What Are The Causes Of Childhood Obesity Health Essay

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The rise of obesity in children

Throughout the years, obesity has been a very important topic in our society and has risen exponentially among children and many researchers have wondered what are the causes of childhood obesity. There are many components which contribute to the causes of child obesity. Also people need to understand what exactly is body-mass-index and how it will be used to decide whether the child is categorized as being obese or not. Here are the some of the primary causes that affect children leading into obsession. The children consume so much food, are exposed to too many advertisements, lack physical activity, parents influence their actions, and the children’s living environments and socioeconomic factors influence them. Many blame that children eat beyond their control and this happens to be the number one cause. The second cause is children are exposed too many food commercials of less healthy foods and eventually are convinced into consuming the product. The third reason is children tend to lack physical activity by rather spending countless hours playing video games and browsing the internet. The fourth cause is that the children parents influences them, and the genetics of the parents is a great influence on children’s overweight and obesity. The last cause is the child’s living environment and their

socioeconomic status

influences their decisions and actions. These are the main components that lead into causing obesity among the children.

What factors make children to be considered obese from a normal weight?

What is obesity and BMI?

Typically, obesity and overweight children are characterized as having a body-mass-index (BMI) greater than a particular threshold set point. BMI or body-mass-index undistinguished as a measurement in “kilograms divided by height in meters squared (kg/m2)” (Anderson 20). Reported by the guidelines in National Institutes of Health, a child is well categorized as obese if their “body-mass-index is less than 18.5”, the kids are considered overweight if their “BMI is 25 or more, and obese if his BMI is 31 or more” (20). Most people have no significant idea of what exactly is obesity. According to the Center for Disease Control and prevention, obesity is defined as “a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced 6 life expectancy and/or increased health problems” (CDC, 2013). In the article Childhood Obesity: An Overview, it mentions that it can happen only when the number of calories being consumed surpasses the quantity of calories burned, and usually an increase of this action has to last for long periods of time for obesity to be developed (Reily 2007) In order for a child to not be obese, it will take them days of lifestyle changes which produce a small every day calorie deficiency in their food diet. In the long run it is necessity that lifestyle changes is a huge contributor to the failure of efforts to resolve obesity once it has become established. When the children consume much more calories than they burn off, they increase that as obese weight. (WebMD 1) How children eat, how physically active they are, and many numerous components play a part on how it impacts their body and uses the energy units and when weight is increased. These are the basics of obesity and how the body-mass index is use to classified children as obese.

The number one cause is children intake way too much unhealthy food products such as soft drinks, fast food, convenient snack food, chips, and junk food, etc. When the children eat this certain type of food, the calories sum up creating body fat or also known as BMI. Most children tend to miss a great diet and are easily exposed to unhealthy food; therefore, they will consume as they are pleased (Anderson and Butcher 14). The three major food categories are convenience foods, soft drinks, and obviously fast food. All these are calorie dense and there is some evidence that consuming these items are correlated with obesity in children (35). Also the much more children consume this type of food, the easier it is for them to get addicted. The world’s leading global fast food service retailer with more than 34,000 and counting restaurants worldwide goes to the McDonald’s Corporation franchise and they happened to sell the two unhealthiest leading food products that causes obesity, which are french fries and chicken nuggets (McDonalds 1). Nevertheless, children tend to always eat them at any fast food place. They cannot enjoy their meal without a side of french fries or chicken tenders. Another thing children face are the easy access to junk food in schools. Much more schools across America have carried out school vending machines that contain highly calorie snacks such as candy bars and chips. Fast food companies use tactics against children such as advertising to brain wash them to consume their food products.

The second cause leading to child obesity is that many of the children that end getting overweight are exposed to hundreds of advertising of unhealthy foods. The television advertisements are very influential and persuasive to the children’s mind. On average, the child watches an estimate of more than 23,000 food commercials every year and works out to at least 60 commercials per day (Anderson and Butcher 32). Also many children get influenced by prizes or characters of the advertisement. For example, when children see an advertisement on the television for a kid’s meal; they will get convinced into buying the meal because their neurons urges the kid to wan the super, marvelous action figure found inside. This is why the McDonald’s Happy meals are the number one selling food product to children. The children in today’s society tend to not do physical activities because their days consist of computer and television interaction.

Another cause to child obesity is that many obese children do not control their overall health and lack physical activity to burn off the excess of calories. Children may be substituting different sorts of media for television watching, including video games and the internet (Anderson and Butcher 26). The kids already are not burning up the calories by not choosing to exercise and add many more calories to their bodies. The body systems of the child will not be able to burn off the calories when they do this actions. Thus, this cause raises the energy consumption or decreases energy outgo by even a little measure that will cause obesity in the long-run. Prospectively, physical activity was inversely related to with “BMI alteration in girls, and media time periods (watching television or videos, playing video or computer games) was directly connected with BMI alterations in both sexes” (Hans-Reiner Figulla 209). A factor that many really don’t notice that affect the child health choices are the parents themselves.

A cause that usually is not taken in consideration to child obesity are the parents themselves. While parental behavior is important, perhaps the largest influence on the children weight, and obesity is through genetics. For example, it is known that parents influence the children’s food choices. Also the laboring of the parents, makes it difficult to plan and cook healthier meals. For most Americans, it is effortless to get precooked products, eat out in the restaurants, or go to the store to buy products. But these types of foods are higher in fat and high in calories. The quantity of fast food products have gotten a lot bigger in size and this contributes to bad food consumption. Occupation agendas, lengthy travels from the workplace, and other commitments also cuts into the time period the parents have their kids doing physical exercise. Recent reports have concluded that about 26 to 41 percent of BMI is hereditary (Anderson and Butcher 10). Alternately it seems that parents may pass on to their children a condition to overweight in the existence of energy imbalance. (10) The environment in which the children live can also influence and effect children to getting obese.

The fifth cause is that is taken in consideration to child obesity is the environment and socioeconomic conditions of the children. Obesity is higher among minority children and low-income children such as African-American and Hispanics decent (Anderson 15). It all the depends where the children live. If the environment is under poverty conditions, the parents will most likely expose their children to consume cheap food for the penny. Now much more fast food corporations have increased their portion sizes of their products and cost a lot cheaper. Whose family members that are overweight may be at jeopardy of becoming overweight themselves, but this can be connected to common family actions such as consumption and human activity habits. For example, my mother was a considerably overweight at the time of pregnancy when she had me; therefore I was born obesity and I was two pounds overweight.

In conclusion, these are some of the major components that cause child obesity. Most of the time it isn’t just the child itself but there are much more to what causes obesity among them. Also most don’t realize that by using the body mass index or BMI is used to categorized the child as being obese. The obvious one is when the child over eats too much and doesn’t burn off the calories they intake and that add fat weight on their bodies. Many people also didn’t realize that the environment the child lives in can not only influence the children but also their parents. It is mainly the child’s environment that influences the children to either make positive or negative choices. The causes are child obesity are clearly that they consume so much food, are exposed to too many advertisements, lack physical activity performance, parents influence their actions, and the children’s living environments and socioeconomic factors influence them as well.

Nursing Competencies; Communication

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Nursing Competencies; Communication

Choose one out of the ten of the “Nurse of the Future Competencies Model” (developed by Massachusetts department of higher education).

choose communication as the most important competency for Nursing.

APA style

The Challenges In Paediatric Radiography

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In generally paediatric radiography is take the radiography image of children. The purpose to take the radiography image has two purposes which are for the diagnostic and therapeutic purpose. Diagnostic purpose commonly is for evaluate or see the children body condition in anatomical and pathological aspect. But therapeutic purpose mainly is for treatment like surgical repair the fracture such as insert plate to join the bone that fracture. Children presenting to do radiographic examination range from newborn (neonates), toddlers (12 months to 2 years old), school age (6 to 8 years old) and adolescent (10 to 13 years old) Different age of children group representing the different challenges to the diagnostic radiographer on duty. Diagnostic radiographer have think many or different method to examine the children at same must reduce total dose receive by the children and provide high quality image to radiologist for diagnosis.

Paediatric patient will always come with special or in other word say as a unique problem to the radiographer. This situation always challenges diagnostic radiographer in both physically and mentally aspect. They have to use different way to communicate will paediatric patient. Staff on the radiography department must always response to the non verbal communication of paediatric patient. Because they are not like adult patient which can voice any complication to us.

Paediatric Patient Consideration

Like what have mention above, Paediatric Patient is not like adult patient. When Paediatric Patient present in the department for the diagnostic examination, few aspect should be consider in order to make they fell comfort and friendly. Some Paediatric Patient will not understand the normal word which we use to communicate to adult patient, because adult patient easy to communicate and they can understand the as a radiographer attempt to say and the level of understanding is much higher than child. But for Paediatric Patient, they can’t understand the many word. Paediatric Patient has limited range of word or limited knowledge about the world especially if the Paediatric Patient is under school age or adolescent patient and they have lower level of understanding. For school age patient and adolescent patient they may be able to communicate easily than other Paediatric Patient. So, in communication aspect. Radiographer has to shown excellent communication skill to all kind Paediatric Patient according they age. Radiographer must use appropriate, easy and simple wording and language to the Paediatric Patient, the tone of voice must low and friendly. Don’t ever using the high tone of voice when talk to Paediatric Patient, they may think you (radiographer) is try to hurting them. Don’t ever try to rude to the Paediatric Patient when they are not understand what you (radiographer) attempt to saying. Always observe the non verbal communication of the Paediatric Patient. This kind of communication always provides more information about what Paediatric Patient wants to express. Example of non verbal communication is facial expression, body posture and other.

Staff in the department must always allow the Paediatric Patient is company by parent or guardian during the examination in order to comfort them. The present of parent or guardian always make radiographer work become easy, because present of them can give security factor through the eye or physical contact to the Paediatric Patient. The presence of family member which stand behind the protective screen from radiation also reduce the fear of the Paediatric Patient School age and adolescent patient commonly is can do the radiography examination independently. Because the level of understanding of them is higher compare to toddlers.

Don’t leave the paediatric patient alone in the imaging room. When we left them alone at the imaging room, they will start to fear to the stranger environment and the dark area. This condition will lead to the some unfavourable complication such as rapid heart rate, paediatric patient start to cry or paediatric patient may ingest or inhale foreign body due to the interesting. If the complication is severe and paediatric patient health condition is critical, then the whole department will get in trouble. So , to avoid all this unwanted phenomena happen in imaging department, please don’t ever try to left them alone although they are school age or adolescent because they in the range of the age to explore to world. Environmental and privacy factor are also must considered in advance of the examination. Check the imaging room temperature whether too warm or too cold, if the temperature is not suitable for the particular patient, radiographer can adjust the room temperature to the appropriate degree according to the patient size and age. When radiographer takes off some cloths from they and allow strangers to see their body, try to ask they permission or confirmation from their parent or guardian, because we don’t want they feel like shame and uncomforted. If can, try use hospital grown to cover their body after takeoff some their cloths, this can give them comfortable.

Role of the Radiographer before Examination

Before the examination, radiographer has to do something in order to the whole examination procedure in carry smoothly without facing any problem. In other word, to make sure your (radiographer) work is easy. When you (radiographer) see the imaging request form, make sure you (radiographer) know the name of patient, especially they age and indication. This will help radiographer in aspect of communication, how to talk will them because different age of paediatric patient have different level of understanding, tone of voice and how to handle the paediatric patient will especial indication including alternative method to conduct the examination. Before start examination, make sure that the physical environment in imaging room is suitable for the particular paediatric patient including the room temperature and all the facility including the suitable immobilization devices is provide. This is very important factor to ensure the work can carry smoothly. After then, introduce yourself (radiographer) including your age and name or other relevant information about yourself. Try asking the paediatric patient name, bringing them walk around the imaging department, and introducing some staff and the instrument to them to make them familiar in new environment to avoid the feeling of strange and fear from of the paediatric patient. When taking to the paediatric patient, try use simple and appropriate language to give the instruction to them. To ensure them whether they understand or not, you can ask the feedback from them. If you failure to communicate with them, you can explain the instruction to them parent or guardian. Otherwise radiographer has to think other way to communicate. Let the child known about the examination mean tell them what will happen before, during and after the examination, the whole procedure about the examination, inform them during examination will have some noisy from the movement of table , x ray tube and anode rotation. When talking to them, make sure talk at the eye level in order to get the trust and cooperation from them. Try to establish the rapport with them, ask the question from them. Always allow the parent and guardian present in imaging room to give better feeling to child.

Preparation for the Examination

When preparing for the examination, radiographer always prepared alternative way to perform the examination. The primary method may not be allowed by the imaging room condition such as lack of immobilization devices, temperature too cold or other factor. Patient condition also one of the factor which make radiographer prepare alternative way to perform examination. They may come with wheel chair, with trolley or limited in movement. Some child may have disability, so have use other method to do the examination. Before the paediatric patient enter the imaging room, in advance take the image receptor, immobilization pads to the imaging room. Place the image receptor, immobilization devices, x ray tube and table on the correct position according to examination request. So, this action will can decrease the working ‘noise’ like movement of the X ray tube and table during the examination. Choose the suitable exposure factor like low Mas for examination according to the part be x ray and patient’ age and size. Make sure that the exposure factor that select can produce high quality image if not the examination need to repeat, it will give more dose to the paediatric patient. Radiographer also can collimate the radiation field to the size of cassette and place the anatomical marker in advance, so this will reduce time for the child in the imaging room. When the stages of preparation are complete, position the paediatric patient accurate and allow parent or guardian accompanies their child, and gives the lead grown to them.

Immobilization Devices

Immobilization devices are instrumentation that can found in radiology department. This kind instrumentation in create to make the radiography examination undergo more successfully. Immobilization devices normally have few important functions. The devices can hold the patient in position according to the radiography examination procedure requirement. Radiographer will use these devices when the desire position of the paediatric patient cannot be achieved. Other than this function, immobilization devices also can prevent movement of the paediatric patient due to the physical condition. Patient movement during the examination will cause artifact on the image that produce. Artifact effect on the radiography image will make the radiologist difficult to diagnose and cannot further evaluate the image. If the examination is repeated due to image artifact, this will cause double exposure to the paediatric patient. Another function of the immobilization devices is to make patient in comfort position. Paediatric patient may feel uncomforted when place their hand or feet on the x ray table relative cold. So, when use the devices, we can direct contact of child’s body part to the x ray table and child also feels comfortable. The immobilization devices also can use to compress the thicker part of patient like during the abdomen examination. Thicker part means have many tissue, these tissue will attenuate the total amount of x ray and dose receive by patient is high. The type of immobilization devices is adhesive tape, sandbags, compression bands, towels, ace bandages and radiolucent sponges

Radiation Protection and Dose Reduction for Paediatric Patient

Whenever the paediatric patient come to imaging department, radiographer must apply the radiation protection to the paediatric patient and parent, guardian or family member when they in the imaging room. Application of the Radiation protection has 2 functions in imaging department. One is to reduce the total effective dose receive by the patient and the scattered radiation receive by the radiographer. If the dose receive by the patient and radiographer is exceed the recommend dose, the bad effect will happen to they like loss of hair, effect the reproductive part, effect the eye and other. Another function is to protect the patient, radiographer, family member from direct expose by the primary beam. This protection is very important in order to reduce the total dose receive by them. The selection of the exposure factor like KvP, MaS should be according to the examination requirement, patient size and patient age. Normally, small and low age patient is requiring low exposure factor than adult patient. Radiographer must using low MaS to the small and young patient. Because the MaS control the total x ray beam that produce, amount of the x ray is direct proportionally to the MaS. Mean when increase the MaS; we will increase the amount of the x ray. Short examination time should be apply, so the examination period will be short and further reduce the movement of patient. Movement of patient can cause the artefact on the radiography image. Accessory equipment should be provide in the department to hold the patient in the position, so it can reduce the movement of the patient and decrease the possibility to repeat the examination. Proper collimation also one of the way that can reduce the radiation expose to the patient. Radiographer can collimate the primary beam to the area to be exam and no longer than unnecessary area. So, patient unnecessary part would not expose to the radiation. When the parent or family member is in the imaging room to hold their child during examination, radiographer must provide the lead grown to them to avoid direct expose by the radiation. Before any examination, ask patient (female above 10 years old) last menstrual period. If they are suspecting in pregnant, the examination cannot be perform. Because the radiation will directly affected the fetus. While the radiographer is applying the radiation protection to the patient, must also produce the high quality image.

Point for the Radiographer

This is meant the thing which radiographer must do before, during and after the examination. Before the examination, a clear and simple instruction should give to the child, don’t try using the language level more than they understanding level. When they want change to hospital grown, please give the sufficient time to them. Because paediatric patient is take slightly longer time than adult and ask the family member to assist them. Avoid behave rudely to them, because this will hurt them.

What to Think about Paediatric Patient

When handle them, radiographer must use appropriate approach don’t ever use threatening approach toward them. Communication skill is very important especially communicate will child due to the level of understand, appropriate language must apply. The concept of ALARA must apply in all the examination. Patient care in one of the aspect which radiographer has to apply, like give blanket during examination, assists patient whenever they need.

Inflammatory Mediators Of Asthma Health Essay

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Once IgE binds to mast cells (or activated eosinophils), an amplification system operates since the cells not only release the spasmogens and other mediators specified but also can stimulate β cells to produce more IgE. Furthermore, the production of IL-5, IL-4 IL-13 and IL-9 amplifies the Th2-mediated events.

It is believed that asthma symptoms are manifested because of Th2 mediated immune response. Pulmonary allergic inflammation in mice lead to decrease in pulmonary IL-5 concentration, specific IgE, IgG1, and eosinophil and T cell recruitment in wild type mice in the absence of T cells. T cells are important in IL-4 dependent IgG1, IgE and Th2 cell mediated lung inflammation, further more there is evidence that CD4+T cells have a role in asthma process. For example, in murine model external protein induced T cells increases IL-5 production and produces airway eosinophilia. (Larche et al. 2003)

Asthma is a complex chronic inflammatory airway disorder that involves the activation of the inflammatory and structural cells. These released inflammatory mediators cause typical pathophysiological changes of asthma (Peter et al., 2003).

There are several lines of evidence that may implicate a mediator in asthma. Firstly, it may mimic features of clinical asthma. Secondly, the mediator may be produced in asthmatic patients. Thus, mediators or their metabolites may be detected in plasma (e.g. histamine), urine (e.g. LTE4), or more likely, the airways in biopsies, bronchoalveolar lavage fluid, induced sputum or exhaled air.

1.8.3.1. Histamine

Histamine was the first mediator implicated in the pathophysiological changes of asthma (Barnes et al., 1998). Histamine is one of the important mediator of allergy, inflammation and bronchoconstriction. Histamine is synthesized and released by mast cells in the airway wall and by circulating and infiltrating basophils.

Antigen-induced histamine secretion is initiated by the bridging of the adjacent IgE receptors on the mast cell surface. Histamine receptors are among the thousands of members of the 7-transmembrane-spanning family of receptors that couple ligand binding to intracellular reactions through interactions with another large family of guanosine triphosphate (GTP)-binding heterotrimeric proteins. H1-receptors mediate a host of intracellular events most readily characterized by changes in free cytosolic calcium levels.

Histamine show different response in mammalian tissue depends upon presence of receptor on that tissue Kulkarni, (1976).

1.8.3.2. Adenosine

Adenosine can act as an autocoid cause bronchoconstriction in asthmatics and increase immunologically induced mediator release from mast cells of human lung (Cushley et al., 1984; Peachell et al., 1988). Mast cells also release adenosine in response to IgE cross-linking and other stimuli for mast cell activation.

1.8.3.3. Lipid-Derived Mediators

Leukotrienes

Leukotrienes are potent lipid mediators produced by arachidonic acid metabolism in cell or nuclear membrane. Several types of airway inflammatory cells, like eosinophils, macrophages, mast cells, neutrophils, and epithelial cells, can synthesize LTs in response to a variety of stimuli. Leukotrienes are important inflammatory mediators involved in the pathogenesis of asthma. All the Cys-LTs are potent constrictors of bronchial smooth muscle. On a molar basis, LTD4 is 1000 times more active than histamine and constrict bronchioles (Dahlen et al., 1980).

Cys-LTs, acting on Cys-LT1 receptors produce bronchospasm, airway hyper-responsiveness, proliferation of airway smooth muscle, excess production of mucus and mucosal edema and eosinophilia in the airways, and other features in asthma (Sundeep et al., 2001; Peter, 1998).

Platelet Activating Factor (PAF)

PAF is ether-linked phospholipid. The synthesis of PAF occurs in inflammatory cells, including platelet, neutrophils, basophils, macrophages and eosinophils. PAF induces airway smooth muscle contraction by releasing other mediators. PAF-induced bronchoconstriction is not inhibited by H1 receptor antagonist Ketotifen. However, PAF-induced bronchoconstriction can be inhibited by LT antagonists, because of involvement of LTD4 in this response. PAF stimulate chemotaxis and adhesion of eosinophils and neutrophils in-vitro (Peter et al., 2003).

Prostanoids

Prostanoids include prostaglandins (PGs) and thromboxane (Tx), which are generated from arachidonic acid, usually by the action of COX. In general PGF2 and PGD2 contract and PGE relax tracheal muscle. Asthmatic individuals are particularly sensitive to PGF2α, which may cause intense bronchospasm. Although both PGE1 and PGE2 can produce bronchodilatation when given to such patients by aerosol, bronchoconstriction sometime is observed. Tx analogue U 46619 is a potent constrictor in asthmatic patients, and this effect is mediated in part via acetylcholine release. Prostanoids stimulate airway mucus secretion in various animal species. It inhibits the release of mediators from mast cells, monocytes, neutrophils and eosinophil inflammatory cells (Peter et al., 2003).

1.8.3.4. Cytokines

Cytokines are small protein mediators that play an integral role in the coordination and persistence of inflammation in asthma. Many inflammatory cells macrophages, mast cells, eosinophils and lymphocytes) are capable of synthesizing and releasing these proteins. Th2 lymphocytes produce a panel of cytokines, including IL-5, IL-4, IL-13 and IL-9 (Barnes et al., 1998).

1.8.3.4.1. Interleukin-4

IL-4 is critical for the synthesis of IgE by B-cells and for eosinophils recruitment. IL-4 is also involved in Th2 cell differentiation. IL-4 is a key factor in the development of allergic inflammation, and they may also play a major role in exacerbating asthmatic symptoms (Adcock and Caramori, 2003).

Figure 11. Role of CD4+Th2cells and Various cytokines in asthma pathogenesis.

1.8.3.4.2. Interleukin-5

It play important role in allergic asthma. IL-5 promote the maturation of eosinophils from bone marrow processor, prolongs their survival by inhibition of apoptosis, activates mature eosinophil recruitment to tissue via synergistic effect with chemoattractants such as eotaxin and promote eosinophil adhesion of vascular endothelium.IL-5 can also promote basophils to release exaggerated amounts of histamine and leukotrienes, mediators that contribute to allergic bronchospasm and congestion in asthma (Fred et al., 2000).

1.8.3.4.3. Interleukin-9

Its major actions include maturation of eosinophils, airway inflammation, airway hyper-responsiveness and mucus over production (Adcock and Caramori, 2003).

1.8.3.4.4. Interleukin-13

IL-13 is critical for the synthesis of IgE by B-cells. Activates eosinophils, monocyte. IL-13 is a key factor in the development of allergic inflammation and they may also play a major role in exacerbating asthmatic symptoms (Barnes et al., 1998).

1.8.3.5. Granulocyte-Macrophage Colony-Stimulating Factor (GM-CSF)

GM-CSF is one of the colony-stimulating factor that acts to regulate the growth, proliferation and maturation of hematopoietic cells.GM-CSF can enhance the release of superoxide anions, also induce eosinophil apoptosis and activation, induces release of LTs, endothelial cell migration (Barnes et al., 1998).

1.8.3.6. Reactive Oxygen Species in Asthma

Reactive oxygen species (ROS) are generated by various enzymatic reactions and chemical processes or they can directly be inhaled. ROS are essential in many physiological reactions and are important for the killing of invading microorganisms. However, when airway cells and tissues are exposed to oxidative stress elicited by environmental pollutants, infections, inflammatory reactions or decreased levels of anti- oxidants, enhanced levels of ROS can have a variety of deleterious effects within the airways thereby inducing several pathophysiological conditions.

It has been shown that ROS can damage DNA, lipids, proteins and carbohydrates leading to impaired cellular functions and enhanced inflammatory reactions. ROS are known to play a prominent role in the pathogenesis of various airway disorders such as adult respiratory distress syndrome (ARDS), cystic fibrosis, idiopathic fibrosis, chronic obstructive pulmonary diseases (COPD) and asthma (Gillissen and Nowak, 1998; Repine et al., 1997).

Discussion 1 Based on- Companies Improperly Cut Home Care Hours and the textbook Chapter 8: Community Based Services- what issues is the author discussing How do they affect access to home care serv

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Discussion 1

Based on, Companies Improperly Cut Home Care Hours  and the textbook Chapter 8: Community Based Services, what issues is the author discussing? How do they affect access to home care services and community-based services in general?

Discussion 2

Based on, 5 Big Issues in Senior Living in 2018   and textbook Chapter 7: Senior Housing, identify and discuss significant trends impacting senior housing.

please reference this text APA Chapter 7 and 8 are attached

Chies, S. (2021). Pratt’s long-term care. Managing across a continuum: (5th ed.) Jones & Bartlett ISBN: 978-1-284-18433-4.

Use only the APA method for in text citations and include a reference list. 300 words each discussion

Laminar Air-flow to Control Operating Room Infection

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INTRODUCTION

Surgical site infections (SSIs) are defined as infections occurring within 30 days after surgical operation or within one year if an implant is left in place and affecting either the incision or deep tissue at the operation site (Owens and Stoessel 2008). SSIs are reported as the major cause of high morbidity and mortality among post -operative patients (Weigelt et.al. 2010). According to UK National Joint Registry Report, during 2003 -2006 period infection was responsible for about 19 % failure of joint surgery resulting in revision procedures (Sandiford and skinner 2009).

Micro-organisms in the air particles settle on the wound, dressings and surgical instruments and cause infections (Chow and Yang 2005). Whyte et.al (1982) identified that contamination from patient’s skin as the cause of infection in 2% cases and from theatre personnel in 98% cases. They also found that in 30% cases, contaminants reach the wound from theatre personnel via air and in 70% cases it is via hands.

Generally air quality in the operating room is maintained ventilation system. Additional improvements can be achieved by laminar air-flow system or UV lights. Laminar air-flow system is expensive and require continues maintenance. Its installation increases building cost and the operational cost (Cacciariet.al., 2004: Hansen, 2005). Studies conducted to evaluate the effectiveness of laminar flow produced mixed results and there is no consensus on its role in infection control (Sandiford 2007). In this setting, this paper reviews the recent studies to examine the effectiveness of laminar air-flow in reducing SSIs.

Studies for this review were found by searching on databases such as CINAHL, PubMed, Science Direct, Ovidsp, Science Citation Index (ISI) and Google scholar. Keywords used for this search are “laminar air flow”, “surgical site infection”, “operating room air quality”, “airborne infections + operating theatre”, “LMA + infection control”. As laminar air-flow is used mainly in orthopaedic theatres, majority of the studies are on joint surgery.

OPERATING THEATRE AIR QUALITY AND INFECTION CONTROL

Indoor air in an operating theatre contains dust which consists of substances released from disinfectant and sterilizers, respiratory droplets, insect parts smoke released from cautry. Dust particles act as a carrier for transporting microorganisms laden particles and can settle on surgical wound and there by cause infection (Neil 2005). Air particles are found to be responsible for about 80% – 90% of microbial contamination (CDC 2005).

Modern operating theatres are generally equipped with conventional ventilation system in which filters can remove airborne particles of size >5mm about 80-95% (Dharan 2002). The efficacy of operating room ventilation is measured by the colony forming units (CFU) of organisms present per cubic meter. The conventional ventilation (Plenum) with 20 air exchanges is considered efficient if it achieves the colony count of 35cfu/m3 or less (Bannister 2002).

Ventilation system with laminar air-flow directs the air-flow in one direction and sweeps the air particle over the wound site to the exits (CDC 2003). Laminar air-flow with HEPA (High Efficiency Particulate Arrestment) filters system has the capacity to remove air particles of size 0.3 µm up to 99.9 % and can produce 300 air exchanges per hour in ultraclean orthopaedic theatres. (Sandiford and skinner 2009).

Laminar air-flow units are generally two types; ceiling-mounted (vertical flow) or wall-mounted (horizontal flow). There are inconveniences associated with both types. Generally the major problem associated with laminar air-flow is flow disruption. With vertical laminar flow, it is the heat generated by surgical lamps creates air turbulence while with horizontal laminar flow it is the surgical team that disrupt the air-flow (Dharan 2002).

LAMINAR AIR FLOW IN INFECTION CONTROLL

Laminar air-flow system is mainly used in implant surgeries where even a small number of microorganisms can cause infection. In joint replacement surgeries, one of the main causes of early (within 3 months) and delayed (within 18 months to 2 years) deep prosthetic infections was found colonisation during surgery (Knobben 2006). Laminar air flow is supposed to minimize contamination by mobilizing uniform and large volume of clean air to the surgical area and Contaminants are flushed out instantly (Chow and Yang, 2004). Some studies found that this method is effective in reducing infection but some others produced contradicting results (give some reference)

A recent study conducted by Kakwani et.al. (2007) found that laminar air-flow system is effective in reducing the reoperation rate in Austin-Moore hemiarthroplasty. Their study compared the reoperation rate between theatres with laminar air-flow and theatres without laminar air-flow system. A cohort of 435 patients who had Austin-Moore hemiarthroplasties at Good Hope Hospital in Birmingham between August 2000 and July 2004 were selected for this study. Of those 435 patients, 212 had operation in laminar air-flow theatres and 223 had operation in non-laminar air-flow theatres. Data were collected by reviewing case notes and radiographs. For all cases antibiotics were administrated and water impervious surgical gowns and drapes were used. In the non-laminar air-flow group it was found that the re-operation rate for all indication in the first year after hemiarthroplasties was 5.8 % (13/223), while in the laminar air-flow group it was 1.4% (3/212). Analysis found that there were no statistically significant relation between re-operation rate and water impervious gown and drapes (p=0.15), while use of laminar air-flow found a statistically significant drop (p=0.0285) in re-operation rate within the first year after hemiarthroplasties. They found that re-operation rate in no-laminar air-flow theatres were four times greater than that in laminar airflow theatres.

Even though the aim of the study was clearly described there was no review of existing studies to identify the gap in the research. Study methods and details of statistical analysis were given elaborately. The sample size seems sufficient. Results were summarized and presented using graphs and charts. Discussion of results was short and seems not adequate to address the objectives of the study. There was no attempt to explain the casual relationship. For example researches were making statements such as “…the introduction of water-impervious drapes and gowns did not seem to make a statistically significant improvement in the result….” (p.823). Researchers failed to acknowledge any limitations of the study. Data for this study was collected by reviewing patients’ records. Patients records are considers as confidential and researchers didn’t mention whether they received consent from the patients or ethical approval form institution to conduct the study. This can be considered as an ethical flaw of this study.

There are studies which found that laminar air-flow system is not effective in reducing infection rate. In their study Brandt C et.al (2008) found that infection rate was substantially high in theatres with laminar air-flow system. This was a retrospective cohort-study based on routine surveillance data from German national nosocomial infections surveillance system (KISS). Hospitals which had performed at least 100 operations between the years 2000 and 2004 were selected for this study. Type of ventilation technology installed in operation rooms of selected hospitals were collected separately through questionnaire from infection control teams in the participating hospitals. Surgical departments were grouped into categories according to the type of ventilation system installed. Departments using artificial operating room (OR) ventilation with either turbulent or laminar airflow was included in this study.

Total 63 surgical departments from 55 hospitals were included in this study. Analysis was performed to the data set created by merging the questionnaire data on OR ventilation and surveillance data from the KISS data base. The data set analysed contained 99230 operations with 1901 SSIs. Age and gender of the patient was found a significant risk factor of SSI in most procedures. Univariate analysis conducted found that rate of SSIs was high in departments with laminar air flow ventilation. Multivariate analysis also confirmed this finding. Authors argue that it may be due to the improper positioning theatre personnel in horizontal laminar flow room.

Researches provided a well-researched literature review which clearly identified gap in current research. Objectives and design of the study was properly explained. Study was based on a large sample size. Results were discussed in detail and casual relations were well explained. Enough tables were used to present results. Limitations were properly discussed.

Knobben et.al (2006) conducted an experimental study to evaluate how systemic changes together with behavioural changes can decreases intra-operative contamination. This study was conducted in the university Medical Centre Groningen, The Netherlands. A random sample of 207 surgical procedures which involved total knee or hip prosthesis from July 2001 to January 2004 was selected for this study. Two sequential series of behavioural and systemic changes were introduced to ascertain their role in reducing intra-operative contamination. The control group consisted 70 cases. Behavioural changes (correct use of plenum) were introduced to the first intervention group of 67 operations. Intense behavioural and systemic changes were introduced to second intervention group of 70 operations. The systemic changes introduced was the installation of new laminar flow with improved airflow from 2700m3/h to 8100m3/h. Two samples each were taken from used instruments, unused instruments and removed bones. Control swabs were also collected to make sure that contamination was not occurred during transport and culturing. Early and late intra-operative contamination was also checked. All patients were monitored for any wound discharge while in hospital and followed-up for 18 months to check whether intra-operative contamination affects post-operative infection.

Among the control group contamination was found 32.9% while in intervention group 1 it was 34.3% and in intervention group 2 it was 8.6%. Except in Group 1 (p=0.022) late phase contamination was not significantly higher than early phase contamination. During the control period wound discharge was found in 22.9% patients and 11.4% of them had wound infection later. Deep periprosthetic infection had been found in 7.1% of them in the follow-up period. Deep periprosthetic infection was found in 4.5% cases of first intervention group and in 1.4% of cases in second intervention group in the follow-up period. But none of these decreases were found statistically significant. Contamination, prolonged wound discharge and superficial surgical site infection were found decreased after both first and second intervention. But a statistically significant reduction was found only in second intervention (contamination p=0.001, wound discharge p=0.002 and superficial SSI p=0.004). This study concluded that behaviour modifications together with improved air flow system can reduce intra-operative contamination substantially.

Purpose of the study was clearly defined and a good review of the current literature has given. Gap in current research was clearly presented and justification for the study had given. Sample size seems sufficient. It is reported that “….bacterial cultures were taken during 207 random operations…” (p. 176), but no details of the sampling method used were provided. Details of interventions were given elaborately and results were discussed in detail. But only one table and two charts used to present it. The readers would have been more benefited if more tables were used to present the results. Discussions of the results were concise and findings were specific and satisfying the objective. No information on whether they received informed consent from the patients and approval form the ethical committee of the institution was missing. This arise a serious question about the ethics of this study.

It is found that laminar airflow is more effective when use in conjunction with occlusive clothing (Charnley, 1969 cited in Sandiford and Skinner 2009). While in their recent study Miner et.al (2007) compared the effectiveness of laminar airflow system and body exhaust suits found that body exhaust suits are more effective than laminar flow system in reducing infection.

For their study Miner et.al (2007) selected 411 hospitals which have submitted the claim for total knee surgery (TKR) for the year 2000 from four US States were surveyed to collect the details of use of laminar air flow system and body exhaust suits. Those hospitals which were fulfilled three criteria were included in this study. The inclusion criteria were 1) returned the survey instrument, 2) using laminar air flow system or body exhaust suits for infection control and 3) was evidence of at least one Medicare claim for TKR for the study period. Total 8288 TKRs performed in 256 hospitals between 1st January and 30th August 2000 were selected. Data on patient outcomes after total knee replacement (TKR) were collected from Medicare claims. The patients who underwent bilateral TKR were not included in this study and for those who underwent a second TKR during a separate hospitalisation during the study period, only the first procedure was included. International Classification of Diseases, Ninth Revision (ICDS-9) codes was used to identify post-operative deep infection that needed additional operation. Hospitals were grouped as users or non-users for both laminar airflow and body exhaust suits. “Users” were defined as those who use any of these methods in more than 75% procedures and “non-users” were those use any methods less than 75%. The over-all 90-day incidence of deep infection, subsequent operation was found required only in 28 cases (that is 0.34%). Analysis found that the risk ratio for laminar airflow system was higher (1.57, 95% confidence interval 0.75-3.31) than body exhaust suits (0.75, 95% confidence interval 0.34-1.62). Study found that there were no significant differences in infection between hospitals that use specific either protective measure.

Other than mentioning few studies researchers failed to provide any background of the research problem. Methods used for this study were explained concisely. Even though the sample size was large, limited number of events (28) were there to be observed. Analysis was based on this small number of events; this may have affected the result. Not many variables were included in this study, and researchers didn’t mention how they controlled some possible confounders. Researchers were successful in identifying the advantages and limitations of the study. Results were properly presented in tables.

Instead of expensive laminar air-flow system, installation of well-designed ventilation system is found beneficial. Scaltriti et.al (2007) conducted a study in Italy to examine effectiveness of well-designed ventilation system on air quality in operation theatre. They selected operation theatres of a newly built 300 beds community hospital which have ventilation system designed to achieve 15 complete outdoor air changes per hour and are equipped with 0.3 µm, 99.97% HEPA filters. All these satisfy the condition for a clean room as per ISO 7 standard. Passive samples of microbiological air counts were collected using Tripticase Soy Agar 90 mm plates left open thorough out the duration of the procedure. Active samples were also collected using a single state slit-type impactor. Total 82 microbiological samples were collected of which 69 were passive plates and 13 were active. Air dust was counted with a light-scattering particle analyser. Details of the surgery, number of people in the room, door opening rate and estimated total use of the electrocautery unit were also collected.

It was found that there were positive correlations between particle contamination, surgical technique (higher risk from general conventional surgery), electrocauterization and operation length. Door opening rate was found negatively associated. Researchers suggest that this may because when theatre door open a turbulent air flow blows out of the operating room which may result decrease in the dust particles. No association was found between particle contamination and number of people present at the time of incision. Researchers suggest that human movement rather than human presence is the factor that determines airborne microbial contamination. It was found that average particle concentration in the theatres did not exceed the European ISO 14 644 standard limits for ISO 7 clean room, and so concluded that well-designed ventilation system is effective in limiting particulate contamination.

Uncultivable or unidentifiable organisms can also be a reason for surgical site infections. It may be difficult to identify such organisms through standard culture techniques (Tunney 1998). Clarke et.al (2004) conducted a quantitative study to examine the effectiveness of ultra-clean (vertical laminar flow) theatres in preventing infections by unidentifiable organisms. They used the molecular technique, Polymerase Chain Reaction (PCR), to detect bacteria presence. Their study compared the wound contamination during primary total hip replacement (THR) performed in standard and ultra clean operation theatres. 20 patients underwent primary THR from 1999 to 2001 were recruited for this study. Patients with previous incidents of joint surgery or infection were excluded. The standard operation theatres had 20 air changes per hour and CFU count was 50 CFU/m3, while ultra-modern theatres had 530 air changes per hour and CFU count was 3 CFU/m3.

For all surgeries same infection control precautions were used. Two specimens each of pericapsular tissues were collected from posterior joint capsule both at the beginning and at the end of the surgery (total 80 samples). Patients were given antibiotic prophylaxis after taking the first specimen. All these samples were underwent Gram stain and culture to detect bacterial colonies and Polymerase Chain Reaction (PCR) to detect bacterial DNA.

Among the 20 specimens taken form the standard operation theatres at the beginning of the surgery only 3 were found positive with PCR, while from the ultra-clean theatres only 2 were found positive. None from both theatres found positive with culture. Samples from the standard theatres taken at the end of the surgery, 2 found positive by culture and 9 found positive by PCR. The contamination rate in the standard theatre at the end of the surgery found significantly greater than the beginning (p=0.04). Samples taken from the ultra-clean theatres, none was positive by culture while only 6 were positive by PCR. Statistical analysis found that contamination rate at the end of the surgery is not statistically different than the start (p=0.1). It was found that there were no statistically significant difference in overall contamination rate (p=0.3) between standard and ultra clean theatres. (I will add critique of this study here)

NURSES’ ROLE IN INFECTION CONTROL

Understanding the source of contamination in operating theatre and knowing the relationship between bacterial virulence, patient immune status and wound environment will help in improving the infection rates (Byrne et al 2007).

Nurses are responsible to take a proactive role in ensuring safety of their patients. To improve patient outcome, it is necessary for the nurses to take lead role in environmental control and identifying hazards through environmental surveillance (Neil 2005). Non-adherence to the principle of asepsis by surgical team is identified as a significant risk factor of infections. Hectic movement of surgical team members in the operating room and presence of one or more visitors were also found as major causes of SSI (Beldi G 2009). Nurses and managers should emphasise on controlling factors like the traffic in theatre, limiting the number of staff and reinforcement of strict aseptic technique (Allen 2010). Creedon (2005) argues that infections can reduce up to one third if staffs follow best practice principles. For better outcome staffs needs additional education and positive reinforcement.

Nurses have a vital role in the development, reviewing and approving of patient care policies regarding infection control. Nurses are not only responsible for practicing the aseptic techniques but also responsible for monitoring other staff for their adherence to policies. They are responsible for developing training programmes for members of staff. Educating the environmental services personnel like technicians, cleaners will not only improve their knowledge in patient care but also provide a sense of commitment in patient outcomes (Neil 2005).

Perioperative nurses can contribute in research regarding theatre ventilation system through organised data collection and documenting evidences. Nurses can contribute in giving optimum and safe delivery of care in areas where environmental issues can put the patient at risk. Knowledge is changing fast, so it is important that staff must keep themselves up to date. Continues quality improvement is needed and it should be based on evidence based research and on-going assessment of information (Hughes 2009).

CONCLUSION

Reviews of current research shows that still there is a lack consensus on the effectiveness of laminar airflow in infection control. Studies include in this review has used either clinical outcomes (infection or reoperation rate) or intermediate outcomes (particle count or bacterial count) to evaluate the effectiveness of laminar flow. Kakwani et.al (2007) found that re-operation rate was lower in laminar airflow theatres but Brandt et.al (2008) found SSI rate was high in hospitals with laminar flow. Clarke et.al (2004) found that contamination was not significantly different in ultra clean theatres compared to standard theatres equipped enhanced ventilation system. Supporting this finding Scaltriti et.al (2007) found well designed ventilation system is effective in reducing contamination.

Study by Knobben et.al (2006) found that combination of systemic and behavioural changes are required to prevent intra-operative contamination. Miner et.al (2007) found that there were no significant differences in infection between hospitals that use laminar airflow and body exhaust suits.

From these studies it can be concluded that use of laminar airflow alone can guarantee infection prevention. Behavioural and other systemic changes are necessary to enhance the benefits of laminar airflow. Evidence shows that conventional theatres equipped with enhanced ventilation system can prevent infection effectively, this can be consider as an alternative for expensive as laminar flow system.

Meeting nutritional needs in the nursing homes

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Meeting nutritional needs in the nursing homes

– The student will have knowledge of the most common forms of dementia and how diseases affect the ability for the patients and nurses to meet basic needs
– Students will reflect on nursing challenges and dilemmas during meal situations in nursing homes
Scenario:
A clear and sunny autumn day, it’s time for breakfast in the unit. The unit is occupied by six elderly people with varying degree and type dementia. Some also somatic and psychiatric problems in addition to dementia.
The unit is committed to creating a homely atmosphere where meals are important satisfaction factors. In addition, emphasis is placed on the patients’ opportunities to contribute their resources and meals are considered as an important activity in this context.
It is almost 9am and the 6 patients are gathering around the table for breakfast. There are usually only 2 workers on the unit, a head nurse (you) and an assistant. But right now there is also a nursing student in the unit, whom the head nurse is in charge of. As the head nurse, you are also responsible for dosing out medications to all the patients in your unit, as well as the unit next to you.
One of the patients has frontal lobe dementia, with repetitive speech, and can often be quite rude to others during mealtimes.
All of the patients have varying need for guidance and support during breakfast, although none of them need help eating (feed). The situation requires a good structure and planning so that the patients’ nutritional needs will be handled in a respectful and dignified manner.

smilesmilePLACE THIS ORDER OR A SIMILAR ORDER WITH NURSING TERM PAPERS TODAY AND GET AN AMAZING DISCOUNT

Essay On Bariatric Surgery and Nutrition

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The Prevalence of Anastomotic Stenosis Post Laparoscopic Gastric Bypass Surgery and the Efficacy of Medical Nutrition Therapy

Bariatric surgery has grown in popularity coinciding with a steady increase of obese individuals. Globally obesity has nearly tripled since 1975. More than 1.9 billion adults were overweight in 2016. Of these over 650 million were obese (“Obesity and Overweight” 2017). Before a person is evaluated for qualification by a bariatric surgeon, a person must show unsuccessful efforts of weight lost. Insurance companies generally require patients to complete a medical weight loss management program for 4-6 months before a claim for surgery is even considered for approval. The guidelines for determining if a person would qualify for surgery are as follows: body mass index (BMI) is 40kg/m2 or higher, BMI is 35kg/m2 or more and have a serious weight-related health problem, such as type 2 diabetes and a person may still qualify if BMI is 30 to 35kg/m2 with serious related health concerns. A team of health professionals including a doctor, dietitian, psychologist and surgeon will elevate the suitability of gastric bypass with weight loss goals per individual case (“Gastric Bypass Surgery”, 2017). Insurance companies will then approve or deny the claim for surgery. Insurance companies require in some cases, patients meet a specific percentage of weight loss at 5-15% (Insurance-Mandated, 2019). Bariatric surgery for the morbidly is considered the next steps on the weight loss ladder. After surgery is completed, the patient will then begin their weight loss journey. For a patient to reach those top steps of the ladder, success is attainable through medical compliance, compliance to diet, engaging in physical activity and coping with behavioral factors. Bariatric surgery is a life-long change that is needed to be reverberated to ensure the patient can make permanent lifestyle changes for successful weight loss. These lifestyle patterns will be new terrain for many patients and should require mandated education hours. Follow-up after surgery requires an interdisciplinary approach from numerous care team members that deliver expertise in their specialized areas of medical care. While the patient is responsible for compliance the care team is expected to educate, coordinate and monitor care.

The Roux-en-Y via laparoscopy is a major surgery although less invasive than open surgery. Stomach, intestines and organs are all pushed out of place and cut and stapled where necessary. The surgeon creates a small upper pouch and a much larger lower remnant pouch of the stomach with the small intestine rearranged to connect to both. All major procedures have risks involved. In comparison, complications following gastric bypass can be vast.  Complications can arise from a surgical standpoint and behavioral, both are common. After undergoing bariatric surgery, 10-30% of patients will require follow-up operations from complications. The most common complications are gastrojejunal anastomotic stenosis(stricture) and marginal ulcers with incidence rates up to 35% and up to 16% respectively. Gallstones may develop and lead to the need of a cholecystectomy. This occurs in more than 33% of bariatric surgery recipients. Rapid and substantial weight loss increases the risk of developing gallstones. Also, nearly 30% of patients who have gastric bypass develop nutritional deficits leading to osteoporosis, anemia and metabolic bone disease. Consuming a lifelong multivitamin daily is a way to avoid these deficiencies (“Obesity Surgery”). Complications at the gastrojejunal anastomosis after Roux-en-Y are frequent and potentially life-threatening. They usually appear within 1-3 months, up to several years following surgery. Stenosis is noted to occur most frequently to occur when a patient has attempted to advance the postoperative diet from full liquid to semi-solid. Patients may complain of the inability to advance diet due to symptoms including dysphagia, abdominal pain, nausea, or vomiting. These symptoms must be taken seriously and investigated early. Stenosis or marginal ulcers are successfully diagnosed and treated nonoperatively in most cases. Smoking, alcohol consumption and use of NSAIDs are key players to produce the serious complications stated above. These risks and complications should be reiterated preoperatively.

Roux-en-Y decreases stomach size to just between 15-30mL from an average stomach size of 300mL, which reduces the amount of food that can be ingested. This surgery significantly alters many important physical properties and gastrointestinal functions. During the initial consultation with a dietitian, life-long diet modifications are discussed along with specific weight loss goals. The risk for malnutrition is serious and should be defined in pre-operative education. The dietitian’s role of follow-up education is the most important facet for safe weight loss and prevention of weight gain. Currently, patients are given a set of guidelines or rules rather than a detailed eating pattern. The nutritional guidelines succeeding gastric bypass are, NPO until passed oral gastografin study; clear liquids anywhere from 2-14 days until a week after surgery; full liquids 2-3 weeks advancing to semisolid food within 4 weeks of surgery; follow by eating solid foods by 3 months after surgery. Patients are to consume 64 ounces of fluid each day and a minimum of 65 grams of protein each day. The optimal amount of protein gastric bypass patients should consume each day is still unknown. Obese patients may ignore the potential risks associated with not following eating guidelines and focus considerable attention on losing weight quickly. For many, hearing one potential risk of surgery could be losing too much weight might sound like a blessing, not a chronic and incapacitating condition that can lead to hospitalization or even death. The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition collaborated in 2009 to set standards to diagnose malnutrition. Undiagnosed malnutrition may lead to longer length of hospital stays, decreased quality of life and increased health care costs. Unfortunately, there is no single lab test can be used to diagnose malnutrition. For malnutrition to be determinable, two or more of the following six characteristics must be met: insufficient or poor oral intake; moderate or severe weight loss; muscle wasting, subcutaneous fat loss, edema and diminished functional status measured by a dynamometer (Marcason,2017). Following a stenosis diagnosis, a patient should be examined for severe protein calorie malnutrition. Enteral or Parenteral nutrition should be considered for patients that are unable to orally consume nutrients for several days or weeks due to the severity of the symptoms from stenosis. Gastric bypass patients are at grave risk if unable to maintain hydration and take a daily multivitamin. Using parenteral and enteral nutrition support related to preventing or minimizing the effects of stenosis on the body remains poorly researched at this time, no protocol or guideline found.

Shuster et al transcribed a continuing education article that pointed out the protein calorie malnutrition  signs are not always crystal clear. Pories et al reported, from the 397 patients in their Greenville gastric bypass study, 4% were diagnosed with malnutrition and dehydration. MacLean et al. used body composition analysis, while analyzing multiple techniques to assess the incidence of protein calorie malnutrition after gastric bypass. The reported findings were, postoperative 16-34 months, 47 patients or 25% were diagnosed with malnutrition. Patients that underwent the Roux-en-Y procedure lost more weight and developed malnutrition earlier than other types of bariatric surgery. Curiously, most if not all, of those patients that contributed to the percentages above had also developed stenosis. Also, Faintauch et al studied the prevalence of malnutrition after Roux-en-Y in a series of 236 consecutive patients over a 68-month period. There were 23 patients or 10% had developed protein calorie malnutrition. Postoperatively 63% of the patients had external events that caused the development of malnutrition. Anastomotic stenosis was the most common complication. Poor intake and edema were other events presented that preceded malnutrition in this study. Patients who were malnourished were treated with a combination of oral, enteral, or parenteral nutrition which required an average of 3-4 months of nutrition therapy.

Recently Serrato et aldescribed obesity as a “multifactorial disease” generating a public health crisis. Genotype and environmental factors are considered most relevant to contributing to obesity. An obese person will undoubtedly experience significant health comorbidities. When medical weight loss programs that include pharmacological with psychological therapies prove to be non-effective, a person may choose to undergo bariatric surgery. However, there are risks and complications correlating with gastric bypass surgery. Stenosis is the most common complication. In addition, the mechanism behind why stenosis occurs is not well understood. Ischemia of the suture, stomal ulcers, reflux or retraction of scar tissue is thought to contribute to these cases of severe stenosis. As well as, diet advancing from liquid to semi-solid foods at the 4-6 week point following surgery may contribute to lesions, which commonly causes that narrowing leading to stenosis. A study conducted by Nguyen et al. have shown that the stenosis complication is more common with laparoscopic Roux-en-Y procedure, 11.4% comparatively to open hand sewn procedure respectively at 2.6%.

A case study was used to determine the association between a Roux-en-Y procedure leading to stenosis complications and nutritional deficits. A 37-year-old with a BMI of 45 kg/m2 was followed retrospectively. The patient suffered from GERD and hypertension preoperative gastric bypass. After surgery, barium transit showed no anastomotic leakage and the patient was able to tolerate clear liquid diet moving on to full liquids thereafter. Post-op 2-months, the patient had symptoms that accelerated weight loss to an unsafe percentage. Gastrointestinal distress with nausea and vomiting were the main symptoms which correlated to poor intake and nutritional status. Stenosis should be suspected when patients are showing signs of nausea, vomiting and/or dysphagia following surgery. Excessive vomiting could lead to malnutrition and vitamin deficiencies, particularly B vitamins. Enteral nutrition was required for several weeks following the diagnosis of severe stenosis determined by endoscopy. Pneumatic dilation was used as treatment with no complications. It should be noted that this case study patient had their comorbidities disappear 2 years post gastric bypass.

Garcia-Garcia et al clarified that there are over 30 different gastric bypass surgery techniques. For a gastric bypass surgery to be deemed safe, it must have less than 10% morbidity and less than 1% mortality. The surgery must offer a good quality of life and minimum side effects. The gold standard technique is deemed to be the laparoscopic Roux-en-Y. This is because it has been shown to have few and manageable complications as compared to other techniques. However, stenosis is the most common early complication and is far from a trivial complication. Endoscopy is essential for diagnosis and treating almost all cases without the need for surgical repair. As this type of surgery increases, specialists must be able to assist and seek answers for the prevention of complications. Subsequently, when complications arise, the multidisciplinary team must recognize and treat complications post-surgery.

The article conducted a retrospective study looking at 280 patients that underwent gastric bypass at general and digestive surgery departments at J.M. Morales Meseguer University General Hospital. Patients had a mean age of 44 years old and had a BMI equal or greater than 40kg/m2 or BMI equal or greater than 35kg/m2 with several comorbidities. Follow-up care was maintained through the clinical guidelines regarding medical, nursing and nutritional aspects. From the 280 patients, 265 patients received Roux-en-Y preformed using no. 21 autosuture instrument (circular mechanical anastomosis). There were 15 patients that received this surgery, preformed using GIA 45 reload beige (linear side-to-side mechanical anastomosis). From circular mechanical anastomosis group 20 patients (7.1%) developed stenosis presented against no cases from linear side-to-side mechanical anastomosis. The authors concluded this study met publishing averages and determined that from no reported stenosis cases in the linear technique group, it is plausible to lower the complication incidence of stenosis following gastric bypass surgery by using linear anastomosis.

Goitein et al studied the occurrence of stenosis after Roux-en-Y. The article hypothesized the pathophysiological mechanisms for stenosis formation to ischemia; with or without ulceration causing scarring at the anastomotic junction, non-ischemia related scarring and inadequate technique with the formation of a tight anastomosis or angulation. The method of constructing gastrojejunal anastomosis may as well play a role in complications. Circular staplers appear lead to a higher percentage of postoperative stenosis in comparison to linear staplers or completely hand sewn. Unfortunately, these hypothesized mechanisms are lacking scientific investigation. Contingent on the severity of stenosis, dehydration and malnutrition are significant misfortunes the patient will endure following an endoscopy. Prompt recognition of stenosis and appropriate management are essential in order to prevent severe protein malnutrition and muscle wasting.

A retrospective analysis of 369 patients that underwent Roux-en-Y procedures were used in the article conducted by Goitein et al. All patients were followed up on a standard schedule in the bariatric surgery center by a team of physicians, physician assistants and a dietitian. Of the 369 patients, 19 developed anastomotic stenosis (5.1%). These patients suffered from postprandial nausea, vomiting and dysphagia consistent with stenosis symptoms. All were referred to endoscopy. The mean time of the development of stenosis was 32 days post gastric bypass. Stenosis following Roux-en-Y procedure leads to patient dissatisfaction with substantial morbidity. Of the 19 patients that developed stenosis only six received nutritional support in the form of protein shakes, enteral nutrition or a brief course of parenteral nutrition. One patient was noted to have protein malnutrition and proximal weakness.

The pathophysiological mechanisms that cause stenosis are not understood or studied enough to have a definite answer or solution to halt the prevalence. Much research has confidence in stating the technique of the surgery as well as scarring factors support stenosis to form after gastric bypass surgery. All the studies above used retrospective analysis of patients that had undergone a Roux-en-Y procedure. The variances astray at which technique was performed during the operation. The lack of information behind each study’s bariatric program made for it to be undeterminable what the nutrition practices or protocols were in place preoperative and postoperative. There has been little new research on this topic and the studies are not able to be randomized thus far.

Nutrition after bariatric surgery has not been abundantly researched. Presently, hospitals use standard postoperative oral intake guidelines based on protocols from previous gastric surgeries. Preventative measures for undesirable conditions like dumping syndrome, is the justification behind these guidelines. Losing weight after gastric bypass is affected by the degree of compliance with dietary and physical activity but has not been adequately researched. It is believed that many patients after surgery want to lose excess weight as fast as possible and purposely avoid eating or consuming fluids. The ideal oral intake following Roux-en-Y is unidentified. There is a great probability for inadequate nutrient intake following gastric bypass because patients are not given set targets to meet. Patients receive diet advancement steps to follow which allows for intake to be rather variable. More research is needed to determine the optimal diet composition post Roux-en-Y that inhibit nutritional complications while sustaining controlled weight loss.  The snapshot of how much nutrition support is used following gastric bypass is not readily available. This may be due to patients being followed closely for the first 30 days after surgery and then moving into less routine follow-up visits. The care team must develop therapeutic plans to combat dehydration, electrolyte disorders and malnutrition. In addition, clinical research is needed to determine if diet composition postoperative can prevent stenosis entirely. By closely following a patient post Roux-en-Y with a diagnosis of stenosis, it is possible to limit undiagnosed malnutrition as well the effects or symptoms.

Works Cited

  • Fringeli, Yannick, et al. “Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-En-Y Gastric Bypass.” Journal of Obesity, vol. 2015, 2015, pp. 1–6., doi:10.1155/2015/698425.
  • García-García, María Luisa, et al. “Gastrojejunal Anastomotic Stenosis After Laparoscopic Gastric Bypass. Experience in 300 Cases in 8 Years.” Cirugía Española (English Edition), vol. 92, no. 10, 2014, pp. 665–669., doi:10.1016/j.cireng.2014.06.006.
  • “Gastric Bypass Surgery Isn’t for Everyone.”

    Mayo Clinic

    , Mayo Foundation for Medical Education and Research, 16 Sept. 2017, https://www.mayoclinic.org/healthy-lifestyle/weight-loss/in-depth/gastric-bypass-surgery/art-20046318
  • Goitein, D., et al. “Gastrojejunal Strictures Following Laparoscopic Roux-En-Y Gastric Bypass for Morbid Obesity.” Surgical Endoscopy, vol. 19, no. 5, Nov. 2005, pp. 628–632., doi:10.1007/s00464-004-9135-z.
  • “Obesity and Overweight.” World Health Organization, World Health Organization, 2017, https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight.
  • “Obesity Surgery.” Cleveland Clinic,

    https://my.clevelandclinic.org/health/treatments/17285-obesity-surgery

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  • Marcason, Wendy. “Should Albumin and Prealbumin Be Used as Indicators for Malnutrition?” Journal of the Academy of Nutrition and Dietetics, vol. 117, no. 7, 2017, p. 1144., doi:10.1016/j.jand.2017.04.018.
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Techniques for Extraction of Impacted Lower Third Molars

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Abstract



Objectives:

Many series of side effects will be produced with the extraction of impacted lower third molar which including pain, swelling, inflammation, and trismus. Flap design is important to allow good visibility, reach to the impacted tooth, and for healing of the surgically created defect. This study aims at the evaluation and comparison of standard flap design with comma type of flap design used in the surgical extraction of impacted mandibular third molar and to objectively evaluate the merits and demerits of individual flap design.


Study Design:

In this study 200 patient with bilateral mandibular third molars impaction of age group of 18-30yrs were selected for the study, To reflect the mucoperiosteal flap On one side standard incision and on other side comma incision were used and , after which the steps are common in the removal of impacted third molars. Immediately on the post –operative days 1, 3 and 7 the post– operative parameters (pain, swelling and mouth opening were recorded. And periodontal status were recorded pre operatively, 1

st

month and 2

nd

month respectively.


Results & Conclusion:

The pain and swelling scores were found to be significantly lower in the surgical area with comma incisions which was recorded on days 1, 3 and 7 as compared to the the area where standard incisions were made. In mouth opening There was a sufficiently great difference seen between the two incisions on 1 post-operative day, but though there was clinical difference between the two incisions on day 3 and 7 there was no statistical significance.

The results of the study shows no lingual nerve paresthesia or any other morbidity, hence the new incision design should probably be made the conventional method, considering the less degree of post operative complications encountered. although it may require some practice initially.


Key words:

Standard Incision, Comma Incision, Mandibular Impaction, disimpaction,Visual Analog Scale


Clinical Implications

:-third molar impactions are common and usually associated with postoperative complications like pain, swelling, trismus and pocket formation. Incision and flap design is important in healing wound and minimizing post-operative complications. Comma incision design has shown less post-operative complication in compare to standard incision


Introduction:

Impaction is defined as cessation of the eruption of a tooth caused by a clinically or radio graphically detectable physical barrier in the eruption path or by ectopic position of the tooth. at least one impacted third molar will be present in 33% of the population which requires surgical removal of impacted third molar hence disimpaction is the one of the most frequently performed procedure.

1

Lower third molars constitute a major bulk of teeth that are impacted in the oral cavity

2

. Many series of side effects will produced with the extraction of impacted lower third molar which including pain, swelling, inflammation, and trismus

3

. Flap design is important to allow good visibility, reach to the impacted tooth, and for healing of the surgically created defect.

Many different incisions have been used to raise the flap, like Ward’s Incision, modified ward’s incision, envelope, ‘S’ shaped incision [Bould Henry] etc

4

. Ward’s and modified ward’s incision are more commonly used and it was observed that Ward’s and modified Ward’s incision provide excellent visual and mechanical access and can be closed by means of a suture inserted between the buccal and lingual soft tissues alone


5



,

However when a releasing incision is made a small buccal artery is sometimes encountered and this may be mildly bothersome during the early portion of surgery, and also the suture is usually placed on a bone defect and not on healthy bone this may cause additionally pain, delayed healing are also seen.


6


Nageshwar

has tried a new type of incision- comma shaped incision and has compared it with the modified wards technique (Figure 1). However the number of cases in his study were very less [n=15], hence this study was undertaken to compare this new comma shaped incision with wards incision using more objective and subjective parameters with a larger sample size.



Material and Methods:


200 patients between the age group of 18-30yrs, having completely impacted bilateral mandibular third molars or partially erupted third molar, with good oral hygiene, without any symptoms of pain or swelling were included for the study. Patient on any medication, pregnancy, severe Pericoronitis, soft tissue impaction, medically compromised, Missing mandibular second molars was the exclusion criteria for the study and were excluded from the study.

The instruments used to compare two flap designs were

Williams probe to measure pocket depth.

Visual analog scale of 0 to 10 was used to estimate pain by subjectively asking the patient to rate the nocioceptive experience

7

.

Swelling was assessed by measuring by the distance between the:

  1. Tragus notch and a reproducible soft tissue pogonion a long the skin surface.
  2. Tragus notch to angle of mouth
  3. Tragus notch to ala base
  4. Tragus notch to outer surface on lateral wall of eye
  5. Angle of mandible to outer surface of lateral wall of eye

The percentage difference between the postoperative and preoperative measurements was calculated.

Mouth opening was evaluated by measuring the maximum inter incisal distance.

After obtaining ethical clearance from the hospital ethical committee, written consent was obtained from all the patients who satisfied the inclusion criteria. Preoperative radiographs were taken to assess the position, depth and angulation of the third molars and to exclude any local pathosis such as a cyst, tumor etc. pain, swelling, mouth opening and pocket depth were recorded Preoperatively . One side of impacted mandibular molar is surgically removed under local anesthesia Using standard flap (figure 2). pain, swelling and mouth opening were measured Postoperative on day 1, 3 and 7 respectively. The extraction on the opposite side was done with the alternate flap design-Comma incision (figure 3). The follow up and postoperative complications of patients on day 1, 3 and 7 were recorded for the parameters studied.

After flap reflection standard procedural steps were followed. Flap was sutured with 3’0 Braided silk sutures. Post operative instructions were given and patients with a standard antibiotic regimen of

Cap. Amoxicillin 500mg TDS* 5days

Tab. Ibuprofen 400mg TDS* 5 days

Tab. Metronidazole 400mg TDS* 5 days

Bilateral The pocket depth is recorded after month.


Data management and Analysis

The post-operative complications for each subject for both incisions were recorded and all data was entered in Microsoft Excel. Data was analyzed using computer software, Statistical Package for Social Sciences (SPSS) version 10. Data are expressed in its frequency and percentage as well as mean and standard deviation. To elucidate the associations and comparisons between different parameters, Chi square (

2

) test was used as nonparametric test. Student’s t test was used to compare mean values between two groups. For all statistical evaluations, a two-tailed probability of value, < 0.05 was considered significant.


Results:

Out of 200 extractions done using ward’s incision 107 were non erupted and 93 were partially erupted,

Out of 200 extractions done using comma incision 111 were non erupted and 89 were partially erupted, {table 1}

In extractions done with standard incision 26.67%of subjects had severe pain on day 1 where as only 13.33% of subjects had severe pain on the exaction side done by comma incision. There is a high statistically significant difference between the two type of incision on day 1 in comparing the pain. (Chi -Square=15.627, P=0.0062) similarly the pain was severe for 6.67% of the patients extracted with ward’s incision and there was no pain on other side where comma incision was used on the 7

th

post operative day (Chi -Square=28.799, P=0.000) {Table 2}

In extractions done with standard incision 46.47%of subjects had severe swelling on day 1 whereas only 33.33% of subjects had severe swelling on the exaction side done by comma incision. But the difference seen was statistically significant difference between the two type of incision on day 1 in comparing the swelling, (Chi -Square=2.4762, P=0.2889). the swelling was sever for 20% of the patient extracted with ward’s incision and there were no patient with sever swelling on comma incision side, (Chi -Square=8.6872, P=0.0365). on 7

th

day there were no patient with severe swelling in both the groups but 40%of the patients experienced moderate pain in ward’s incision group where as only 13.33% had moderate swelling in comma croup. There is a statistically significant difference between the two groups on day 7 (Chi -Square=18.879, P=0.0158).{Table 3}

The mouth opening on day 1 in ward’s incision side is between 29-25mm where 33.33% where as only 13.33% of the patients in comma group. There was highly statistical significant difference between the inter incisal measurements to check for mouth opening on day 1 (Chi -Square=24.658, P=0.000). but though there was clinical difference between the two incisions on day 3 and 7 there was no statistical significance.{Table 4 }

There is significant statistical difference between wards and comma incision in relation to pocket depth recorded after first month and the second month in first month is (t=2.684, P=0.025), and in second month is (t=4.937, P=0.000). and even when ward’s and comma incision are compared separately over time there was statistical significance between the pocket depth in first and the second month was seen, I’e (wards incision t=5.176, P=0.000) and (comma incision t=6.812, P=0.000) in second month. {Table 5}


Discussion:

Third molar surgery has been associated with a variety of complications, flap design is one important factor influencing the severity of these complications . The incisions used in surgical treatments of impacted 3

rd

molars can be grouped in to envelop and triangular varients.all incisions irrespective of there variations, were extended from the distal aspect of second molar towards ramus. These standerd incisions have been modified by many surgeons.the incision modified by Groves and Moore started distal to the distobuccal line angle of the second molar to conserve the periodonsium

8

. Berwick designed a lingually based flap using an incision line that was tongue shaped and did not lie over the bony defect.

9

. Comma shaped incision was designed by Nageshwar to limit the post operative pain and swelling.

Post operative pain of moderate to severe intensity is usually noticed after third molar surgery, the pain usually begins as the effect of local anesthesia fades off. The peak intensity of pain is noticed after about 6 hours. The pain then disappears slowly within a few days if it heals normally.

10

In our study, pain was assessed by using a Visual Analogue Scale (VAS) as it takes little time to describe to the patient and it is easily understood by the patient. The results showed less pain scores on comma incision side as compared to ward’s incision side which is similar to that of the study of Nageshwar. (This may be because small mucoperiosteal flap was elevated during comma incision, the drainage in comma incision is good and this is single flap hence it will give a tight closure on occlusal surface distal to second molar.) This result is not in correlation with the results of Gool et al as they have seen that severity in pain is not related to the type of incision.

11

trauma and infection are the main cause for postoperative swelling. The truma to the tissues associated with oral surgical procedures is the usual cause of early postoperative swelling. It is most marked after 19-24 hrs and then diminishes after about seven days.

12

Swelling in cases with comma incision was comparatively lees than cases with standard incision was done. This study results compliments the study by Nageshwar.

1

but the method of measuring swelling was not satisfactory in that study because the swelling is three dimensional hence it is measured by marking on 6 different points on the face as described earlier.

Salata L.A et al and Szmyd et al reported that restricted mouth opening peaks on the day of surgery. This study is in agreement to this statement too

13

. The comma incision encountered less number of subjects with limited mouth opening when compared with the standard incision side which is in agreement with the study of Nageshwar’s result’ The inter relation between trismus and pain have been reported in many studies. It might therefore be expected that mouth opening after the removal of impacted mandibular third molars is painful and consequently reduced to its full extent. The hypothesis has been confirmed by an electromyographic study which proved that restricted mouth opening is a voluntary action to avoid pain.

14

There was a statistical difference in the postoperative probing depth between the two types of incision after the first and second months. These results are contradictory with many studies, by Rosa et al, Quee et al and Schofield et al which show no differences in pocket depth related to flap designs

15

. But

A.A. Krausz, E.E.Machtei,M.Peled

suggest that increased second molar pocket may be related to osteotomy

16

. However others believe that the flap design and the patient’s age might have an effect on second molar periodontal status. When removal of impacted molars was done during developmental stage of the tooth faster regrowth of the alveolar bone crest . However as all our subjects were in the age group of 18 -30 we feel that age was not a major factor and the difference in pocket depth is related to the type of flap.


Conclusion:

The results of the study shows that none of the patients in the study developed lingual nerve paresthesia or any other morbidity, hence the new incision design should probably be made the conventional method, considering the less degree of post-operative complications encountered. although it may require some practice initially. Further research with newer flap designs like the comma design, which will minimize the post operative complications, should be considered in the extraction of impacted third molar surgery.

Discuss in detail the four main aspects of globalization in healthcare delivery.

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Discuss in detail the four main aspects of globalization in healthcare delivery.

Cite at least 1 external reference (in APA format) in your answers.* needs to be 250 words or more*

Discuss the different reasons listed in your text as to why national health insurance has not developed in the U.S.
“Trade without prestige” was a common phrase coined for the medical profession during pre-industrial America. Specifically, as it relates to this phrase, who practiced medicine in pre-industrial America? Also, what were other factors that affected medical treatment and explained the lack of educated doctors.
Discuss in detail the four main aspects of globalization in healthcare delivery.