward achieving these goals. After identifying high-priority vulnerabilities, the Board directs corrective actions and tracks issues to resolution. Since that expansion, the moratoria have been extended three times in six-month increments for all areas, with the most recent moratoria extension effective July 29, 2015. The focus of these efforts is to prevent and deter fraud, waste, and abuse in high-risk services and areas across the country while ensuring beneficiary access to care. These savings were 80 percent higher than the savings from the previous implementation year, with a nearly 10 to 1 return on investment. For example, the Medicaid Integrity Program has provided the assistance of federal staff specializing in program integrity and contractor support to bolster state activities. However, it is important to note that the measurement periods for each program vary. Therefore, the future outlay estimates presented may not be the actual amounts against which the error rates will be applied to compute the dollars paid improperly in future years. This adjustment factor reflects the difference between what was paid for the inpatient hospital claims under Medicare Part A and what would have been paid had the hospital claim been properly submitted as an outpatient claim under Medicare Part B. Application of the adjustment factor decreased the overall improper payment rate by 0. The tables include categories of improper payments and the amount of overpayment or underpayment associated with each improper payment category. Additional information on the root causes, and corrective actions, for each high-risk program can be found in each program-specific reporting section. Underpayments in the Medicare Part D program are mainly due to discrepancies in prescription drug event documentation. If these criteria are not met, the claim is counted as either a total or partial improper payment, depending on the error category. The factors contributing to improper payments are complex and vary from year to year. The primary causes of improper payments are insufficient documentation and medical necessity errors. The other causes of improper payments are classified as Medical Necessity errors (17. While some corrective actions have been implemented, others are in the early stages of implementation. Now reviewers can consider all entries in the medical record as supporting documentation when determining medical necessity. The templates will help physicians and hospital staff capture the information needed to complete the face-to-face encounter documentation and will become part of the medical record upon completion. Prior authorization reviews are being performed timely and feedback from the industry and beneficiaries has been largely positive. These projects will also ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before rendering services and paying claims. Providers in Michigan could begin submitting prior authorization requests on March 1, 2015, and providers in Illinois and New Jersey could begin submitting prior authorization requests on July 14, 2015. This program prevents payments for services such as a hysterectomy for a man or a prostate exam for a woman. All Medicare providers and suppliers already enrolled prior to the new screening requirements becoming effective were sent revalidation notices by March 23, 2015. The contractor evaluates medical records and related documents to determine whether claims were billed in compliance with Medicare coverage, coding, payment, and billing rules. Finally, it establishes document retention and access to documentation requirements for providers and suppliers that order and certify certain items and services for Medicare beneficiaries. However, current law does not allow for prior authorization of any other claim types or services. The task forces hold open door forums to discuss documentation requirements and answer provider and supplier questions, and distribute informational articles as needed to improve documentation and to educate providers on Medicare policies. This education involves national training sessions, individual meetings with providers or suppliers with high improper payment rates, presentations at industry association meetings, and the dissemination of educational materials. Follow-up medical record request letters have also been developed to explain what missing documentation needs to be submitted. For example, a third party provider may be a hospital that possesses the record for professional services provided by a billing physician while the beneficiary was hospitalized. The Part C methodology estimates errors resulting from incorrect beneficiary risk scores. Once the appeals process is complete, adjustments to the overpayment recoveries will be made. Combining these four component measures poses complex technical and statistical challenges in calculating a confidence interval for the composite rate. This report provided feedback on their submission and validation results against an aggregate of all other participating plan sponsors. Plans submit updates to their reported direct and indirect remuneration amounts throughout the year. The eligibility component measurement is currently on hold as described in the eligibility component section that follows. The eligibility review pilots provide more targeted, detailed information on the accuracy of eligibility determinations. In addition, individual state improper payment rate components are combined to calculate the national improper payment rates for each component. National component improper payment rates and the Medicaid program improper payment rate are weighted by state size, so that a state with a $10 billion program counts 10 times more toward the national rate than a state with a $1 billion program. A small correction factor ensures that Medicaid eligibility improper payments do not get double counted. Eligibility Pilot Review Findings the eligibility review pilots identified vulnerabilities in processes and systems that states took action to address, which is essential to preventing future improper payments.

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