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Organisational Discharge summaries should be given to cholesterol medication side effects effective 30 mg vytorin the patient cholesterol levels lipid profile purchase vytorin 30 mg amex, with copies sent Efective day surgery requires strong multidisciplinary team working cholesterol levels vitamin d cheap 20mg vytorin mastercard, to cholesterol in eggs study discount vytorin 20mg free shipping the family doctor. This can be vital if the patient needs treatment and this may be difcult to achieve. Expansion of day case facilities needs to occur maintain efciency and quality of patient care. Routine nurse led alongside reductions in inpatient capacity, and community services follow up (via phone call) is one way to monitor complications may need to be developed. Trying to shift towards viewing day surgery and patient experience, and allows continuous collection of data as the norm for most elective patients may seem a daunting challenge, for regular audit and review. Audits and evaluations of unplanned but can result in real benefts to both patients and healthcare services. Day surgery development and practice: Increasing the availability of day surgery for patients often requires a key factors for a successful pathway. Alterations to national policies and regulations Anaesthesia, Critical Care and Pain 2014; 14: 256–61. Policy Brief Tere may be fnancial incentives for either the hospital or the surgeon – Day Surgery: Making it Happen. World Health Organization (2007), on behalf of the European Observatory in Health Systems and associated with inpatient stays. Unplanned admission rates and Educational post discharge complications in patients over the age of 70 Medical students and doctors may not be trained in the benefts of following day case surgery. Pre operative Assessment and Patient Preparation: the Role Facility design of the Anaesthetist. Recommendations for the Perioperative Care of Patients Selected for Day Care Surgery. Around one in six of these anticoagulated patients • Prophylaxis and treatment of venous thrombosis will require interruption of therapy for a surgical and pulmonary embolism. The traditional strategy to ‘bridge’ replacement (edoxaban not yet licensed for this Surgery causes interrupted warfarin therapy for atrial fbrillation indication). Interruption of pharmacokinetics of these drugs and their use in the • Rivaroxaban also licensed in acute coronary syn anticoagulation increases perioperative period. This article aims to give a concise drome for prevention of artherothrombotic events this risk further and must be update of perioperative anticoagulation and to guide in combination with aspirin and clopidogrel or balanced against the risk of readers on the perioperative management of patients ticlopidine. Each score (0, 1, 2) represents a risk contributing to the likelihood of an embolic event as Emily J Hatton Wyatt outlined in Table 1. It assesses the extrinsic and common pathway of the clotting cascade and can vary depending on the situation and laboratory equipment used. This format does conform with the information that laboratory coagulation tests provide; however, in the last 15 years, a cell based model of coagula tion that better explains coagulation function and pathology that is seen in clinical practice has been proposed. Examples of such factors are: Pharmacokinetics • cognitive dysfunction Warfarin is almost completely absorbed from the gut with peak blood • adherence to prescribed therapy concentration reached within 4 hours. Peak time of action is 48–72 • illness hours, and anticoagulation efect generally occurs within 24 hours. Inducers of cytochrome P450 will generally decrease whilst on therapeutic warfarin. The through displacement of warfarin from its binding site on albumin type of bridging therapy ofered is based on the patient’s thrombotic and also through inhibition of platelet function. The aim of the study was to determine if avoiding bridging in patients with atrial fbrillation Table 2. Common inhibitors and inducers of cytochrome P450 undergoing elective procedures decreased the risk of perioperative Inhibitors Inducers bleeding and/or increased the risk of arterial thromboembolism. The trial included 1884 patients with atrial fbrillation (valvular and Sodium valproate Carbamazepine non valvular) with at least one risk factor for stroke (hypertension, Isoniazid Rifampicin age >75 years, congestive cardiac failure, diabetes, previous ischaemic Cimetidine Alcohol stroke/transient ischaemic attack). Ketoconazole Phenytoin Fluconazole Griseofulvin The results showed that, at 37 days postoperatively, there was no increase in thromboembolic complications but that there was a Alcohol Phenobarbital signifcant decrease in the amount of perioperative bleeding in Chloramphenicol Sulphonylureas patients who did not receive bridging therapy. Tere was no signifcant diference between the groups with regard to myocardial infarction, venous thromboembolism or death. The premise that warfarin Rivaroxaban, apixaban and edoxaban also have predictable interruption leads to rebound hypercoagulability and that the milieu pharmacokinetics and can be stopped close to the time of surgery; of the procedure confers a prothrombotic state, which in turn leads to consequently, patients receiving these medications do not require arterial thromboembolism, is not supported by the results of this trial. Owing to lack of information we cannot safely neurosurgery, and patients with mechanical heart valves. Risk relates to complications such as angiography, pacemaker insertion); bleeding, haematomas and compression of other structures leading • high bleeding risk procedures (spinal, epidural anaesthesia, to potential airway compromise or tissue ischaemia. Epidurals and lumbar puncture, cardiothoracic surgery, abdominal surgery, spinals are thought to be associated with the highest risk of complica major orthopaedic surgery, liver biopsy, transurethral resection tions, with the risk decreasing as the blocks become more peripheral. However, clinicians remain wary of these agents stopped close to the time of surgery. Bridging is not currently because of the lack of options for reversal of their anticoagulant recommended. Check renal function preoperatively and use results efects in situations where this is imperative – such as emergency to plan the timing of the last dose presurgery (see Table 5). Warfarin is well known to increase results depending on the reagents used and no standard calibration is the prothrombin time and its efect can be reliably measured by available. Dabigatran has been shown to have a linear relationship would suggest that haemostatic function is not impaired. Using renal function to time dosing of dabigatran4 Renal function (estimated glomerular fltration rate in mL min–1) Timing of last dabigatran dose before surgery 50 2 days 30–50 4 days 30 > 5 days Table 6. Rivaroxaban, apixaban and edoxaban also increase undergo a high risk intervention such as epidural cannulation or the prothrombin time; however, again, this efect is unreliable and neurosurgery. Rivaroxaban, apixaban and edoxaban have no efect varies depending on the reagents used. Tere is slowly emerging evidence in support of the Hemoclot direct The amount of thrombin present and the concentration of thrombin thrombin inhibitor assay (Hyphen BioMed, France). The thrombin time on inhibition of a constant amount of highly purifed human alpha can be used to detect if there is any dabigatran present. Tere is a thrombin by adding it to diluted test plasma mixed with normal linear relationship between the thrombin time and therapeutic doses pooled human plasma. However, at high doses the coagulometers cannot quantity of dabigatran present in small study populations. The test is therefore not suitable for routine over the past 2 years no really convincing evidence for its accuracy use; however, it can be useful for testing for the presence of dabigatran has emerged and therefore it is not in widespread use. It could be useful to check for a normal availability limit its use in low income settings. Idarucizumab (Praxbind) is a monoclonal Warfarin reversal depends on the presentation of the patient and antibody indicated for emergency reversal of dabigatran with the consideration should be given to the indication for warfarin in the recommended dose being 5g and reversal efects being evident patient. Binding afnity is approximately 300 fold greater than the binding afnity of dabigatran to thrombin. The reversal agent used for warfarin is a synthetic preparation of phytomenadione (vitamin K1). The presence of vitamin K is essential The half life of dabigatran after multiple doses is approximately for formation of prothrombin, factor 7, factor 9 and factor 10. This makes dabigatran useful in patients with minor bleeding since withdrawal of the drug • Major bleeding – stop warfarin sodium; give 5 mg phytomena may be enough. Since the anticoagulant efect of dabigatran declines dione (vitamin K1) by intravenous injection; give four factor in parallel with its plasma concentration, urgent but not emergency prothrombin complex (factors 2, 7, 9 and 10); if prothrombin surgery may need to be delayed for 12 hours from the last dose complex unavailable, fresh frozen plasma can be given but is of dabigatran. No studies have the thrombotic risk posed by stopping a patient’s anticoagulation produced results showing complete reversal of anticoagulation using and the risk of bleeding. However, use of • New evidence has shown that patients at low thrombotic risk non specifc haemostatic agents does reverse parts of the coagulation can safely stop warfarin for a surgical procedure without bridging pathway. Most guidelines suggest 48 hours from of their predictable and consistent pharmacokinetics. Perioperative • Specifc emergency reversal of dabigatran is now available and Anticoagulation Guideline. Major complications of central neuraxial block: report on the Third National Audit Project of the 3. National Institute for Clinical Excellence (2014) Atrial fbrillation: January 2016. Guidance on the emergency reversal of coagulation tests (accessed 7 January 2016).

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Attach copies of additional test results and interpretation reports to cholesterol killing foods buy generic vytorin 30mg online the Medical Examination Report form cholesterol medication starting with v generic 30mg vytorin with visa. Medical Examination Report Form Page 3 Record the physical examination and certification status on the third page of the Medical Examination Report form cholesterol ratio life insurance cheap vytorin 30 mg overnight delivery. Physical Examination the physical examination should be as thorough as described in the Medical Examination Report form foods to keep cholesterol down generic vytorin 30mg line, at a minimum. Note any abnormal finding, including the safety implication, even if not disqualifying. Inform the driver of any abnormal findings and as needed advise the driver to obtain follow up evaluation. Physical examination may indicate the need for additional evaluation and/or tests. Document the certification decision, including the rationale for any decision that does not concur with the recommendations. Certification and Documentation Certification Status Document the certification decision in the space provided for certification status. The driver who must wear corrective lenses, a hearing aid, or have a Skill Performance Evaluation certificate may be certified for up to 2 years when there are no other conditions that require periodic monitoring. Federal exemptions and some Federal Motor Carrier Safety Administration guidelines specify annual medical examinations. Certification and recertification occur only when the medical examiner determines that the driver is medically fit for duty in accordance with Federal qualification requirements for commercial drivers. The expiration date should be consistent with the Medical Examination Report form certification status and cannot exceed 2 years from the date of the examination. The certificate can be the original or a photocopy, and can be reduced in size (usually wallet sized). The examiner may provide a copy to a prospective or current employing motor carrier who requests it. If the driver was certified as physically qualified, then the medical examiner should also retain the medical certificate as well for at least 3 years from the date the certificate was issued. Provisions of the vision exemption include an annual medical examination and an eye examination by an ophthalmologist or an optometrist. At the annual recertification examination, the driver should present the current vision exemption and a copy of the specialist eye examination report. The motor carrier is responsible for ensuring that the driver has the required documentation before driving a commercial vehicle. At the conclusion of that study, 2,656 drivers received a one time letter confirming participation in the study and granting a continued exemption from the monocular vision requirement, as long as the driver is otherwise medically fit for duty and can meet the vision qualification requirements with the one eye. The driver who was grandfathered must have an annual medical examination and an eye examination by an ophthalmologist or optometrist. At the annual medical examination, the driver should present to the medical examiner the letter identifying the driver as a participant in the vision study program and a copy of the specialist eye examination report. The Federal Diabetes Exemption Program is responsible for determining if the driver meets program requirements and for issuing the diabetes exemption. The driver must provide a quarterly evaluation checklist from his/her endocrinologist throughout the 2 year period or risk losing the exemption. Please direct questions concerning Driver Exemption Programs to medicalexemptions@dot. Individuals with type 1 diabetes mellitus: • Are distinguished by a virtual lack of insulin production and often severely compromised counter regulatory mechanisms. Although hypoglycemia can occur in non insulin treated diabetes mellitus, it is most often associated with insulin treated diabetes mellitus. Mild hypoglycemia causes rapid heart rate, sweating, weakness, and hunger, while severe hypoglycemia causes headache and dizziness. The examination is based on information provided by the driver (minimum 5 year history), objective data (physical examination), and additional testing requested by the medical examiner. Key Points for Examination When the Driver Has Diabetes Mellitus and Uses Insulin this physical examination starts the Federal Diabetes Exemption Program application process. The driver must provide a 5 year medical history for your review before you determine certification status. You should ask about and document diabetes mellitus symptoms, blood glucose monitoring, insulin treatment, and history of hypoglycemic episodes. Recommendations — Questions that you may ask include Does the driver: • Newly started on insulin have documentation of completion of minimum waiting period Page 220 of 260 Regulations — You must evaluate On examination, does the driver have: • Glycosuria (dip stick urinalysis) State issued Medical Waivers and Exemptions It is important that as a medical examiner you distinguish between intrastate waivers/exemptions and Federal diabetes exemptions for insulin treated diabetes mellitus. Record Regulations — You must document discussion with the driver about: • Any affirmative history, including if available: o Onset date, diagnosis. When the driver has or must obtain a Federal diabetes exemption: • Mark the "accompanied by a " exemption checkbox. The driver is responsible for ensuring that both certificates are renewed prior to expiration. You should review the report at recertification for any medical changes before determining driver certification status. All proposed changes to the medical standards are subject to public notice and comment rulemaking. Yes if: Annual Ultrasound to identify Asymptomatic; Ultrasound for change in change in size. Aneurysms of other Assess for risk of rupture No vessels and for associated cardiovascular diseases. Subvalvular Aortic Mild = favorable Yes if: Annual Stenosis Has potential for No valvular abnormality Evaluation by cardiologist progression. Yes if: Annual At least 3 months after Evaluation by cardiologist successful surgical knowledgeable in adult resection when cleared congenital heart disease by cardiologist required, including knowledgeable in echocardiogram. At least 3 months post Evaluation by cardiologist surgical intervention; knowledgeable in adult Cleared by cardiologist congenital heart disease knowledgeable in adult is recommended. Evaluation by cardiologist knowledgeable in congenital heart disease including echocardiogram. Symptoms of dyspnea, palpitations or a paradoxical embolus; Pulmonary hypertension; Right to left shunt; or Pulmonary to systemic flow ratio > 1. Yes if: Annual At least 3 months after Evaluation by cardiologist surgery or at least 4 knowledgeable in adult weeks after device congenital heart disease closure; asymptomatic every 2 years. Evaluation by cardiologist knowledgeable in adult congenital heart disease required including echocardiogram. Yes if: Annual At least 3 months after Evaluation by cardiologist surgical intervention if knowledgeable in adult none of the above congenital heart disease. Small shunt and Evaluation by cardiologist Prognosis depends on hemodynamically knowledgeable in adult size of atrial septal defect. No if: Symptoms of dyspnea, palpitations or a paradoxical embolus; Echo Doppler examination demonstrating pulmonary artery pressure greater than 50% systemic; Echo Doppler examination demonstrating a right to left shunt; A pulmonary to systemic flow ratio greater than 1. Yes if: Annual At least 3 months after Evaluation by cardiologist surgical intervention; knowledgeable in adult Hemodynamics are congenital heart disease, favorable; including Holter Monitor. Rest angina or change in (If test positive or Condition usually implies angina inconclusive, imaging at least one coronary pattern within 3 months of stress test may be artery has examination; indicated). Yes if: Annual At least 3 months after Should have evaluation surgery or 1 month after by cardiologist device closure; knowledgeable in adult None of above congenital heart disease. Coarctation of the Aorta Unfavorable prognosis Yes, if Annual after intervention with persistent risk of perfect repair (see text p. Yes if: Annual 3 months after surgical Recommend evaluation valvotomy or 1 month by cardiologist after balloon knowledgeable in adult valvuloplasty; congenital heart disease. None of above disqualifying criteria; Cleared by cardiologist knowledgeable in adult congenital heart disease. Other causes of right Double chambered right Yes if: Annual ventricular outflow ventricle. Hemodynamic data and Recommend evaluation obstruction in persons Infundibular pulmonary criteria similar to by cardiologist with congenital heart stenosis. Mild; Asymtomatic; Evaluation by cardiologist No intracardiac lesions; knowledgeable in adult No shunt; congenital heart disease.

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Additional Documents the Provincial Assessment Sector supports the instruction of Science 30 in classrooms with the following documents available online: • School Reports and Instructional Group Reports available at phoenix cholesterol levels diabetes 2 buy vytorin 30 mg overnight delivery. A common heart defect occurs when a hole between the left and right sides of the heart does not close before birth cholesterol foods to eat generic vytorin 20mg free shipping. The hole results in abnormal blood fow between chambers healthy cholesterol ratio australia discount vytorin 30 mg with amex, as shown in the diagram below cholesterol medication new generic 20mg vytorin mastercard. Which of the following rows identifes the affected heart chambers in the diagram above and describes a result of the heart defect Ventricles Mixing of oxygenated and deoxygenated blood Alberta Education, Provincial Assessment Sector 7 Science 30 Use the following information to answer questions 2 to 4. A researcher makes the following hypothesis: Athletes who have trained at a high altitude before competing at a low altitude will have greater endurance because they are able to use oxygen more effectively. Experimental Designs of Some Circulatory System Studies I the average red blood cell count of a group of people living at a high altitude was compared with the average red blood cell count of a similar group of people living at a low altitude. V the concentration of antibodies in a group of people living at a high altitude was compared with the concentration of antibodies in a similar group of people living at a low altitude. Two studies described above that would best test the researcher’s hypothesis are A. Two of the studies described above helped to establish that altitude has an effect on immunity. Variables in One of the Circulatory System Studies Manipulated variable – Altitude Responding variable – Ability to clot blood Controlled variable – Age of participants 4. Blood Vessel Description of Blood Vessel Function of Blood Vessel 1 Pulmonary 4 Walls are only one cell thick 7 Carries blood from the artery heart to the lungs 2 Aorta 5 Carries blood with a relatively 8 Allows nutrients and high pressure and high oxygen wastes to be exchanged content 3 Capillary 6 Carries blood with a relatively 9 Carries blood from the high pressure and a low oxygen heart to the rest of the content body Numerical Response 1. Using the numbers above, choose one blood vessel and match it with the description of that blood vessel and the function of that blood vessel. In a study investigating the effects of caffeine on the circulatory system, heart rate and blood pressure readings of study participants were measured after the participants were given either a caffeine pill or a placebo (sugar pill). Effects of Caffeine on the Circulatory System Time (h) 0 1 3 5 8 Average Heart Rate (beats/min) Caffeine 72 77 72 72 72 Placebo 72 72 71 71 72 Average Systolic Pressure (mmHg) Caffeine 121 128 126 126 123 Placebo 120 119 120 120 120 Average Diastolic Pressure (mmHg) Caffeine 80 83 81 81 80 Placebo 79 80 79 80 80 5. After a person has been vaccinated against a particular pathogen, he or she often needs to receive injections of the same vaccine, called booster shots, in the future in order to maintain a suffcient level of immunity against that pathogen. Booster shots increase the length of time that the person is immune to that particular pathogen. In some varieties of pea plants, the trait for drought tolerance is controlled by a single dominant allele represented by D. If a pea plant having the genotype Dd is crossed with a pea plant having the genotype dd, what percentage of the offspring would be expected to be drought tolerant Marfan syndrome is an autosomal genetic disorder that affects connective tissue in the body. Dominant Unaffected mm Alberta Education, Provincial Assessment Sector 13 Science 30 Use the following information to answer numerical response question 2. Some Biological Molecules 1 Proteins 2 Enzymes 3 Hormones 4 Amino acids 5 Nitrogen bases 6 Deoxyribose sugars 7 Phosphate molecules Numerical Response 2. Match the descriptions of each protein numbered above with its classifcation below. Some scientists are researching the possibility of using viruses to treat genetic disorders caused by a mutated gene. Three Erlenmeyer fasks were set up for an experiment to compare the properties of three different acids of equal concentration. A few drops of bromocresol green were added to each fask prior to experimentation. Which of the following rows identifes the colour of the acid solution within each fask Green Blue Yellow Alberta Education, Provincial Assessment Sector 18 Science 30 Use the following information to answer question 15. A student plans to perform a titration on lake water near her house where acid rain has been reported. Steps of the Titration 1 Rinse the burette with distilled water and then with standardized sodium hydroxide. Which of the following rows identifes an incorrect step in the student’s procedure above and specifes the reason why it is incorrect Alberta Education, Provincial Assessment Sector 19 Science 30 Use the following information to answer numerical response question 4. A student wants to compare the buffering capacity of soil samples collected from four different locations. She records the initial pH of the soil, adds 10 mL of a strong acid solution to each sample, and after 24 hours records the pH of each soil sample. Comparison of Soil pH Before and After Addition of 10 mL of a Strong Acid Soil Source of Soil pH After Sample Soil Sample Initial Soil pH Addition of Acid 1 Nova Scotia beach 7. When the soil samples listed above are placed in order from greatest buffering capacity to least, the order is Greatest Least (Record all four digits of your answer in the numerical response section on the answer sheet. Which of the following pairs of substances could regulate changes in pH by acting as a buffer NaCl(aq)/Cl (aq) Alberta Education, Provincial Assessment Sector 20 Science 30 Use the following information to answer numerical response question 5. Much of this site is contaminated with creosote that was used to preserve wood in railway ties. One concern regarding the release of creosote into the river ecosystem could be the resulting A. Structural formula: Compound 1Chloropropane Propan1ol Propanoic acid Propyl name: propanoate (Record all four digits of your answer in the numerical response section on the answer sheet. Which of the following types of atmospheric pollutant is harmful in the lower atmosphere but benefcial in the upper atmosphere because it blocks harmful ultraviolet rays Which of the following diagrams best represents the shape and direction of the magnetic feld close to a strong permanent bar magnet Two identical resistors are connected in parallel, as shown in the circuit diagram below. If the total resistance of the circuit represented by the diagram shown above is 1. The instrument used to directly measure the current fowing through the circuit represented above is i, which should be connected in ii with the battery in the circuit. Scientists hypothesize that a conductive copper wire suspended from a satellite orbiting Earth would produce enough energy to power the satellite’s electrical components. The number of turns on the secondary coil of the ideal transformer shown above is turns. Security threads have been added to Canadian bills to help detect counterfeit money. Radio and infrared Alberta Education, Provincial Assessment Sector 28 Science 30 Use the following information to answer numerical response question 9. Some Technologies Used to Study Celestial Bodies 1 Refecting telescope 2 Refracting telescope 3 Radio telescope 4 Spectroscope Numerical Response 9. Match each technology numbered above with a key component used by that technology. A beam of incoming red light strikes a glass ball at an angle, as shown below, and two scattered beams of red light (beams S and T) are observed. Which of the following rows describes the appearance of light from an object that is moving away from Earth and provides the name of this phenomenon Appearance of Light from an Object Name of this Row Moving Away from Earth Phenomemon A. Lower frequency and shorter wavelength Blue shift Alberta Education, Provincial Assessment Sector 31 Science 30 Use the following information to answer numerical response question 10. Power Station Diagram 1 2 3 Energy Conversions Type of Energy Used 4 Egravitational > Ekinetic > Eelectrical 7 Renewable 5 Echemical potential > Ekinetic > Eelectrical 8 Non renewable 6 Enuclear potential > Ekinetic > Eelectrical Numerical Response 10. Using the numbers above, choose one power station diagram and match it with the energy conversions that occur in that power station to produce electricity and the type of energy used by that power station. Available Output for an Electricitygenerating Technology During a Fourday Period 29.

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The Committee on Prevention of Mental Disorders (Mrazek et al cholesterol nutrition chart cheap vytorin 20mg with mastercard, 1994) describes a continuum of interventions going from prevention at one end and treatment at the other end cholesterol score of 3 cheap 20 mg vytorin mastercard. The following are three main forms of prevention: universal cholesterol over 200 purchase vytorin 30 mg online, targeted or selective cholesterol test high effective vytorin 30 mg, and indicated. A universal preventive approaches are either designed to enhance resilience in all children. These programs are more readily accepted because they are proactive, emphasizing positive coping skills and provided to everyone thus avoiding any possibility of stigmatization though labeling. Under the targeted programs, selective programs are for children who are at increased risk of developing disorders and involves screening. Indicated programs also require screening and are for individuals with minimal symptoms who do not meet diagnostic criteria for any disorder. Treatment programs target children with a diagnosed condition (Lowry Webster et al, 2001). In this paper both the universal and targeted school based anxiety prevention programs will be reviewed. Universal prevention strategies A study by Hains (Hains et al, 1992) examined the effectiveness of two cognitive behavioral interventions to help adolescent boys cope with stress and other negative emotions. The project was described to all sophomores and juniors and those who were interested were invited to attend an orientation meeting. Twenty five adolescent boys ages 15 16 year old were randomly assigned to either a group receiving cognitive restructuring or to a second group receiving anxiety management training. Both these groups were compared to a wait list control group on measures of anxiety, anger, self esteem, depression, and reports of anxious self statements. Both the intervention groups showed significant decline in levels of anxiety, expression of anger, and depression. There are 2 4 parent sessions teaching parents coping strategies for their own anxiety, reinforcement strategies, contingency management and problem solving and communications skills. Barrett et al (2000, 2001) evaluated a “train the trainer” model of intervention in children ages 9 10 years in grade 6. Children with internalizing symptoms were assigned to either an intervention led by a psychologist, a teacher or a control condition with a standard curriculum. At the end, children reported considerable decrease in anxiety symptoms in either intervention by a psychologist or a teacher. Both groups reported significant decrease in anxiety and the decline was significantly greater in the intervention group regardless of their risk status. A follow up study after one year by Lowry Webster et al (2003) showed that results were maintained with the intervention group having lower scores on anxiety self report measures. Eighty five per cent of children in the intervention group who were scoring above the clinical cut off for anxiety and depression were symptom free in the intervention condition compared to 31. In a study of universal prevention with 733 children enrolled in grade 6 (ages 9 10) and grade 9 (ages 14 16), Lock et al, 2003 studied children from 7 different socioeconomic school settings. Students who were “high risk” based on high scores on anxiety measures were given a structured diagnostic interview. Results showed a general decrease in anxiety scores which were significant for students in the intervention group at the end of the program and at 1 year follow up. This study also showed that children in Grade 6 had higher levels of anxiety before intervention but post intervention had greater reductions in anxiety and depression at 12 month follow up compared to grade 9 children. In addition, there was a delayed effect in improvement of depression symptoms that was apparent only at the 1 year follow up. In addition, girls tended to have higher levels of anxiety than boys and girls in Grade 6 were more responsive to the intervention than Grade 9 girls. Barrett et al (2006) evaluated the above mentioned study by Lock et al for its long term effectiveness at 36 months. The decrease in scores due to the intervention were maintained in grade 6 but not for children in grade 9 emphasizing the fact that intervention in grade 6 might be an optimal time for decreasing risk for anxiety. There were significantly fewer high risk students at 36 month follow up in the intervention condition than in the control condition proving the durability of prevention effects for children in Grade 6. The outcomes were noticeable for up to 3years following a brief 92 Anxiety and Related Disorders cognitive behavioral intervention delivered by teachers within the school. For girls who had the highest anxiety and showed the biggest decline after one year, the preventive effect lasted for only 24 months. The program was delivered by school nurses to 10 11 year olds in one urban and 2 rural schools. The children were assessed 6 months before the program, at the start of the program and 3 months after the program. Results showed that the levels of anxiety and self esteem were stable 6 months before the program. Three months after the completion of the program, anxiety had significantly decreased and self esteem had increased. The study is limited by its small sample size, short follow up and the single cohort design. In a public elementary school, 118 children were randomly assigned either to an 8 week intervention or to a wait list control. The study cited its limitations as having a small sample size, absence of screening for co morbid disorders and lack of follow up. Targeted prevention strategies Early intervention and prevention programs can be more cost effective in reducing the burden of illness of childhood disorders. To effectively conduct an early intervention program there should be a reliable way to screen children at risk, an access point to identify these at risk children. The Queensland Early Intervention and Prevention of Anxiety Project (Dadds et al, 1997), an indicated prevention program in Australia, targeted 1,786 children ages 7 14 years to evaluate the effectiveness of a cognitive behavioral and family based group intervention (using the Coping Koala: Prevention Manual) for preventing the onset and development of anxiety problems in children. All the children were screened for anxiety symptoms using children self reports and asking teachers to nominate children in their class who displayed the most anxiety. After screening, 128 children were assigned to a 10 week school based child and parent focused psychosocial intervention or a control group. The children received weekly 1 2 hour cognitive behavioral sessions delivered by psychologists. At 12 months, both the intervention and the control group converged, however, at 2 year follow up the group receiving the intervention was again superior to the control group. This study is an example of an indicated intervention targeted towards individuals who already show early signs or Prevention of Childhood Anxiety Disorders 93 low levels of a disorder. Because the interventions are targeted only towards those at greatest risk, (Offord et al, 1998) they are more cost effective and can be provided to only those who need it. To assess the effectiveness of an indicated early intervention and prevention program for anxiety disorders when conducted by school staff, Hunt et al, (2009) conducted a randomized controlled trial. A total of 1120 children in their first year of high school were recruited from 19 schools. Students who were at risk for the development of an anxiety disorder (1 standard deviation above the average score based on an age related normative sample) were screened and identified. Teachers were asked to nominate 3 students with increased anxiety and subsequently 24 students were added to the study. Nine schools were randomly assigned to the control condition (n=137), and 10 to the intervention condition (n=260). There was little difference between conditions at the 2 year and 4 year follow up on self reported symptoms. This study replicated the Queensland Early Intervention and Prevention Project (Dadds et al, 1997) with a few changes. The intervention was delivered by school counselors and teachers instead of psychologist, there was assessment of treatment fidelity and a long term follow up was added. This study highlights the challenges of delivering a school based program effectively by school staff. Because of the potential role of withdrawn or inhibited temperament as an important risk factor for later development of anxiety disorders, some researchers have focused on very young age groups. It is difficult to differentiate in this age group between temperament and disorder since these can be overlapping but are also distinct constructs (Rapee & Spence, 2004; Turner et al. It is possible that some of these children with inhibited temperament already meet criteria for an anxiety disorder and thus could qualify for assignment to either selective or indicated intervention (Mrazek & Haggerty, 1994). LaFreniere & Capuano (1997) identified 43 anxious and withdrawn preschoolers, ages 31 70 months.

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  • http://www.onlinejacc.org/content/accj/early/2018/11/02/j.jacc.2018.11.003.full.pdf?download=true
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