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Jeffrey A Brinker, M.D.

Jeffrey A Brinker, M.D.

  • Professor of Medicine
  • Joint Appointment in Radiology and Radiological Science


Appendix C outlines some of the costs associated with common classes of antihypertensive therapy and provides information on some programs available to order lipitor toronto cholesterol levels in blood assist clients with prescription costs purchase lipitor 10mg on line cholesterol test black coffee. Nursing Management of Hypertension Best Practice Guideline this guideline highlights a key nursing role in detection buy lipitor cheap cholesterol levels conversion, assessment and development of a treatment plan for clients with hypertension. The lifestyle risk factors contributing to hypertension are identified and recommendations about key assessment and management strategies are included. Information regarding the types of pharmacological treatment is outlined to serve as direction for practice, and to assist in the education of the client and family. Client adherence assessment tools are included, and interventional strategies and behavioural tools that promote adherence are outlined. The following are selected theoretical frameworks that nurses can use to facilitate behaviour change and to promote adherence in clients with hypertension. Stages of Change (Transtheoretical) Model the transtheoretical model (Prochaska & DiClemente, 1983; Prochaska & Velicer, 1997; Prochaska et al. Relapse – resumption of previous behaviours, a normal event in the process of making behaviour change. Most patients at one time or another make unintentional errors in taking their medication because of forgetfulness or misunderstanding of instructions. Decisional Balance Model the decisional balance model by Horne and Weinman (1999) is a framework that suggests that medication adherence is related to a client’s perceptions of the necessity (perceived benefits or the pros) of the medication/treatment modality and the concerns (perceived risks or the cons) about potential adverse effects and the way in which an individual balances these perceived risks (concerns). The decisional balance consists of identifying the pros and cons of the proposed/actual behaviour change. Conversely, the cons/risks of the health behaviour change are high initially then gradually decrease and are the lowest at the maintenance stage. The perceived benefits of changing behaviour begin to outweigh the perceived risks in the preparation stage. Clients develop their perception of treatment based on their implicit model of their illness, as well as their appraisal of the effect of the treatment relative to their expectations/prior experiences. Clients’ model of illness comprises beliefs about the etiology, perception of the symptoms, likely duration, and personal consequences. The necessity-concerns construct offers a method for conceptualizing the salient beliefs that need to be addressed. Patients should be provided with a clear rationale for the necessity of a particular treatment that is consonant with their own model of illness. Moreover, their specific concerns should be elicited and addressed” (Horne & Weinman, 1999, pg 493). Self-Efficacy Model Self-efficacy is an individual’s belief that she or he is capable of dealing with a specific problem. Low self-efficacy results in avoiding changing behaviour, whereas, high self-efficacy promotes change in behaviour (Betz & Hackett, 1998). Bandura (1977) specified four sources of information through which self-efficacy expectations are learned and by which they can be modified. Self-Care/Self-management Model Self-care/self-management is situation and culture specific; involves the capacity to act and make choices; is influenced by knowledge, skills, values, motivation, locus of control and efficacy; and focuses on aspects of healthcare under the control of the individual. Orem’s Self-Care Deficit Theory of Nursing (1991) delineates three main roles for nurses: 1. Interventions/Strategies for Change In addition to the models and theories discussed above, there are interventions that nurses can use to facilitate behaviour change in their clients. Some examples include: Motivational interviewing – systematically directs the client toward motivation for change; offers advice and feedback when appropriate; selectively uses empathic reflection to reinforce certain processes; and seeks to elicit and amplify the client’s discrepancies about their unhealthy behaviour to enhance motivation to change (Botelho & Skinner, 1995). Appendix E provides details related to motivational interviewing, and examples of the application of these principles. These strategies are outlined in the practice recommendations related to promoting adherence. Detection and Diagnosis Nurses have an important role to play in the detection and diagnosis of hypertension. Often, nurses are responsible for obtaining, recording and reporting a client’s blood pressure. They also play an important role in the provision of education to their clients, which includes sharing blood pressure results with the client and other members of the healthcare team. As the largest group of healthcare professionals, nurses work with clients in a wide range of settings and are in a key position to facilitate early detection of elevated blood pressure. A specific interval for screening is not recommended, however it is suggested that checking a blood pressure in a normotensive client every 2 years and every year in the client with borderline blood pressure would be prudent (Sheridan, Pignone & Donahue, 2003). When the cuff is correctly sized, the bladder of the cuff should encircle 80 -100% of the arm. Utilizing a blood pressure cuff that is too small may lead to a significant overestimation of blood pressure. In contrast, use of a cuff that is too large leads to an underestimation of blood pressure. Regular calibration of aneroid and electronic blood pressure monitors is required in order to ensure that blood pressure measurements begin from a starting point of zero. Monitors can drift from a zero starting point due to use and over inflation, resulting in potentially inaccurate blood pressure readings. Monitors 28 Nursing Best Practice Guideline are manufactured with instructions for calibration, which should be utilized to develop a maintenance schedule and procedure. Table 2 provides a description of the appropriate technique for measuring blood pressure, and Figure 1 illustrates proper positioning of a blood pressure cuff. Table 1: Appropriate cuff sizing based on arm circumference Reproduced with permission.

Structural brain changes complex regional pain syndrome: a systematic review and meta-analysis lipitor 5 mg visa cholesterol lowering foods nuts. Is there an association associated with structural abnormalities in pain-related regions of the human between psychological factors and the complex regional pain syndrome type brain cheap lipitor online cholesterol levels natural remedies. Risk factors for suicidal ideation among during recovery from complex regional pain syndrome purchase lipitor 10 mg amex cholesterol lowering foods in sri lanka. Quantitative sensory testing, complex regional pain syndrome type I after distal radial fracture. Clin J Pain neurophysiological and psychological examination in patients with complex 2010;26:175-81. An updated interdisciplinary are associated with complex regional pain syndrome with fixed dystonia. Relationships between psychological factors, 127 Jellad A, Salah S, Ben Salah Frih Z. Complex regional pain syndrome type I: pain, and disability in complex regional pain syndrome and low back pain. Anxious personality is a risk factor for developing some eight years after diagnosis: a quantitative sensory testing study. Patterns of spread in complex regional neuropeptide signaling, inflammatory changes, and nociceptive sensitization pain syndrome, type I (reflex sympathetic dystrophy). Osteoprotegerin: a new biomarker unaffected limbs of patients with complex regional pain syndrome. Bradykinin produces pain hypersensitivity hand in patients with complex regional pain syndrome type 1. Adrenergic excitation of cutaneous pain receptors induced by disinhibition in complex regional pain syndrome type I. Prog Brain Res symptomatic and recovered complex regional pain syndrome in children. A new clinical approach for diagnosing reflex sympathetic inflammation and pain sensitization in a rat model of complex regional pain dystrophy. Isoprostanes, novel eicosanoids that sympathetic dystrophy: prospective study of 829 patients. Psychological and behavioral aspects of complex criteria for complex regional pain syndrome and proposed research regional pain syndrome management. A critical review of controlled clinical trials for peripheral randomized, controlled, multicenter dose-response study. Evidence based dose vitamin C on complex regional pain syndrome in extremity trauma guidelines for complex regional pain syndrome type 1. Complex regional pain management of adult complex regional pain syndrome type one A syndromes in children and adolescents: regional and systemic signs and systematic review. Role of alendronate in therapy regional pain syndrome: a randomised controlled trial. Pain2004;108:192 for posttraumatic complex regional pain syndrome type I of the lower 8. Reduction of allodynia in patients regional pain syndrome in clinical practice: failure to improve pain. Eur J Pain with complex regional pain syndrome: a double-blind placebo-controlled 2012;16:550-61. Ann controlled trial of gabapentin in complex regional pain syndrome type 1 Intern Med2010;152:152-8. The response of neuropathic pain and pain, and function in chronic cold complex regional pain syndrome: a pain in complex regional pain syndrome I to carbamazepine and sustained randomized controlled trial. Low-dose naltrexone for the treatment in patients with chronic reflex sympathetic dystrophy. N Engl J Med of fibromyalgia: findings of a small, randomized, double-blind, placebo 2000;343:618-24. The box on the next page describes these categories and the gen eral parameters for the types of evidence supporting each category. The numbers in parentheses after each conclusion correspond to chapter conclusion numbers. Each blue header below links to the corresponding chapter in the report, providing much more detail regarding the committee’s fndings and conclusions. For other health effects: There is strong evidence from randomized controlled trials to support or refute a statistical association between cannabis or cannabinoid use and the health endpoint of interest. For this level of evidence, there are many supportive fndings from good-quality studies with no credible opposing fndings. A frm conclusion can be made, and the limitations to the evidence, including chance, bias, and confounding factors, can be ruled out with reasonable confdence. For other health effects: There is strong evidence to support or refute a statistical association between cannabis or cannabinoid use and the health endpoint of interest. For this level of evidence, there are several supportive fndings from good-quality studies with very few or no credible opposing fndings. A frm conclusion can be made, but minor limitations, including chance, bias, and confounding factors, cannot be ruled out with reasonable confdence. For other health effects: There is some evidence to support or refute a statistical association between cannabis or cannabinoid use and the health endpoint of interest. For this level of evidence, there are several fndings from good to fair-quality studies with very few or no credible opposing fndings. A general conclusion can be made, but limitations, including chance, bias, and confounding factors, cannot be ruled out with reasonable confdence. For other health effects: There is weak evidence to support or refute a statistical association between cannabis or cannabinoid use and the health endpoint of interest.

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If buprenorphine/naloxone products are swallowed instead of dissolved under the tongue or inside the cheek generic lipitor 40mg overnight delivery cholesterol medication pictures, the patient may experience no effect due to buy lipitor 10 mg fast delivery cholesterol lowering drugs definition the poor bioavailability and first pass metabolism of buprenorphine generic lipitor 10 mg overnight delivery cholesterol medication knee pain. Whenever you receive a new prescription from any health care provider, be sure they are aware of your opioid use. Inform the health care professional about any past history of alcohol or substance abuse. All patients treated with opioids for pain require careful monitoring by their health care professional for signs of abuse and addiction and to determine when these analgesics are no longer needed. Opioids are associated with significant side effects, including drowsiness, constipation, and depressed breathing depending on the amount taken. Taking more than is prescribed could cause severe respiratory depression or death. This can alter the rate at which the medication is absorbed and lead to overdose and death. Do not mix opioids with alcohol, antihistamines, barbiturates, benzodiazepines and other sedatives including some muscle relaxants. All of these substances slow breathing and their combined effects could lead to life-threatening respiratory depression. Prevent theft, diversion, and child access to your opioids by keeping them in a locked safe. Help keep others safe by never storing opioids in the medicine cabinet or where others have access to the medications. Although you may feel you are helping someone in need, you may cause harm and even death. Keep track of when refills are needed to prevent going without medications which can lead to withdrawal. Some p a i n American Chronic Pain Association Copyright 2018 96 clinics will not fill prescriptions without a visit to the clinic. Other clinics will not fill prescriptions on Friday afternoons or weekends/evenings. Avoid unintentional medication overdoses by helping people with memory problems receive assistance in creating a safe plan for taking medication. Such a plan may include help from family members, home care medication reconciliation, or using time-of-day labeled pill boxes (that are also kept in a locked safe). The consensus of the members of the American Pain Society is that the primary goal in treating people with chronic pain with opioids is to increase the level of function rather than just to provide pain relief. When people are less uncomfortable, they usually resume activities that they had previously avoided. If a person with pain fails to do this, it suggests that symptom relief has not occurred even though the person may believe that the medications “take the edge off”. Clearly, maximizing quality of life entails both factors: minimizing suffering and maximizing function. It is important to understand that the antianxiety and sedative actions of opioids may improve the person’s well being in the short-term, but these effects rapidly develop tolerance and the opioid dose will need to be escalated to achieve the same level of “Well-being”. Opioids should be used for analgesia alone and when prescribing them the physician should inquire about the goals of opioid treatment and the limitations of opioid therapy. If reducing anxiety or sedation is desired, more appropriate medications and physical, behavioral therapies should be tried before escalating opioid dose. Additionally, opioids work best for constant pain at rest and less well for movement evoked pain. It is important that people using opioids do not try to elevate the dose of opioids to achieve an effect that would be best served by other treatments. While opioids are very useful medications they are not a complete answer to the reduction of pain and restoration of function. In many respects the primary goal of pain management is essentially rehabilitation. The person experiencing pain and the family must ask to what end they want to be rehabilitated. Webster defines rehabilitation as “to restore to useful life through education and therapy”. If a person’s goal is solely to reduce pain at the expense of function, then he or she may overlook the more important (and attainable) goal of rehabilitation. The essence of rehabilitation and maintaining wellness is for the person to take an active part in the recovery process. It is important to mention that taking opioids precludes certain types of employment, even if one is tolerant and does not have side effects. People should be aware of the rules currently put forth by Federal and State authorities and individual employer drug use policies. There is no question about the usefulness of opioids in acute pain and end-of-life pain. Benefit is suggested when there is a significant increase in the person’s level of functioning, reduction/elimination of pain complaints, a more positive and hopeful attitude, and when the side effects can be managed safely. Those who take opioids should not have the expectation of prolonged opioid use without concomitant side effects. Some of the following questions may help clarify how appropriately opioid pain medications are being used and whether they are helping or harming the person’s well-being: Is the person’s day centered around taking medication If so, consultation with the health caer professional may clarify long-term risks and benefits of the medication and identify other treatment options. If so, then it is important to inform the health care professional who will need to take that into consideration when prescribing. Often, people with pain with a history of substance use disorders are not ideal candidates for opioid treatment for pain management because the opioids may trigger recurrent addiction. Daily activity is necessary for the body to produce its own pain relievers, to maintain strength and flexibility, and to keep life full and meaningful.

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To some extent buy discount lipitor 5mg online cholesteryl ester storage disease, differences in drug dosing or side effect risk may be related to order lipitor 20mg line cholesterol levels definition genetically based differences in drug metabolism buy discount lipitor 5mg on line cholesterol test kit. There is also sugges tive evidence that up to one-third of African Americans possess genetic polymorphisms of other enzymes that metabolize psychotropic agents, resulting in altered metabolism and potential for enhanced medication side effects. Ethnic factors may also confer a susceptibility to medication side effects in certain persons. For example, patients of Jewish descent have been noted to be at greater risk for clozapine-induced agranulocytosis than other patients with schizophrenia (501) and therefore may require close monitoring during clozapine treatment. Men with schizophrenia have been noted to have a younger age at onset, a poorer premor bid history, more negative symptoms, a greater likelihood of having the deficit syndrome (306, 309), and a poorer overall course than women with schizophrenia (503, 506). Compared with men, women are more likely to have affective symptoms, auditory hallucinations, and persecu tory delusions, but they have a better overall course and better outcomes than men, as evidenced by better social and occupational functioning, fewer hospitalizations, and less substance use and antisocial behavior (504, 505, 507). While such differences may be biologically mediated, psy chosocial factors, including family and societal expectations, may also affect outcome. Haas and colleagues (507) noted that social and occupational role demands may result in unrealistic family expectations of men with schizophrenia, and this issue should be dealt with in treatment. There are also gender differences in both response to and adverse effects of treatments for schizophrenia. Most of this research has been conducted with first-generation antipsychotic med ications. Women exhibit more rapid responses to antipsychotic medications and a greater degree of improvement in both first-episode and multi-episode schizophrenia (504). It has also been ob served that even after body weight is considered, women require lower antipsychotic doses (508, 509) than men, although there is suggestive evidence that postmenopausal women may require higher doses (504). Although women may show greater responsivity to antipsychotics, they also experience more neurological side effects, including acute dystonia, parkinsonism, akathisia, and tardive dyskinesia (504). Women also develop higher serum prolactin levels in response to both first-generation antipsychotics and risperidone, compared with men (504), and therefore women may be more prone to the sexual side effects of the medications. A general reference on medications in pregnancy and lactation is the text by Briggs et al. Controlled studies of psychotropic drug risks during pregnancy are, for obvious ethical rea sons, not done. Knowledge of the risks of these agents comes from animal studies and from un controlled exposures in humans. Nonetheless, there is a body of information that can help guide clinicians’ and patients’ decision making about the use of psychotropic agents during pregnancy and lactation. In addition, two periods of high risk to the fetus or newborn are identifiable: teratogenic risk is highest in the first trimester, and withdrawal risk is highest at the time of birth. Only with planned pregnancies is management of first trimester psychotropic drug exposure under full control of the doctor and patient. Drug withdrawal risk at the time of parturition may be more predictable and manage able, depending on the drug(s) involved and the circumstances of delivery. There are substantial data on fetal exposure to first-generation antipsychotic medications, with relatively little evidence of harmful effects, especially with high-potency agents (511–513). Much less information is available regarding fetal exposure to second-generation antipsychotic medications. Such an outcome would be an indirect rather than a direct effect of these medications. A limited number of reports of treat ment with olanzapine during pregnancy and lactation showed that olanzapine did not appear to increase the risk of harm (515). A case report of clozapine treatment during pregnancy described development of gestational diabetes, possibly exacerbated by clozapine, but no fetal abnormali ties (516). Pregnancy can be a period of decreased symptoms for women with schizophrenia, but relapses are frequent in the postpartum period (517). Thus, the clinical risks of not using anti psychotic medications may be somewhat less during pregnancy but are greater thereafter. Compared with antipsychotic medications, mood stabilizers and benzodiazepines are much more closely associated with fetal malformations and behavioral effects (511, 513, 518). Thus, their risk/benefit ratio is different, and the need for their continuation during pregnancy and breast-feeding requires strong clinical justification. A number of studies have shown that pregnant women with schizophrenia receive relatively poor prenatal care. These women have more obstetric complications, and their offspring are more likely to have adverse outcomes, such as low birth weight and stillbirth (519–522). There are many contributing factors to the relatively poor prenatal care and outcomes, such as low socioeconomic status, high rates of smoking and substance use disorders, and obesity. For the clinician treating a pregnant woman with schizophrenia, it is particularly important to insist on early involvement of an obstetrician who can help reduce the risks of the pregnancy and with whom risks and benefits of pharmacological treatment options can be discussed. While schizophrenia can emerge or worsen in the absence of environmental Treatment of Patients With Schizophrenia 51 Copyright 2010, American Psychiatric Association. Sometimes the stress is internal, and knowledge of developmental vulnerabilities can assist in identifying and assisting with this variety of stress. Treatment strategies include preventing the development or accumulation of stressors and helping the patient develop cop ing strategies that keep tension levels within manageable bounds. The rate of aging associated cognitive decline in older patients with schizophrenia is similar to that in age-com parable normal persons, although, as with younger patients, they have greater overall cognitive impairment (530, 531).

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In addition Department offer a safe means to generic 40mg lipitor mastercard cholesterol ratio 2.8 good or bad remove unused to cheap lipitor 40mg on line cholesterol ratio heart disease risk public events that educate residents about the or expired medications from the home and to buy lipitor 40mg otc cholesterol foods bad pre potential for abuse or misuse of medications in vent accidental poisoning or misuse, and they com the home and the environmental impact of trash plement the ongoing efforts of Chatham Drug Free ing or fushing pills, Operation Medicine Drop also to educate parents and students about the dangers offers collection sites for safe disposal of unused or and legal consequences of illicit drug use. Lamanna, a professor at the University of North Believing this event would beneft the resi Carolina School of Nursing, member of Chatham dents of Chatham County, Roberson encouraged Drug Free, and a resident of Chatham County, says the Pittsboro Police Department to participate in Roberson “truly understands the strong connec Operation Medicine Drop despite procedural bar tion between community safety and the health of riers regarding the collection, holding, and disposal a community’s residents. Giving your baby the recommended immunizations by age two is the best way to protect him from 14 vaccine-preventable diseases, like whooping cough and measles. We sought to measure its utilization among practices that provide primary care for children who are enrolled in a prospective infuenza surveillance study. After Cthe past decade for children of all ages, including young informed consent was obtained from a parent or guardian children and adolescents [1, 2]. Children frequently obtain (along with child assent, when appropriate), children were vaccines from multiple sources. Many children receive enrolled in the study and permission was obtained to verify their frst dose of hepatitis B vaccine during the birth hos their infuenza and pneumococcal immunization history by pitalization [3, 4], and some children receive immuniza contacting their primary care practice and by reviewing the tions from multiple providers [5]. The study population comprised all children who were prospectively enrolled, had immuniza Methods An infuenza surveillance study prospectively enrolled Electronically published June 18, 2013. For each vac lent infuenza vaccine, particularly for children 9 years of cine, we also computed the sensitivity, specifcity, positive age, for whom the recommendation was that they receive predictive value, and negative predictive value for each child 2 doses of the latter but only 1 dose of the former [9-11]. Hence, we limited the assessment of agree authorization agreement between the institutional review ment to children whose immunization status was verifed boards of Forsyth Medical Center and Wake Forest School using practice records alone. Because the children were younger than 9 years of age, approximately 23-valent pneumococcal polysaccharide vaccine is recom half were male, half were black, and three-quarters of them mended only for children 2 years of age or older who have resided in Forsyth County (Table 2). More parents reported medical conditions predisposing them to pneumococcal dis that their child obtained care from a pediatric practice ease [12], we limited assessment of that vaccine to children (76%) than from a family medicine practice (19%) or a 2–17 years of age. Compared to this group, children whose immuniza weighted) kappa statistic with its P value. Immunization Status Defnitions for the 2009–2010 Seasonal and H1N1 Monovalent Infuenza Vaccines Immunization status Age group Defnition 2009–2010 0. The kappa sta received care from 1 of 56 health care facilities, of which tistics for the 2009–2010 seasonal infuenza vaccine and the 30 (54%) were pediatric practices, 21 (34%) were family H1N1 infuenza vaccine ( = 0. Table 3) were lower than those for pneumococcal conju the mean number of enrolled children per health care facil gate and 23-valent pneumococcal polysaccharide vaccines ity was 8 for pediatric practices (range, 1–60), 3 for family ( = 0. For infuenza vaccines, 2 dif In this study, primary care practices administered the ferent practices reported 1 dose of seasonal infuenza vaccine majority of seasonal and monovalent H1N1 infuenza vaccine and 1 dose of H1N1 monovalent infuenza vaccine in the prac doses in 2009–2010. Conversely, for ment, 3% were administered in a practice other than their the pneumococcal vaccine, 1 child had a pneumococcal con primary practice, and 2% were administered in a school or jugate vaccine and another child had a pneumococcal poly wellness center. This discrepancy nega department, 6% were administered in a school or wellness tively impacted the specifcity and positive predictive value of center, and 3% were administered in a practice other than the pneumococcal immunization status in the registry. For children younger than 5 years who had received 4 doses of 7-valent pneumococcal conjugate vaccine, 1 dose of 13-valent pneumococcal conjugate vaccine was recommended. Further, 221 (98%) of the 226 enrolled children immunizations recorded in such a system [6]. Agreement Between the North Carolina Immunization Registry and Practice-Based Immunization Records Doses in Expected Kappa registry record Doses in practice records Agreement agreement statistica Seasonal infuenza None 1 dose 2 doses vaccine, N=54b None 27 7 1 1 dose 2 11 1 80% 45% 0. Financial incentives for representative of the practices serving Forsyth County and adopting electronic health records and meeting standards its 7 contiguous counties in North Carolina. Among enrolled for meaningful use of these systems should signifcantly children, 76% received primary care at a pediatric prac enhance the adoption of electronic health records in pri tice. An analysis of 2004–2007 data from the National mary care practices throughout North Carolina. We found tially important given the expansion of the adult immuniza that within 6 years of the North Carolina registry being imple tion schedule since 2002 [19, 20]. However, these counties include [15], and 91% of children younger than 5 years of age were urban, suburban, and rural populations, thus refecting the included in the Arizona State Immunization Information metropolitan diversity within North Carolina. Recommended childhood and adolescent immunization sched Carolina were granted temporary authorization to admin ules—United States, 2012. Committee on Infectious Diseases, American Academy of Pediat rics; Advisory Committee on Immunization Practices of the Centers dren 14 years of age or older from October 9, 2009, through for Disease Control and Prevention; American Academy of Fam July 2010 [21]. Recommended childhood immunization schedule— and pneumococcal vaccines, not all recommended pediat United States, 2002. A comprehensive immuniza ric vaccines, and results for up-to-date status for all recom tion strategy to eliminate transmission of hepatitis B virus infection mended immunizations may vary. Assessment of parental report Wake Forest School of Medicine, Winston-Salem, North Carolina. Prevention and control of seasonal as the practices and health departments that made this study possible. Accessed January 10, tion of self-reported and registry-based infuenza vaccination status 2013. The measurement of observer agreement for adult immunization schedule—United States, 2002-2003. Recommended adult im nualized estimates by source of payment, patient age, physician munization schedule—United States, 2013. Accessed cian employment status, and geographic location, 2004-2007, and March 31, 2013. Important information about infuenza/H1N1, Thursday, October 1, eral dentists by infants and one-year-olds, 2004-2007. Goldstein background the middle school and high school years are a time when adolescents are at high risk for initiation of smoking and progression to nicotine addiction. This research examines the prevalence with which North Carolina students receive smoking-related communication from health professionals and how such communication relates to smoking behaviors. Weighted multivariable logistic regression models were used to identify variables that are signifcantly related to health profession als’ communication about smoking and/or advice against smoking.


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