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By: C. Marus, M.B. B.CH., M.B.B.Ch., Ph.D.

Clinical Director, Philadelphia College of Osteopathic Medicine

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The chiropractic profession, which has always had a wellness paradigm and has stood at the forefront of the health promotion and wellness movements, must participate in research and that will better evaluate the basis and implementation of worldwide routine check-ups/prevention services. Expenditures and percent of gross national product for national health expenditures, by private and public funds, hospital care, and physician services; calendar years 1960 87. Applications of Social Science to Clinical Medicine and Health Policy, Chapter 17. The chiropractic practitioner should be aware of programs of cooperation and/or collaboration which can assist the patient. Relationships between health care professionals can only become more complex, and possibly more contentious as we presently enter an era of great change and instability in health care. Concepts such as "managed care, " "preferred provider" and "gatekeeper physician" are becoming the new currency of health care policy. In an era in which greater scrutiny is being given to all health care procedures and pathways, it is particularly important that the chiropractic profession take steps to ensure that relationships with other providers are based on the best interests of the patient at all times. Likewise, we must carefully safeguard the rights of chiropractic patients and ensure that other providers are conscious of the need to conduct patient care in a totally objective and professional manner. When professions interact in the delivery of health care services, economic and social factors as well as professional competition or misunderstanding should never be allowed to override the fundamental obligation to the patient. There is no place for such distractions in the delivery of quality health care, nor should the chiropractic profession or the public tolerate prejudice or discrimination in the conduct of health care policy at any level. As well, hospitals are of great social, political and economic importance in North America. It is here that the largest publicly supported concentration of leading-edge diagnostic equipment is to be found. However, as greater emphasis is now being placed on the concept of nominating one primary care doctor as a "gatekeeper" whose function is to ensure appropriate care yet contain specialist and other costs, new effort is required to understand the appropriate role of different health disciplines. Firstly, from an organizational viewpoint, much of modern medicine is based on a "problem oriented model" rather than one based either on the management of chronic illness or disease prevention. When incorporating chiropractic care into patient care guidelines, it is always understood that the role of the doctor of chiropractic is separate from other health disciplines and should be presented as such. Whatever the unique needs of the individual patient, the objective of chiropractic remains the same. This should be understood when clinical policies and guidelines are made on decision-making in patient management. Determining the role of each profession in the various algorithms for patient management should reflect the varying and unique needs of each individual patient. Developing such algorithms, which are currently not in place nationwide, may reasonably be expected to have a significant impact on health outcomes in general, as well as on the difficult inter-professional issue of cost-containment. It is in the best interest, therefore, of all concerned that the health care system have all its professional resources, and ready information on them, available to all patients. Initially, as the chiropractic profession explores the arena of collaborative care more fully, documents generated by practitioners engaging in this work and setting out inter-professional referral protocols can serve as guidelines. As part of the health care system at large, however, the chiropractic profession must now begin to focus more of its resources in researching and developing clinical standards relevant to collaborative care.

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Doxycycline is an alterna tive agent that has activity against P multocida; use of doxycycline in children younger than 8 years of age must be weighed against the risk of dental staining. Azithromycin and fuo roquinolones display good in vitro activity against organisms that commonly cause bite wound infections, but clinical trial data are lacking and fuoroquinolones are not approved for this indication in children. Meropenem is an option for children with penicillin allergy, but cross-reactions with penicillins can occur infrequently. The duration of treatment for bite wound associated bone infections is based on location, severity, and pathogens isolated. Different species of ticks transmit different infectious agents (eg, brown dog ticks are 1 vector of the agent that causes Rocky Mountain spotted fever; black-legged ticks transmit the agent of Lyme disease), and some species of ticks (eg, the Table 2. Prevention of tickborne diseases is accomplished by avoiding tick-infested habitats, decreasing tick populations in the envi ronment, using personal protection against tick bites, and limiting the length of time ticks remain attached to the human host. Control of tick populations in the feld often is not practical but can be effective in more defned areas around places where children reside and play. Using consumer-applied acaricides (pesticides targeting ticks) or contracting with a licensed pest-control operator can be effcient approaches to reducing tick popula tions and, therefore, the risk of tickborne disease in highly tick-infested areas. For homes located in tick-prone areas, risk of exposure can be reduced by locating play equipment in sunny, dry areas away from forest edges, by creating a barrier of wood chips or gravel between recreation areas and forest, and keeping leaves raked and underbrush cleared. The brown dog tick is able to survive in more arid environments and can be introduced indoors. This species may be found in cracks and crevices of housing or in animal housing or bedding. Permethrin (a synthetic pyrethroid) can be sprayed onto clothes to decrease tick attachment. Permethrin should not be sprayed onto skin, and treated clothing should be dried before wearing. Some newer formulations are microencapsulated to increase the time before reapplication to 8 to 12 hours. Special attention should be given to the exposed hairy regions of the body where ticks often attach, including the head, neck, and behind the ears in children (Dermacentor ticks). Ticks (especially Ixodes ticks) also may attach at areas of tight clothing (eg, belt line, axillae, groin). For removal, a tick should be grasped with a fne tweezers close to the skin and gently pulled straight out without twisting motions. Although not recommended, if fngers are used to remove ticks, they should be pro tected with a barrier such as tissue and washed after removal of the tick.

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Do not try to effect a delivery using oxytocin unless you are prepared to make a symphysiotomy. If the breech is delayed at the outlet, make sure that the episiotomy is adequate. If the pelvis feels contracted, or the foetus (or the feet) are large, perform a Caesarean Section. If all is otherwise well, continue gentle groin traction, as for breech extraction. If you have delivered the legs but both shoulders have now stuck above the pelvic brim, the arms are probably extended (22-5A). Normally you can put a finger up the posterior vaginal wall and easily bring them down. Put your left hand over method is that, by pulling the foetus tightly down, and by the back; put your middle finger on the occiput and your index and turning the body 180, the shoulder which was held up ring fingers over the shoulders. Remember; if you do not know which way to turn the foetus, keep the back anterior, so that it passes under the clitoris. Many practitioners merely wiggle the foetus one way then the other, pull, and try to find an arm: but this is a detailed manoeuvre. A hand in the posterior vaginal space may Smellie-Veit manoeuvre fails to deliver it, rotating the ease the arm down. Grasp the thighs and pelvis with both hands (if the baby is slippery use a gauze swab or small towel), your thumbs If there is hydrocephalus, see 22. If this fails, avoid If, in the extreme case, the foetus obstructs transversely harming the mother and allow the foetus to die. The left shoulder will then be above mother with pethidine 50mg and let the foetus hang for a the symphysis, and the right shoulder above the sacrum while. With your first 180 turn (22-5C), bring the left that the foetus delivers in <1hr. With your second turn traction with a bandage around the foetal legs and 1-3kg (22-5D) bring the right shoulder under the sacrum. Pick up a fold of the skin over the cervical which started posterior always drags across the face. In the worst case you start in 22-5A with both arms up to the occipital bone, and push scissors into the head. If the foetus arrests at a later stage, the brain compartments, withdrawing the scissors in an with only one arm extended, you may only need 2 turns, open position to enlarge the hole.

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For suspected drug-susceptible tuberculous meningitis, daily treatment with isoniazid, rifampin, pyrazinamide, and ethambutol or ethionamide, if possible, or an aminoglycoside should be initiated. When susceptibility to all drugs is established, the ethambutol, ethionamide, or aminoglycoside can be discontinued. Pyrazinamide is given for a total of 2 months, and isoniazid and rifampin are given for a total of 9 to 12 months. Isoniazid and rifampin can be given daily or 2 or 3 times per week after the frst 2 months of treatment. The evidence supporting adjuvant treatment with corticosteroids for children with tuberculosis disease is incomplete. Corticosteroids are indicated for children with tuberculous meningitis, because corticosteroids decrease rates of mortality and long term neurologic impairment. Corticosteroids can be considered for children with pleural and pericardial effusions (to hasten reabsorption of fuid), severe miliary disease (to miti gate alveolocapillary block), endobronchial disease (to relieve obstruction and atelectasis), and abdominal tuberculosis (to decrease the risk of strictures). Corticosteroids should be given only when accompanied by appropriate antituberculosis therapy. Most experts consider 2 mg/kg per day of prednisone (maximum, 60 mg/day) or its equivalent for 4 to 6 weeks followed by tapering to be adequate. Therapy always should include at least 4 drugs initially; should be administered daily, and should be continued for at least 6 months. Isoniazid, rifampin, and pyrazinamide, usually with ethambutol or an aminoglycoside, should be given for at least the frst 2 months. Ethambutol can be discontinued once drug-resistant tubercu losis disease is excluded. Rifampin may be contraindicated in people who are receiving antiretroviral therapy. Careful monthly moni toring of clinical and bacteriologic responses to therapy is important. For patients with pulmonary tuberculosis, chest radiographs should be obtained after 2 months of therapy to evaluate response. Even with successful 6-month regimens, hilar adenopathy can persist for 2 to 3 years; normal radiographic fndings are not necessary to discontinue therapy. Follow-up chest radiography beyond termination of successful therapy usually is not necessary unless clinical deterioration occurs.

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