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Cycloserine is usually well tolerated by children but can cause changes in mood and a variety of neurological complaints purchase 200 mg seroquel amex. Several doctors 552 Tuberculosis in Children think that serum cycloserine levels should be monitored whenever the drug is given (Correa 1997) order seroquel 100mg with amex. Radiographic control Chest X-rays should be obtained at the time of diagnosis and repeated one to two months after beginning treatment 50 mg seroquel fast delivery, to ensure that no progression or complications have occurred. When the results are satisfactory, it is not necessary to repeat the chest radiograph until the planned end of the treatment. For this reason, it is not neces- sary to achieve a normal chest radiograph before discontinuing treatment. If clinical improvement has occurred after six months of treatment, the drugs can be stopped and the chest radiographs repeated at 6- to 12-month intervals until they become stable (Correa 1997). Several trials performed to assess the efficacy of the vaccine have produced results that vary from country to country. The prognosis of tubercular meningitis varies according to the stage of the disease at the time treatment is started. Stage one has good prognosis, while pa- tients with stage three are usually left with sequelae, such as blindness, paraplegia, deafness, mental retardation, movement disorders, and diabetes insipidus. Higher mortality rates occur in children younger than five years old (20 %) and in those with a prolonged illness of more than two months (80 %) (American Academy of Pediatrics 1994, American Academy of Pediatrics 2000, Correa 1997). Gastric lavage is better than bronchoalveloar lavage for isolation of Mycobacterium tuberculosis in childhood pulmonary tuberculosis. Advances in techniques of testing mycobacterial drug sensitivity, and the use of sensitivity tests in tuberculosis control programs. Diseases at necropsy in African children dying from respiratory illness: a descriptive necropsy study. Utilidad clínica de un equipo comercial de reacción en cadena de ligasa para el diagnóstico de la tuberculosis pul- monar y extrapulmonar del adulto. Direct amplification of Mycobacterium tuberculosis deoxyribonucleic acid in paucibacillary tuberculosis. Detection of Mycobacterium tuberculosis in clinical specimens from children using a polymerase chain reaction. Value of bronchoalveolar lavage and gastric lavage in the diagnosis of pul- monary tuberculosis in children. A meta-analysis of the effect of Bacille Calmette Guerin vaccination on tuberculin skin test measurements. This unexpected encounter between the ancient and the new plague is an intriguing biological issue (Heney 2006). Poverty, social inequities, difficult access to public health systems, and lack of sanitary education leads to a critical public health situation that is hampering the international efforts aimed at controlling both diseases. Indeed, it was shown that a single patient can be infected and/or re-infected with more than one strain of M. On chest X-ray, the typical pulmonary localizations can be observed, often with images of lung cavitation (Figure 17-1). As in the immunocompetent host, the clinical presentation of the disease involves fever, night sweats and weight loss accompanied by productive cough with muco- purulent or hemoptoic sputum or even hemoptysis. However, the frequency of extrapulmonary and disseminated presentation scales up to near 50 % of cases and extrapulmonary involvement disease often coexists with pulmo- nary disease. The so-called “atypical” presentations are frequently observed in the chest X-ray (Figures 17-2, 17-3, 17-4) (Daley 1995). These include basal opacities, absence of cavitation, micronodular (miliary) patterns, hilar and mediastinal ade- nopathy, pleural and/or pericardial effusion. Sputum can be easily obtained by spontaneous cough, induced by hypertonic saline nebulization, or recovered through an early morning gastric washing after over- night fasting. Bronchoscopy is a technique that allows the visualization of the ac- cessible respiratory tract, the obtention of bronchial washings, bronchoalveolar lavages and bronchial or transbronchial lung biopsies. Therefore, bronchoscopy offers the advantage of expanding the diagnostic spectrum to non-infectious dis- eases (sarcoidosis, lymphoma, endobronchial tumors). Other organs may be involved, including the gastrointestinal tract, liver, kidneys, urinary tract, adrenal gland, lar- ynx and genital (male and female) tract. Pleural biopsy and mycobacte- rial culture of the fluid are the most useful and specific diagnostic tools. Clinical characteristics 565 nostic procedures such as peritoneal fluid aspiration, laparoscopy or fiber colonos- copy can be performed and provide samples for culture and biopsy. The most common localizations are the thoracic and lumbosacral vertebrae, where there is risk of spinal cord compres- sion and subsequent paraplegia. The specimen for bacteriological confirmation is obtained by aspiration and/or biopsy of the affected vertebral body. Headaches and mental confusion may be the first symptoms to induce the suspicion of a meningeal involvement. The classical meningeal syndrome with the Kernig and Brudzinsky signs and cranial nerve palsies, usually appears late in its evolution (Figure 17-7). In addition to the lum- bar puncture, brain computed tomography imaging is needed to rule out or confirm the diagnosis of tuberculous meningitis. The central nervous system involvement may include intracranial tuberculomas and brain abscesses that require brain biopsy and/or aspiration for bacteriological and/or histopathological confirmation. The cerebrospinal fluid is hypertensive with an elevated protein content, low glucose levels and mononuclear pleocytosis.

Recumbent Position: In the recumbent posture seroquel 200mg on line, more than 50% blood is present within the systemic veins order 100 mg seroquel free shipping, about 30% in the intrathoracic vessels and less than 15 to 20% in the systemic arteries discount seroquel 200 mg otc. It is the low pressure venous system that is involved in shifting in blood volume. Heart size is greater in the lying position because there is little venous pooling in the leg, and most of the venous blood is in the intrathoracic compartment, able to fill the heart. Standing position: On standing, large displacement of blood volume occurs in response to gravitational effect. The most extensive pressure changes occur in the legs, as blood accumulates in the lower limbs. Intravascular pressure decrease above the level of right atrium and increase in the dependent parts below the right atrium. Much of the blood pooled in the legs is displaced from the intrathoracic vascular area during quiet prolonged standing. This significantly reduces the volume of blood in the heart and the pulmonary circulation. Stroke volume and cardiac output fall significantly - a 20% decrease in cardiac output. Abrupt fall in cardiac output is compensated by the cardiovascular responses; first, by a reflex stimulation of heart rate through the sympathetic nerves, and secondly, by strong vasoconstriction in the splanchnic and skin area, that results in increasing the blood shunting to the thoracic area, and increasing peripheral resistance. However, these cardiovascular responses alone cannot fully 182 compensate for a change to standing position. The action of muscle pump is needed to exert external pressure on the veins and push the venous blood toward the heart. The rhythmic contraction and relaxation of skeletal muscles characteristic of vigorous running, cycling, jogging, or skiing are especially effective in activating the skeletal muscle pumping action of the legs. Aldosterone causes the retention of salt and water by the kidneys, which increases plasma volume and compensates to some extent for the fall in arterial blood pressure. At the same time, there is about 20% decrease in blood flow to the brain during prolonged standing, and in case the muscle is not kept contracting rhythmically, fainting is more likely to occur. During prolonged bed rest the entire body is affected by gravitational forces, often resulting in a temporary inability to changes in posture. Blood Volume and viscosity Blood volume normally remains constant, but decreases following hemorrhagic or traumatic shock; there is sharp drop in circulating volume, a fall in venous return, and a pronounced decrease in cardiac output and blood pressure. A rapid loss of 25% of the total blood volume in hemorrhage will reduce cardiac output to almost zero, causing circulatory shock. This results in inadequate tissue perfusion, resulting in progressive tissue damage. The damage involves the cardiovascular system as well as the other tissues of the body, so that the cardiac muscle, the blood vessels, and the vasomotor system degenerate, initiating a vicious cycle where by deterioration cardiovascular system becomes progressively incapable to supply the tissues with blood. Similar picture 183 develops if more than 40% of total blood volume is lost if the bleeding occurs more slowly from one to several hours. High altitude promotes increased red cell production and causes a mild polycythemia; people living at more than 4700 m have red cell count of 6-8 million per cu mm of blood. Acclimatization to high altitude also increases vascularity of the tissues that lowers total peripheral resistance and tries to counteract high red cell count and increased peripheral resistance. In plycythemia vera, the bone marrow becomes malignant and hematocrit may rise from a normal value of 40 – 45% to even 70 –80% blood viscosity rises sharply, peripheral resistance increases, and cardiac output falls. Anemia decreases viscosity, and together with the vasodilatation due to tissue hypoxia, causes a fall in total peripheral resistance and an increase in cardiac output, so that tissue at rest get enough oxygen, But heart has no reserve to use for the demands of exercise and severe exercise may result in heart failure. Blood Vessels The cardiovascular system is designed to provide widely varying metabolic needs under changing physiological circumstances, without overburdening the heart. These two factors: • Control blood flow and consequently regulate the cardiac output • Are influenced by such factors that control extra cellular fluid volume Microcirculation Microcirculation is the organization of the micro-size blood vessels that are present between the arterioles and venules; their number and size of these vessels vary significantly in deferent vascular beds, many of which have specialized features befitting 184 a special function. The vessels included in the microcirculation are: • Terminal arterioles • Meta -arterioles • Arterioles • Arteriovenous anastomoses • Capillaries • Post capillary venules The terminal arterioles are narrow muscular vessels, having a diameter of 35-50 microns and conduct blood directly into the meta arterioles; both the terminal arterioles are the resistance vessels of the microcirculation. Capillaries • Are the thin-walled exchange vessels forming a network linkage between narrow meta arterioles and wide-lumen venules. Fenestrated Capillaries: Have a very thin area of endothelial membrane stretched between adjacent endothelial cells. These fenestrations are not open holes but are closed by a thin diaphragm; these types are found in the capillary tuft /glomerulus of the kidney, in endocrine glands, and in the intestine providing very high permeability. There is no diaphragm between the adjacent endothelial cells that ensures rapid passage of substances through the capillaries e. Sinusoids: are more wide, more irregular in size and shape than capillaries; sinusoid structure is present in liver and the spleen; in the liver, the sinusoids are lined by an incomplete layer of fenestrated endothelial cell, which increases permeability still preventing passage of many small molecules, such as albumin. Postcapillary venules collect blood from the capillaries, have no muscle and elastic tissue like the capillaries; are wider than the capillaries (15-20 microns); some exchange seems to occur in these vessels; these vessels are very susceptible to inflammation. Viscosity and laminar flow According to the Poiseuille’s Law, viscosity is one of the parameter of resistances to flow. Laminar flow is a characteristic of blood flow in large vessels of the circulation; the laminae move parallel to each other in longitudinally oriented concentric sleeves, each sleeve moving at a different rate. In leukemia and polycythemia, blood viscosity may rise markedly, increasing systemic and pulmonary resistance and consequently raising blood pressure. The bore of the vessel also affects viscosity; it decreases as the vessel diameter falls below 150 micron. This 186 is increase in viscosity as blood velocity decreases, an effect probably due to increased adherence of the red cells to each other.

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Teach mothers buy 300 mg seroquel with visa, families and health workers how diet and illness can affect child growth and thereby stimulate individual initiative and improved nutrition and healthcare practices 300 mg seroquel overnight delivery. Poor linear growth (underweight and stunting) usually occurs in the first 24 months of life buy discount seroquel 300 mg line. If the child is not optimally fed during this time, they could lose 11cm from the potential height that they would have reached as an adult. By the time a child is two or three years old, catch-up growth is less likely to occur; such children have probably failed to grow and are potentially stunted for the rest of their lives. You learned how to assess whether a child is stunted in Study Session 4 of this Module. Age of malnourished child Determinant factors Birth Maternal factors (including nutrition), gestational age Four-six months Infant feeding practices, maternal ability to care for the child Six months to two years Complementary feeding practices, exposure to infections, disease and poor household food as the child gets older Two-five years Inadequate access to household food; infections and social deprivation In Ethiopia we use underweight for monitoring growth, as it indicates acute changes in the nutritional status of the child. If you determine that the child is malnourished (underweight), you should be able to analyse the causes, identify resources, suggest alternative solutions and arrive at decisions together with the mother or caregiver as to what should be done about the child. This process of assessment analysis and action is known as the ‘triple A’ cycle which is described below. Assess This stage involves weighing a child on a regular basis, and comparing the child’s growth with the standard and with their previous weight. This helps to identify any nutritional problems and will help you reflect on and review the child’s situation with the mother or caregiver. Analyse This requires exploration of any nutritional problem of the child in order to understand the root causes of any difficulties. You should identify gaps in feeding or care practices and think about different alternative solutions and resources that you can suggest to the mother or caregiver. Action This stage involves counselling the mother or caregiver about relevant actions. It involves decision making and resource identification as well as deciding on individual and collective doable actions. After thorough discussion with the mother or caregiver, you should be able to decide on the specific actions they need to do. Ideally these actions are feasible and can realistically be done by the caregiver and the household. Each time the child is weighed again, re- assessment is done, followed by new analysis and new action as necessary. The most important issue in growth monitoring is not the position of the child ThetripleAcyclemeasuresthe on the growth curve at one particular time, but the direction of his or her direction of the child’s growth. A single point on the line of growth could be reached from different directions (that is, the child’s weight could go down to the single point or could move up to that point on the chart). Normally the child’s measurements are expected to fall between the lines indicated on the graph by -2 and +2 Z-scores (see the right hand side of the graph). It gives you information you need to be able to advise the mother and caregiver what they need to do for their child. You need to find out the problem together with the mother or caregiver and counsel them on what to do. So you should encourage the mother to continue feeding the child in the way she has been doing. Knowing the rate and direction of growth will help you when you are counselling the mother or caregiver. You should always employ nutrition counselling as a tool to help you achieve this objective. Nutrition counselling is a process of finding the solution to the child’s nutritional problem together with their mother or caregiver. Unlike nutrition education, nutrition counselling is a two-way process during which the mother is actively involved in describing the child’s problems as well as participating in analysing the causes and identifying the available resources and solutions. Working together in this way with the mother or caregiver will help them reach a decision about the doable actions. Analysing causes and identifying 156 Study Session 11 Nutrition Education and Counselling actions are an important part of the overall process. Once you weigh the child and determine their nutritional status you need to share this information with the mother and negotiate with her what actions she can take. Follow-up is also very important and you should always recommend to the mother that she makes an appointment so you can see whether she has carried the agreed actions or whether she has had some problems with these. Counselling is an important skill, and as you have seen, a key element of the triple A cycle. Knowledge is not sufficient because at least three contacts are needed to change behaviour or practice. These messages are communicated at the six health contacts and through other contacts outside the health sector. Write your answers on your study diary and discuss them with your Tutor at the next study support meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of the module. Depending on the degree of malnutrition, nutrition care can be given at home or at the out-patient or in- patient level. Learning Outcomes for Study Session 12 When you have studied this session, you should be able to: 12.

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The N orthcroft tions buy seroquel 100mg with mastercard, space maintainers/regainers order 300 mg seroquel, and functional appliances lecture seroquel 200mg sale, 1985 presented to the British Society for the Study of to correct jaw relations are other m odalities. Genetic and epigenetic regulation of craniofacial craniofacial growth patterns in patients with orofacial clefts: developm ent. Gingival and inadequate plaque rem oval, can also cause gingival periodontal diseases affect 90% of the population. Distant causes19–25 Aetiology 11111–66666 These include low socioeconomic and literacy level, difficult Direct causes access to an oral health care facility, poor oral health These include poor oral hygiene leading to accum ulation awareness, and lack of oral health insurance. O ral health such as puberty, pregnancy, menopause, and pathological education is required for the m aintenance of oral hygiene causes such as hyperthyroidism , hyperparathyroidism (brushing, flossing, rinsing, etc. Interventions for the prevention and • Blood disorders such as acute m onocytic leukaem ia and treatm ent of periodontal diseases are given in Table 6. Prevention and treatment of periodontal diseases Medical interventions Non-medical interventions Other interventions • Scaling and polishing of teeth • Oral health education • Make oral health care more accessible • Oral and systemic antibiotics • Nutrition and diet and affordable • Use of mouth washes • Proper methods of oral hygiene maintenance • Improve the socioeconomic and literacy • Gingival and periodontal surgery ·use of toothpaste and tooth brush level of the population ·gingivoplasty, gingivectomy, flap surgery, ·use of inter-proximal cleaning devices such as • Include oral health care in general health mucogingival surgeries, guided tissue interdental brushes, dental floss and water pik, etc. Periodontal m anifestations of system ic in com m unity settings for people with special needs: Preface. It is the m ost com m on cancer in cancers are diagnosed at a very late stage, when treatm ent m en and the fourth m ost com m on cancer in wom en, and not only becom es m ore expensive, but the m orbidity and constitutes 13% –16% of all cancers. The 5- Aetiology year survival rate is 75% for local lesions but only 17% for Direct causes those with distant m etastasis. Since the oral cavity is easily • Tobacco— M any form s of tobacco are used in India— accessible for examination and the cancer is always preceded sm oking (78% ); chewing of betel quid, paan m asala, by som e pre-cancerous lesion or condition such as a white gutka, etc. Increased incidence of • Bacterial infections such as syphilis, and fungal (candi- 8–10 m outh cavity, pharyngeal and laryngeal carcinom as. Dental factors in the genesis Table 7 lists the direct, indirect and distant causes of of squam ous cell carcinom a of the oral cavity. Prevalence of oral subm ucous fibrosis am ong the cashew workers of Kerala, Strategies for prevention and treatm ent of oral cancer are South India. Solar radiation, lip protection, and lip cancer risk in Los Angeles County wom en (California, United 1. The concentration of fluoride in drinking water to teeth, som etim es with structural defects in the enam el such give the point of m inim um caries with m axim um safety. Fluoride water, food and drugs with a high fluoride content, (ii) varnishes— a review of their clinical use, cariostatic m echanism , efficacy and safety. Causes of dental fluorosis Direct Indirect Distant • Exposure to high levels of fluorides: >1 ppm of • Tropical climate·excess ingestion of water • Poor nutritional status·deficiency of fluoride in drinking water and beverages with a high fluoride content vitamin D, calcium and phosphates • Airborne fluoride from industrial pollution (aluminium • Presence of kidney diseases affecting the • Decreased bone phosphatase activity is factories, phosphate fertilizers, glass-manufacturing excretion of fluoride linked to fluoride toxicity industries, ceramic and brick products) • Thyroid and thyrotrophic hormones have a • Fluoride-rich dietary intake·sea food, poultry, grain synergistic effect on fluoridetoxicity and cereal products (especially sorghum), tea, rock salt, green leafy vegetables, etc. Strategies for the prevention of dental fluorosis Primary prevention Secondary prevention Tertiary prevention • Specific guidelines on the use and • Improve the nutritional status, especially of Treat the discoloured/disfigured dentition by appropriate dose levels of fluoride expecting mothers, newborns and children up appropriate aesthetic treatment such as bleaching, supplements, and use of fluoride to the age of 12 years. Equipment, minimum manpower required and approximate cost for medical interventions for oral and dental diseases Medical Equipment/instruments In dental In private clinics* interventions required Time required Personnel Set-up schools (in Rs) (in Rs) Dental check-up Gloves, face mask, 5 minutes Dental surgeon At all levels Nil 100–300 head light, mouth mirror, explorer, tweezers, cotton/ gauze, etc. Dental caries Though not life-threatening, these diseases are often very painful, expensive to treat and cause loss of several m an- Dental caries is a universal disease affecting all geographic days. It has now been recognized that oral and prevalence of dental caries is generally estim ated at the general health are closely interlinked. Periodontal (gum ) ages of 5, 12, 15, 35–44 and 65–74 years for global diseases are found to be closely associated with several m onitoring of trends and international com parisons. The serious system ic illnesses such as cardiovascular and prevalence is expressed in term s of point prevalence pulm onary diseases, stroke, low birth-weight babies and (percentage of population affected at any given point in preterm labour. In India, different caries, (ii) periodontal diseases, (iii) dentofacial anom alies investigators have studied various age groups, which can and m alocclusion, (iv) edentulousness (tooth loss), (v) oral be broadly classified as below 12 years, above 12 years, cancer, (vi) m axillofacial and dental injuries, and (vii) above 30 years and above 60 years (Tables 12–15). Periodontal diseases affect the supporting structures of Therefore, there is no uniform ity in data on the prevalence teeth, i. M ore advanced periodontal disease with pocket Table 17 docum ents only som e studies, and highlights form ation and bone loss, which could ultim ately lead to totally incoherent data. M oreover, m ost of the studies have tooth loss if not treated properly, m ay affect 40% –45% of been conducted on the child population, in whom periodontal the population. The major vary from m ild to severe, causing aesthetic and functional dentofacial deform ity is cleft lip and palate, which is seen problem s, and m ay also predispose to dental caries, in 1. Prevalence of dentofacial anomalies and malocclusion Author and year State Place Age group (years) Prevalence (%) Shourie 1952 Punjab Punjab 13–16 50 Guaba et al. Tooth loss (edentulousness) studies) Age group (years) Number of missing teeth Edentulousness (%) Incidence (%) 60–64 8. Tooth loss increases with advancing age (Table Data available from a field survey in Gujarat, H aryana 20). Loss of the teeth results in decreased m asticatory and Delhi are presented in Tables 22, 23 and 24, respectively. Distribution of fluoride analysis of ground water samples from different States of India Number of Fluoride Fluoride Fluoride Maximum fluoride States water samples <1. Distribution of fluoride analysis of ground water samples from different States of India Number of Fluoride Fluoride Fluoride Maximum fluoride States water samples <1. Incidence of dental fluorosis in two villages in Haryana Drinking water fluoride Incidence of dental Village level (mg/L) fluorosis (%) Sotai 1. Sponsored by the Task Force on Safe Drinking Water, Government of India, 2003) Oral cancer N ational Cancer Registries in M um bai and Chennai for the period 1988–92 is shown in Tables 28 and 29, In India, the incidence of oral cancer is the highest in the respectively. O verall, the incidence per 100,000 m ost im portant of all prem alignant lesions is oral population is 29 for males and 14. Given the large population of India, the paan m asala and gutka by persons of all age groups, actual num ber of cases of oral cancer is gigantic. The prevalence of oral cancer reported by Population- 1994 5961 Bihar, Gujarat, Himachal Pradesh and Maharashtra 1995 6794 Bihar, Gujarat and West Bengal based Cancer Registries is given in Table 27.

Since the Finger Lakes Region shares many of the same population and geographical features as Western New York generic 50 mg seroquel fast delivery, the expansion effort did not require any major structural changes to the program purchase seroquel 300 mg fast delivery. Strong Children’s Hospital in Rochester is analogous to the Children’s Hospital of Buffalo in 23 24 that it is the sole tertiary referral centre for pediatric neurosurgical cases in the region buy seroquel 200 mg low cost. A similar Perinatal Outreach Program was also in full operation; its staff network and hospital linkages were used to introduce and run the program. Linda Barthauer, a pediatrician specializing in child abuse from Strong Children’s Hospital, was appointed to be the principal investigator (Dias & Barthauer, 2001). The two new project co-ordinators assumed many of the administrative roles that Dias had previously fulfilled. During the expansion phase, the commitment statement was amended to include a request that parents consent to receive a follow-up call seven months after their infant’s birth. The call was intended to assess parents’ recollection of the information received in the hospital and to solicit program feedback. The timing of the follow-up call coincided with the midpoint in the peak incidence of shaken baby syndrome and was designed to test the hypothesis that parental retention of the program material could endure for a minimum of seven months (Dias et al. With the addition of the Finger Lakes Region, 33 hospitals in 17 counties would be participating in the Upstate New York Shaken Baby Syndrome Parent Education Program. The following quantitative program performance goals were set at the outset of the expansion: 1) to establish a regional program including all 17 counties in Western New York and the Finger Lakes Region, 2) to educate at least 70% of new parents about shaken baby syndrome prior to discharge from the hospital, and 3) to reduce and maintain the incidence rate of shaken baby syndrome in each region to 50% of the historical baseline figures (Dias & Barthauer, 2001). All other aspects of the program, including staff 24 25 infrastructure, program materials, and incidence-tracking strategies, were introduced in the same manner as in Western New York. They also act as a valuable resource for staff regarding program innovations, trouble-shooting, and the provision of feedback. Additionally, they supervise and communicate directly with the two project co-ordinators, who are responsible for the bulk of the administrative tasks associated with routine program operations. The project co- ordinators orchestrate the purchase, receipt, and delivery of all program materials to the hospitals and conduct obstetrical and perinatology nurse training sessions. Additionally, they communicate regularly with the nurse managers and assist them in tackling local logistical problems. They also monitor the monthly collection of signed commitment statements and maintain the program database. As active participants in the vigilant tracking of new shaken baby syndrome cases, project co-ordinators regularly contact hospitals, the media, and other child abuse professionals to identify new cases. They also conduct the seven-month follow-up phone calls, assist with the preparation of program data for statistical analysis, and provide program updates for a monthly newsletter distributed to all participating centres regarding ongoing concerns, progress reports, and project status. Finally, the project co-ordinators are public speakers and community advocates for the prevention of shaken baby syndrome, as requested by local public service groups, researchers, and other regions interested in replicating the program (Dias & Barthauer, 2001). The nurse managers are responsible for: 1) educating the maternity nurses about shaken baby syndrome and about how to implement the program; 2) receiving and delivering all program materials; 3) collecting and delivering all signed commitment statements from the maternity nurses to the project co-ordinators each month; and 4) providing the project co-ordinators with monthly delivery statistics to be used in future incidence rate calculations. Any logistical difficulties that arise are solved through direct communication with the project co-ordinators. Maternity ward nurses are trained to educate parents, distribute program materials, and collect signed commitment statements from a maximal number of parents, especially fathers. They return signed commitment statements to the nurse managers for delivery to the project co- ordinators each month. These nurses are the “front-line” program workers, directly interacting with the target population and delivering the primary prevention information. Within several months, nearly all hospitals were fully participating and returning commitment statements to the program office. The project co-ordinators were invaluable in ensuring consistent, open communication with nurse managers, diligently tracking returned commitment statements, and providing prompt assistance for hospital staff in tackling logistical hurdles. The smooth expansion can likely be attributed to two main factors: 1) the creation of the two nearly 26 27 full-time project co-ordinator positions, and 2) the demographic similarities shared by the two participating regions. The Finger Lakes Region program was just as well received as that in Western New York, and the program performance goals were consistently met. The seven-month follow-up questions provided valuable insight into parental retention of program information, and the feedback from parents was overwhelmingly positive. A survey of nurse managers in 2001 revealed that nearly every hospital was routinely providing brochures, posters and commitment statements to parents (Dias et al. Most impressively, the project co-ordinators’ persistent efforts in improving the percentages of returned commitment statements produced an increase in return rates from 46% in Western New York before 2001 to 77% from the combined Upstate New York program (Dias & Barthauer, 2001). In all, Western New York has experienced a 47% drop in the incidence of shaken baby syndrome since the inception of the Shaken Baby Syndrome Parent Education Program (Dias et al. Of the 21 infants that did incur shaking injuries during the study period, less than half of the parents participated in the program and signed a commitment statement. Preliminary data from the Finger Lakes Region in 2003 revealed 27 28 that the number of reported cases of shaken baby syndrome had dropped by 41% (Dias et al. These results likely represent a minimum drop in incidence, due to the increased vigilance with which cases have been tracked during the program (Dias et al. Other child abuse statistics suggest that the dramatic and temporal reduction in shaken baby syndrome cases in Western New York can be directly attributed to the Shaken Baby Syndrome Parent Education Program. The incidence rates of other forms of child maltreatment referred to the Children’s Hospital of Buffalo remained stable throughout the duration of the program, and no congruent decline was observed in the number of cases of shaken baby syndrome reported in neighbouring regions of New York State. Finally, a documented sharp decline in the incidence of shaken baby syndrome is not known to have occurred in any other region in the world, as investigated by the Special Interest Group on Child Abuse (Dias et al. The results support the overall program hypothesis that a primary prevention program providing timely education about shaken baby syndrome to new parents can be effective in preventing inflicted infant head injury. The returned commitment statements revealed that 93% of parents were previously aware of the dangers of shaking an infant, yet 95% still felt that shaken baby syndrome educational materials should be provided to all parents (Dias & Barthauer, 2001; Dias et al.

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