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It remains unclear in many cases how to balance the costs of preparing against the costs of responding to a crisis erectile dysfunction otc treatment buy super viagra 160 mg, and where the 1. All of these crisis events have caused disruption in different countries, regions and sectors, but typically it is the poorest communities among those affected that are the worst hit. Two things seem to have changed today: the frequency of catastrophes seems to be increasing; and our population remains relatively unaccustomed to the magnitude and probability of the risks we are currently facing. In the past, events such as floods and earthquakes had significant but largely localized impacts. Today, these events act as harsh reminders of the vulnerability of our interdependent social and economic production systems and the fragility of just-in-time business models. The impacts of such occurrences tend to escalate and spread, surging and stabilizing as new sectors or countries are caught in the chain reaction. Unforeseen shocks, such as the 9/11 terrorist attacks raise questions of how we build capacity to respond to an shocks. A number of underlying factors have heightened awareness of the risks of such events. Additionally, such events can disrupt the interconnectedness upon which modern society depends. The globalization of production processes and optimization of supply chains have stimulated greater efficiencies in the global economy. At the same time, they have increased the level of exposure to risk should a disruption to the system occur, particularly in the transport and power sectors, and they have raised the likelihood of secondor third-order impacts that are hard or impossible to predict. For businesses, this makes it hard to establish effective resilience measures: the security of having more than one supplier for a part may be undermined by disruption to a single major transport hub, while the manufacture of a complex product that requires thousands of parts can be halted by the absence of a single component. High-impact, low-probability events can be broadly divided into three types according to the general level of preparedness: 1 Preparedness for black swans 1 Traditional instruments of risk management concentrate on normal procedures and tend to disregard extremes, yet consideration of these extremes is essential given the nature of our interconnected world. Scenarioand horizon-planning therefore run the risk of preserving the prevailing assumptions and mindsets in terms of risk management. Some crises, such as floods, hurricanes, earthquakes and terrorist attacks, unfold over minutes or hours. The sheer number of potential types of crises and their impacts presents a challenge in itself. Focusing on these (including cross-border sharing of capacity) could be the key to effective practical responses. To a greater or lesser extent, governments and businesses invest in a wide range of preventative actions, warning systems and security measures to limit the impacts. These reflect important choices about the magnitude, scale and duration of an event that preparations are designed to cope with. Evaluating the costs and benefits of different levels of preparedness is difficult, however, given that an event may not occur for years or decades. The tsunami and consequent flooding of the Fukushima nuclear plant, and the 2010 Icelandic ash cloud are examples. To improve preparedness they will need to address many new questions on disaster and crisis management. The response to Hurricane Katrina highlighted, for example, fundamental tensions between federal and local government. Climate change is the classic example of a slow-motion crisis with multiple timescales and stakeholders with divergent interests. The 2010 Icelandic ash cloud over Europe showed how a precautionary approach can lead to severe economic and political pressure to change the whole basis of risk-management procedures in real time. Early and sustained action is required to avoid a problem escalating, but the most serious impacts occur years or decades into the future (climate change, ageing population etc. There is a temptation to delay action rather than investing the required political capital. How do we create incentives for long-term thinking and for more rapid responses to early warnings How can sensible decision-making be achieved when juggling stakeholders with different interests, different assessments of the hazard, fundamentally different tolerances to risk, and hence different approaches to risk management The response to the 2009 H1N1 pandemic is a good example: different perspectives on the risk led some to praise the rapid response and others to argue that commercial lobbying had driven decision-making. For example, although climate change is widely expected to bring serious negative impacts, the specific nature, frequency and location of climate-related extreme climate events (such as flooding, high temperatures and rainfall volatility) cannot be predicted accurately. In addition, the estimated probabilities are often misinterpreted, sometimes deliberately. This is a challenge for detailed preparedness-planning and also makes it harder to dispel scepticism.

Establish strong links with community resources zyrtec impotence super viagra 160mg on line, and identify providers to bring services into the schools. Identify and provide assistance to students who have been seriously injured, who have witnessed violence, who have been the victims of violence or harassment, and who are being victimized or harassed. Develop and implement emergency plans for assessing, managing, and referring injured students and staff members to appropriate levels of care. Educate, support, and involve family members in child and adolescent unintentional injury, violence, and suicide prevention. Train and support all personnel to be positive role models for a healthy and safe lifestyle. No pupil shall be required to take or participate in instruction on disease, its symptoms, development and treatment, whose parent or guardian shall object thereto in writing on the grounds that such instruction conflicts with his sincerely held religious beliefs, and no pupil so exempt shall be penalized by reason of such exemption. Implementation of health education requirements is the responsibility of local school districts. Recommended Content and Standards the Massachusetts Comprehensive Health Curriculum Framework discusses recommended health education content in terms of 4 separate, but interrelated, strands: physical health, social and emotional health, safety and prevention, and personal and community health. The standards most relevant to injury and violence prevention are: Mental Health, Family Relationships, Interpersonal Relationships (Social and Emotional Health Strand), Safety and Injury Prevention and Violence Prevention (Safety and Prevention Strand), and Community and Public Health (Personal and Community Health Strand). They will also acquire skills to maintain and enhance relationships through communication. They will learn to avoid, recognize, and report verbal, physical, and emotional abuse situations, and to assess the factors that contribute to violence and unintentional injury, including motor vehicle accidents, fire hazards, and weapons. Students will acquire the necessary skills to report incidents of violence and hurtful behavior to adults in school and in the community. They will avoid engaging in violence and identify constructive alternatives to violence, including discouraging others from engaging in violence. They will gain skills to promote health and to collaborate with others to facilitate healthy, safe, and supportive communities. Injury and violence prevention curricula should also target injuries and violence for which the age group being taught is most at risk. There is considerable evidence that targeting to a slightly younger age group than those most at risk is also an important strategy for primary prevention (Carter, 2005; Wolfe & Jaffe, 2003). However, it should be noted that assemblies or one time speakers are not effective in teaching students skill development. Begin teaching the concept that "injuries are not accidents" and injuries and accidents may be prevented through careful planning and certain behaviors. For example, discussing the importance of safety belts with younger children can instill lifesaving habits. Because some children will have already experienced and/or witnessed violence by this age, it is important to create clear protocols and to train staff to respond to any disclosures triggered by such discussions. In this light, many school districts have begun to include social competency programs at this early level as a measure to increase positive school climate and reduce bullying. Middle School Prevention efforts targeted for middle schoolers are especially important. It is during the preadolescent and early adolescent years of middle school that elementary school bullying turns to violence and youth most often begin experimenting with risky behaviors (Mertens, 2006). Children and early adolescents are at a developmental stage in which patterns of thought and behavior are not yet fixed. And while students at this age are generally better able to learn facts and figures than are younger students, it is critical to present this age group with safety lessons that challenge them to solve problems or to assume a level of responsibility. Middle school students should be provided with safe opportunities to be role models for younger children. A school might offer such opportunities as leadership classes, mentoring, and peer mediation groups. In addition, the community can partner with the school in offering other skill development opportunities such as a babysitting readiness class or conflict resolution classes, in which preadolescents are taught safety lessons in the context of being responsible community members. The middle school, in partnership with the community, might offer students the opportunity to build relationships with others through mentoring, leadership, or advisor programs to communicate responsible messages about important topics such as bullying and violence prevention, sexual harassment, healthy relationships, respecting diversity, car safety, or wearing a helmet while biking, skateboarding, or skating. Adolescents Although adolescents are at high risk for serious injury and death, particularly from motor vehicle crashes, alcohol abuse, homicide, and suicide, many perceive themselves as invulnerable. Reducing both violence and injury requires a youth development approach that focuses on resiliency and protective factors. Therefore, it is important for adolescents to receive effective training in sequential skill development, as it is known to support health promotion and reduce high-risk taking behaviors. Need for a Comprehensive and Coordinated Approach Most injury and violence prevention experts agree that truly effective prevention efforts must be comprehensive - consisting of education, supplemented by a safety evaluation of the physical and emotional environment, the development and enforcement of safety laws, guidelines, and recommendations, and the coordination of community prevention efforts and messages. Understanding the scope of injury and violence, as well as successful prevention and intervention strategies, is essential in efforts to keep students safe before, during, and after school. Successful injury and violence prevention usually involves multiple stakeholders: school faculty and staff, parents, students, community representatives, and others in the community. All stakeholders, especially students, should be able to recognize signs of potential injury or violence, and should be well informed about safety protocols, including reporting potential threatening situations. Although injury and violence prevention is best addressed in a comprehensive and coordinated fashion, the balance of this chapter will address separately unintentional injury topics and topics related to violence.

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Vibratory sensation is tested by touching a vibrating tuning fork to a bony structure (such as a finger joint erectile dysfunction emedicine purchase 160mg super viagra fast delivery, the lateral malleolus, or the great toe) and asking the patient whether he or she can tell if it is vibrating; if so, the tuning fork is held in place and the patient is asked to say when the vibration ceases, with the physician taking note, in a rough sort of way, of how much the tuning fork is still vibrating at that point. If there are any abnormalities in elementary sensation it is critical to determine whether or not they are bilateral. In general, it is sufficient to test sensation at both hands and both feet, reserving more detailed testing for cases in which the history suggests a more focal sensory loss. Graphesthesia and two-point discrimination tests also constitute part of the sensory examination but these should only be used if elementary sensation is intact. Agraphesthesia is said to be present when patients, with their eyes closed, are unable to identify letters or numerals traced on their palms by a pencil or dull pin. Two-point discrimination may be tested by `bending a paperclip to different distances between its two points. If there are any abnormalities, both Weber and Rinne testing should be performed to determine whether the hearing loss is of the conduction or sensorineural type. In the Rinne test, a vibrating tuning fork is placed against the styloid process and the patient is asked to indicate when the sound vanishes, at which point the tines of the tuning fork are immediately brought in close approximation to the ear and the patient is asked whether it can now be heard. With conductive hearing loss, the Weber lateralizes to the side with the hearing loss, and on Rinne testing, bone conduction. Agraphesthesia and diminished two-point discrimination suggest a lesion in the parietal cortex; elementary sensory loss, especially to pin-prick, is also seen with parietal cortex lesions but in addition may occur with lesions of the thalamus, brainstem, cord, or of the peripheral nerves. In the finger-to-nose test, patients are instructed to keep their eyes open, extend the arm with the index finger outstretched, and then to touch the nose with the index finger. In the heel-to-knee-to-shin test, patients, while seated or recumbent, are asked to bring the heel into contact with the opposite knee and then to run that heel down the shin below the knee. In both tests one observes for evidence of dysmetria (as, for example, when the nose is missed in the finger-to-nose test) and for intention tremor, wherein, for example, there is an oscillation of the finger and hand as it approaches the target (in this case the nose, with this tremor worsening as the finger is brought progressively closer to the nose). Here, while seated, patients are asked to pronate the hand and gently slap an underlying surface. Once they have the hang of it, patients are then asked to repeat these movements as quickly and carefully as possible. Decomposition of this movement, known as dysdiadochokinesia, if present, is generally readily apparent on this test. Importantly, dysarthria may also be seen with lesions of the motor cortex or associated subcortical structures. If they are comfortable with these instructions then the test can be carried out, observing the patients for perhaps half a minute to see whether or not any swaying develops once the eyes are closed. An ataxic gait, seen in cerebellar disorders, is wide based and staggering: steps are irregular in length, the feet are often raised high and brought down with force, and the overall course is zigzagging. In a steppage gait, seen in peripheral neuropathies, the normal dorsiflexion of the feet with walking is lost and patients raise their feet high to avoid tripping on their toes. In a spastic gait, seen with hemiplegic patients, the affected lower extremity is rigid in extension and the foot is plantar flexed: with each step, the leg is circumducted around and the front of the foot is often scraped along the floor. Strength Strength may, according to Brain (1964), be graded as follows: 0, no contraction; 1, a flicker or trace of movement; 2, active movement providing that gravity is eliminated; 3, active movement against gravity; 4, active movement against some resistance; and 5, full strength. In the process of assessing muscular strength one should also observe for any atrophy, fasciculations, or myotonia. Myotonia is sometimes apparent in a handshake, as patients may have trouble relaxing their grip, and may also be assessed by using a reflex hammer to lightly tap a muscle belly, such as at the thenar eminence, and watching for distinctive myotonic dimpling. Common patterns of weakness include monoparesis, if only one limb is involved, hemiparesis if both limbs on one side are weak, paraparesis if both lower extremities are weak, and quadriparesis (or, alternatively, tetraparesis), if all four extremities are weakened. In cases when strength 0 then one speaks not of paresis but of paralysis, and uses the terms monoplegia, hemiplegia, paraplegia, or quadriplegia. When weakness is present, note should be made whether the proximal or distal portions of the limb are primarily involved; in cases of hemiparesis in which both limbs are not equally affected, the limb that is more affected should be noted. Station, gait, and the Romberg test Station is assessed by asking patients to stand with their feet normally spaced, and observing for any sway or loss of balance. Rigidity Rigidity should, at a minimum, be assessed at the elbows, wrists, and knees by passive flexion and extension at the joint, with close attention to the appearance of spastic, lead pipe, or cogwheel rigidity. Spastic rigidity, seen with upper motor neuron lesions, is most noticeable on attempted extension of the upper extremity at the elbow and attempted flexion of the lower extremity at the knee. Lead pipe rigidity, seen in parkinsonism, is, in contrast with spastic rigidity, characterized by a more or less constant degree of rigidity throughout the entire range of motion, much as if one were manipulating a thick piece of solder. Cogwheel rigidity, also seen in parkinsonism, may accompany lead pipe rigidity or occur independently. After testing for these forms of rigidity, one should then test for gegenhalten at the elbow by repeatedly extending and flexing the arm, feeling carefully for any increasing rigidity. Rest tremor is most noticeable when the extremity is at rest, as for example when the patient is seated with the hands resting in the lap. Postural tremor becomes evident when a posture is maintained, as, for example, when the arms are held straight out in front with the fingers extended and spread. This is an especially valuable sign and the physician should remain alert to its occurrence throughout the interview and examination. In severe cases the flinging movements of the extremity may actually throw the patient off the chair or bed. Characteristically, the restlessness is worse when lying down or seated, and most patients find some relief upon standing or moving about.

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