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The only after-effects you may feel are due to bacteria and viruses escaping from dead parasites! Pet Parasite Program Pets have many of the same parasites that we get buy discount lamisil 250 mg on-line, including Ascaris (common roundworm) buy lamisil cheap, hookworm lamisil 250mg, Trichinella purchase lamisil toronto, Strongyloides, heartworm and a variety of tapeworms. Every pet living in your home should be deparasitized (cleared of para- sites) and maintained on a parasite program. But if you are quite ill it is best to board it with a friend until you are better. Your pet is part of your family and should be kept as sweet and clean and healthy as yourself. Parsley water: cook a big bunch of fresh parsley in a quart of water for 3 minutes. Pets are so full of parasites, you must be quite careful not to deparasitize too quickly. The purpose of the parsley water is to keep the kidneys flowing well so dead parasite refuse is elimi- nated promptly. Treat dogs daily, for in- stance a 30 pound dog would get 3 drops per day (but work up to it, increasing one drop per day). Begin by pouring salt and iodine on the mess and letting it stand for 5 minutes before cleaning it up. Finally, clean your hands with diluted grain alcohol (dilute 1 part alcohol with 4 parts water) or vodka. Wormwood capsules: (200-300 mg wormwood per cap- sule) open a capsule and put the smallest pinch possible on their dry food. Parsley Black Walnut Wormwood Clove Cap- Water Hull Tincture Capsule Dose sule Dose Dose (Size 0 or 00) Week teaspoons on drops on food, open capsule, open capsule, food cats twice per put smallest put smallest week, dogs pinch on food pinch on food daily 1 1 or more, based on size 2 1 or more 1 3 1 or more 1 or more, 1 based on size 4 1 or more 1 or more 1 1 5 and 1 or more 1 or more 1 1 onward Parasites Gone, Toxins Next Healing is automatic when you clean up your body tissues. Launder the sheets and towels yourself at a Laundromat with borax and/or washing soda. When you get better on vacation, let that be your inspiration to move from your home. Select a warm climate where you can spend your time outdoors in the shade most of the day. Have no refrigerator, air conditioner, clothes dryer, hair dryer, new clothing, detergent. Watch For Bacteria In the later stages of cancer the tumors are more and more infected with the common bacteria Salmonella, Shigella, and Staphylococcus aureus. Now, more than ever, must you stay off dairy products (except for boiled milk), do the Bowel Program, take Lugol’s. Zap your pet along with yourself by holding them and touching a bare spot such as nose or paw. If you have taken a risk, zap yourself as soon as you get home to minimize the damage. Cancer could be completely eliminated in the entire country if laws required testing for solvents in animal feeds and human food and products. Another reason for propyl alcohol pollution (and other pol- lutants) in our food are the chemicals used by manufacturers to sterilize their food handling equipment. Sanitizing solutions may be safely used on food-processing equipment and utensils, and on other food-contact articles as specified in this section, within the following prescribed condi- tions: (a) Such sanitizing solutions are used, followed by adequate draining, before contact with food. In addition to use on food processing equipment and utensils, this solution may be used on beverage containers, including milk containers and equipment and on food-contact surfaces in public eating places. Even if there were regulations governing removal of sani- tizing solutions, the overwhelming truth is missed: that nothing can ever be completely removed after it has been added. Perhaps they be- lieved that small amounts–too small to measure with an ultra- violet spectrophotometer–could surely do no harm. Aflatoxin A common mold found on bread, nuts and fruit and in beer, apple cider vinegar and syrups, produces aflatoxin. This is what prevents you from detoxifying tiny bits of propyl alcohol that get into your body! Vitamin C helps your body detoxify all the mold toxins I have tested, including aflatoxin. For ten years or more you poi- soned your body with freon, fiberglass, asbestos, mercury, lead, copper, etc. Your aflatoxin-ed liver tamin C powders in closable then lets propyl alcohol build plastic shakers. Somewhere, over the years, you pick up the intestinal fluke in a hamburger or from a pet or person. So cure yourself, prevent reinfection, heal the damage and go through life without this sword hanging over you. Over 100 consecutive case histories of cured cancer vic- 16 tims are the subject of another book along with more detailed instructions and suggestions. It is caused by the same parasite but the solvent is benzene instead of propyl alco- hol. When the body can no longer detoxify benzene it soon may not be able to detoxify propyl alcohol. Food mold, at the base of the propyl alcohol problem, is also at the base of the benzene problem. Zearalenone, a mycotoxin I find in popcorn, corn chips, and brown rice specifically inhibits detoxification of benzene. Several common mold toxins inhibit the immune system, too, specifically those white blood cells that are supposed to eat and destroy viruses. Benzene goes to the bone marrow where T-cells are made, and to the thymus where T-cells are programmed, two big blows to the immune system. Benzene, a most unthinkable pollutant, is widespread in ex- tremely small amounts. Grilled food, smoked food, hot dogs and lunch meats with “smoke flavor” all have benzopyrenes—even toast has it. Zap daily until you feel completely well: no night sweats, no coughing, no symptoms of any kind. You will be able to resume your plans for education, professional life, personal relationships, free of the sword hanging over you. Always take Vitamin B2 (three 100 mg tablets three times a day) and vitamin C (1/8 tsp. Plan For The Future After you are well again, you may wish to indulge in some philosophy. After all, rabies virus comes to us from animals, and many encephalitis viruses come from mosquitoes. Should the government agencies responsible for food and product safety be depoliticized? Tapeworm Stage or Mites The fascinating story of how we really “catch” a cold kept me spellbound for a year. My evidence comes from a tapeworm stage, cysticercus of Diphyllobothrium erinacea, the mites Sarcoptes and Dermatophagoides, and our own colon bacteria, E. The tapeworm stage flies in the dust as eggs, you can trap these by setting out a pint jar with a little water in it. If you have a household pet, you will always be able to find a tapeworm stage in your sponge or in a dust sample you collect from the table or kitchen counter in the morning. Eating the dust off the tables, inhaling the dust, and eating off surfaces wiped by the kitchen sponge happens to everyone. There is a good chance you will have one that is not given, because the list is so incomplete. Again, you will not find Adenovirus beeping its characteristic frequency out of your mite specimen. Possibly, it is too faint; it must multiply and create a loud chorus before you can hear it. Then the tape eggs hatch into the cysticercus stage, which promptly gets to the liver. If you can do both, you may be able to see which organ allows the virus to replicate after it emerges.

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The majority of pregnant women with asymptomatic bacteriuria can be treated success- fully with a short course (3–5 days) of the antimicrobial regimens listed in Box 2 generic 250mg lamisil. An alternative regimen is to use nitrofurantoin macrocrystals buy generic lamisil 250 mg on-line, 100 mg given once a day at bedtime purchase lamisil pills in toronto, for 7–10 days (Leveno et al order lamisil without prescription. Regardless of the antimicrobial regimen used, approx- imately two-thirds of the patients will be cured and remain bacteriuria-free for the remainder of the pregnancy; approximately one-third of the patients will experience a recurrence and require further therapy. Symptomatic infection of the lower urinary tract (acute cystitis) can be treated with a variety of antimicrobial regimens similar to that used for asymptomatic bacteriuria, with 44 Antimicrobials during pregnancy Table 2. These women can gener- ally be treated as outpatients with an oral antimicrobial agent for 3–5 days (Box 2. Symptomatic infection of the upper urinary tract or acute pyelonephritis is a relatively common complication occurring in approximately 1 percent of all pregnant women. Many of these women experience nausea and vomiting, are dehydrated, and are unable to tolerate oral antimicrobial therapy. These women should be hospitalized for intra- venous antibiotic therapy with one of the regimens listed in Box 2. As many as 25 per- cent of women with acute pyelonephritis during pregnancy will experience another such episode during either the antepartum or postpartum periods. Because of the attendant risks associated with acute pyelonephritis during pregnancy, such as septic shock and pre- mature labor, consideration should be given to continuous suppressive antimicrobial ther- apy following an initial episode of pyelonephritis. One particularly useful regimen is nitrofurantoin macrocrystals, 100 mg orally every night (Hankins and Whalley, 1985). The majority of cases occur in the third trimester, although such infections may occur, secondary to invasive procedures such as amniocentesis or chorionic villus sampling, in the late first or early second trimester. There is no unanim- ity of opinion regarding specific antimicrobial regimens for the treatment of acute chorioamnionitis during pregnancy. Vaginitis The two most common forms of vaginitis during pregnancy are fungal and protozoan. Pregnant women with vaginitis secondary to fungi, such as Candida species, can be treated with a variety of antifungal agents which are listed in Box 2. Although there is no scientific evi- dence that metronidazole is either teratogenic or causes adverse effects in the embryo/fetus, the manufacturer has issued a stern warning regarding its use during the first trimester of pregnancy. Fortunately, many of the patients with trichomoniasis can be treated with antimonilial agents until they are past the first trimester and then treated with metronidazole – the only effective treatment for this protozoan infection. Sexually transmitted diseases Syphilis is a relatively common sexually transmitted disease in pregnant women, espe- cially in the indigent population. Pregnant women with syphilis who are allergic to penicillin present another therapeutic dilemma. For example, erythromycin may eradicate the infection in the pregnant woman, but may not prevent congenital syphilis (Preblud and Williams, 1985; Wendel and Gilstrap, 1990; Wendel et al. Another agent, tetracycline, may be associated with significant yellow-brown discoloration of the fetal deciduous teeth and is currently not recommended for use in the latter half of pregnancy (Genot et al. The cur- rent recommended approach to the pregnant patient with syphilis who is allergic to penicillin is to utilize penicillin desensitization, as outlined in Box 2. Penicillin is the ideal antibiotic choice for the treatment of syphilis during pregnancy (Bofill and Rust, 1996). Chlamydia trachomatis may be isolated in up to 30 percent of women of lower socioeconomic status (unpublished observations, 1990). Erythromycin base or stearate in a dose of 500 mg four times a day for 7–10 days will generally prove satisfactory for the treatment of chlamydial infections during pregnancy. Other antimicrobial agents such as amoxi- cillin (with or without clavulanic acid), clindamycin, or azithromycin (1 g single oral dose), may prove satisfactory in eradicating chlamydial infections in pregnant women who are unable to tolerate erythromycin because of its gastrointestinal side effects. Viral infections Fortunately, the majority of viral infections encountered during pregnancy do not require any specific therapy. Patients with life-threatening disseminated viral infections, such as varicella zoster or herpes infections, should be treated with acyclovir, as the benefits clearly outweigh any potential risk. Acyclovir is not recommended for the routine treatment of localized genital tract herpes simplex virus infections (Scott et al. Vaccines Fortunately, most pregnant women do not require vaccination during pregnancy. However, as with drugs and medications, occasionally a woman will be given an immunization when she does not realize she is newly pregnant. Probably the two most common immunizations given in this instance are rubella and influenza. Needless to say, the mortality to both mother and neonate from tetanus is extremely high, and active immunization to the mother will pro- vide protection to the neonate in the range of 80–95 percent or greater if the mother has received at least two doses 2 weeks before delivery (Faix, 1991; Hayden et al. There are no reports of adverse fetal effects from any of these inactivated bacterial vaccines. The dose schedule recommended for hepatitis B immune globulin and for vaccina- tion is summarized in Table 2. However, several authors have recommended its use in susceptible pregnant women if it can be given within 96 h (Enders, 1985; Faix, 1991; MacGregor et al. Enders (1985) has published the most compelling data to support this recommendation. Although pregnancy is considered contraindicated in women within 3 months of receiving the rubella vaccine, the actual risk of congenital rubella syndrome from maternal vaccination would appear to be extremely small, if it exists at all (Preblud and Williams, 1985). Measles and mumps vaccines are also considered contraindicated during pregnancy, although pooled immune globulin (0. Obviously the benefits of rabies vaccination (considering the high mortality of rabies of nearly 100 percent) far outweigh any theoretical risk to the fetus, which is actually unknown. Although influenza vaccines are not routinely recommended for all pregnant women, they may be efficacious in cer- tain pregnant women with significant medical complications. The physician is concerned with whether a specific medication is safe for the fetus, remaining cognizant that most car- diac medications are chronically used to treat life-threatening conditions, and that these therapeutics cannot be discontinued when pregnancy is first diagnosed (Little and Gilstrap, 1989). Hence, embryos/fetuses of women with cardiovascular disease are exposed to these medications during the critical period of organogenesis (i. Since heart disease may be inherited in a multifactorial or polygenic fashion, pregnant women with many forms of heart disease may give birth to a newborn with congenital heart disease, and this mal- formation may in turn be blamed by both the patient and her attorney on specific car- diac medications. Scientific studies regarding the efficacy and safety of most cardiac medications during pregnancy are not conclusive, but the life-threatening nature of cardiovascular disease mandates that treatment be provided, even during pregnancy. The few investigations that are available indicate that dose and timing adjustment may be necessary because of (1) decreased drug serum concentrations (Cmax and steady state); (2) decreased half-life; and (3) increased clearance (Table 3. Cardiovascular medications may be classified into several categories: antiarrhythmic, cardiac glycosides, anticoagulants, diuretics, antihypertensives, and antianginals. This classification may prove useful in predicting both the efficacy and the toxicity of a specific agent (Brown and Wendel, 1989). Antiarrhythmics have been classified into six classes according to their major mode of action or effect (Vaughan Williams, 1984), as shown in Tables 3. Lidocaine Commonly used as an amide local anesthetic, lidocaine is also effective in the treatment of ventricular and supraventricular tachycardias. Lidocaine rapidly crosses the placenta and fetal levels reach about 50 percent of maternal levels within less than an hour 54 Cardiovascular drugs during pregnancy (Rotmensch et al. Lidocaine’s half-life is twice as long in the fetus/neonate (3 h) than in the mother (1. Importantly, most information available regarding pharmacokinetics of lidocaine in pregnant and postpartum women and newborns is from studies of regional or local anesthesia (Rotmensch et al. No published data are available on lidocaine from women who received the drug for cardiac arrhythmias. However, local anesthetics given in toxic doses may result in central nervous system and cardiac side effects in both the mother and the fetus. Lidocaine is not known to be ter- atogenic at acute therapeutic levels in humans or in chronic doses in animals (Fujinaga and Mazze, 1986; Heinonen et al. Toxicity risk is mini- mal when maternal lidocaine levels are maintained at less than 4 mg/mL (Bhagwat and Engel, 1995). Amide-type local anesthetics given for paracervical block are associated with spasm of the uterine arteries, causing decreased uterine blood flow. Procainamide Another amide compound, procainamide, is used to treat ventricular tachycardia. There is little information regarding the pharmacokinetics of this drug during pregnancy.

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Indicated laboratory tests and radiologic procedures should be per- formed without hesitation to properly guide life-saving surgical procedures purchase lamisil 250mg mastercard. Anesthetic adjuncts order 250 mg lamisil overnight delivery, or other ‘nonanesthetic’ drugs and medications during the pre- purchase cheap lamisil, intra- best lamisil 250mg, and post-operative peri- ods may also adversely affect the fetus. Regional techniques (spinal and epidural procedures, paracervical and pudendal blocks) result in physiologically important fetal exposure to clinically significant anesthetic levels. Anesthetic potency is related to protein-bound fraction, and the amount of binding determines the duration of action. Highly protein bound anesthet- ics are lipid soluble and readily cross the placenta (Morishima et al. Malformations were not increased in frequency among offspring of women who used procaine, lidocaine, benzocaine, or tetracaine during the first trimester, and there were no adverse fetal effects when these agents were utilized at any time dur- ing pregnancy (Heinonen et al. No investigations of bupivacaine, chlorprocaine or prilocaine have been published with regard to their teratogenic effects. Transient newborn neurobehavioral changes in infants whose mothers received local anesthetic agents have been reported, and vary from mod- erate for regional blocks (Rosenblatt et al. Following first trimester exposure there was a significantly increased frequency of inguinal hernias in the epinephrine-exposed group (Heinonen et al. However, it is unlikely that 118 Anaesthetic agents and surgery during pregnancy epinephrine is a teratogen. Epinephrine is also used as a test agent to detect intravascu- lar injection of local anesthetics. It has been suggested that bradycardia is second- ary to vasoconstriction of uterine artery caused by the anesthetic agent (Fishburne et al. Thus paracervical blocking techniques are not recommended in the presence of fetal heart rate abnormalities or compromised uterine blood flow (Carlsson et al. The fetus will be exposed to a variety of agents that include narcotics, paralyzing agents, and inhalational anesthetic agents. Thiopental and ketamine Thiopental and ketamine are narcotic anesthetics, and are given intravenously for rapid induction of anesthesia prior to the intubation and initiation of inhalational anesthetic agents. The frequency of con- genital malformations was not increased in human or animal studies (Heinonen et al. Ketamine is rarely used in obstetrics, except for rapid anesthe- sia in emergency operative vaginal deliveries. Ketamine presents two problems: (1) clin- ically significant increase in blood pressure; and (2) significant maternal hallucinations. Perhaps 20 percent of patients have lowered cholinesterase activity, and pregnancy reduces cholinesterase activ- ity in general. Therefore, pregnant patients probably require a smaller dose of succinyl- choline than nongravid women. Newborns may be exposed to enough drug to experience neuromuscular blockade that requires supportive therapy. Other common agents used for neuromuscular blockade are vecuronium bromide, pancuronium bromide, and atracurium besylate (Box 6. Unlike succinylcholine, which is a depolarizing agent, these three neuromuscular blocking agents are nonpolarizing in action. However, according to its manufacturer, atracurium is potentially teratogenic in animals. Neither ether nor cyclopropane is commonly used in present-day anesthetic techniques, and there have been no adequate human studies regarding potential teratogenicity of either of these agents (Friedman, 1988). Halothane and other halogenated agents Halogenated agents are often used to supplement the standard nitrous oxide, thiopental and muscle relaxant regimens for balanced general anesthesia. Use of halogenated agents decreases maternal awareness and recall, allows for a higher percentage of inspired oxy- gen, and results in higher fetal oxygen concentrations (Shnider and Levinson, 1979). The prototype halogenated anesthetic agent was not found to be associated with an increased risk of congenital malformations in children whose mothers received this agent during the first 4 months (Heinonen et al. Increased fetal loss, growth retardation, malformations, and behavioral abnor- malities have been reported with the use of halothane in animal studies (Friedman, 1988). No epidemiologic studies of congenital anomalies with the use of the other halo- genated agents (enflurane, methoxyflurane, isoflurane) have been published. These agents were reported to cause a variety of malformations in animal studies at doses many times those used in humans (Friedman, 1988). Placental transfer of enflurane and halothane in women who were delivered via Caesarean section had no apparent adverse effects on Apgar scores, newborn acid–base status, and early neonatal neurobehavioral scores. Significant levels of both of these agents were achieved in the fetus at about 50–60 percent of maternal concentrations (Abboud et al. Halogenated agents have also been reported to be associated with an increase in blood loss in the mother at the time of Caesarean section in some studies (Gilstrap et al. Increased blood loss from uterine relaxation may occur, especially in prolonged high- dose use. Otherwise, it seems apparent that halogenated agents are safe for both mother and fetus, although the data are not conclusive. Nitrous oxide Nitrous oxide is the most commonly used inhalation anesthetic agent in obstetrics, and is usually part of a balanced general anesthetic regimen that includes: a fast-acting 120 Anaesthetic agents and surgery during pregnancy barbiturate (e. The frequency of congenital anomalies was not increased among more than 500 infants exposed to nitrous oxide during the first trimester (Heinonen et al. As with many other agents, nitrous oxide has been reported to be associated with increased fetal resorption, growth retardation, and congenital anomalies in animal studies (Friedman, 1988; Mazze et al. Lower nitrous oxide concentrations (50 percent) have been used with higher oxygen concentrations (50 percent), responding primarily to concerns that higher nitrous oxide concentrations may be associated with neurobehavioral alterations. Altered neonatal neurobehavioral effects are associated with nitrous oxide and halothane and have been demonstrated in animal studies (Koeter and Rodier, 1986; Mullenix et al. Current recommendations are to use lower concentrations of nitrous oxide, higher concentrations of oxygen, and to add a halogenated agent to the regimen. Three very potent synthetic opioid analgesics (fentanyl, sufentanil, and alfe- tanil) (Box 6. Fentanyl is also used in combination with a neuroleptic agent (droperidol) for the same indica- tions. None of these narcotic agents has been shown to be teratogenic in a variety of ani- mal studies. First trimester exposure to meperidine was not associated with an increased frequency of congenital anomalies among 268 infants (Heinonen et al. Intravenous fentanyl was not asso- ciated with low Apgar scores or neonatal respiratory depression compared to controls (Rayburn et al. Three synthetic narcotic analgesics (fentanyl, sufentanil, and alfetanil) have been used as an adjunct to epidural analgesia during labor (Ross and Hughes, 1987). However, neonatal respiratory depression is a risk with use of these agents during labor. Maternal mortality nonobstetric surgery is no greater than mortality in the nonpregnant patient. Risks to the fetus from surgery are probably related more to the specific condition requiring the surgery than to the surgery itself. Among 2565 women who underwent surgery during the first or second trimester compared to controls, the frequency of spontaneous abortion in women undergoing surgery with general anesthesia was greater for gynecologic procedures compared to surgery in other anatomic regions (risk ratio of 2 versus 1. Cholecystitis and biliary tract disease are the most common surgical conditions fol- lowing appendicitis and occur in approximately 1–10 per 10 000 pregnancies (Affleck et al. Laparoscopic surgery morbidity and mortality was no dif- ferent from the open cholecystectomy (Affleck et al. Surgical procedures for intestinal obstruction, inflammatory bowel disease, breast dis- ease, and diseases of the ovary are also relatively common. Surgery for cardiovascular disease during pregnancy is less common, but procedures such as mitral valvotomy (el- Maraghy et al. Anesthesia for nonobstetrical surgery may be delivered via either general endotracheal or regional techniques. The choice depends on: (1) procedure to be performed; (2) emer- gent nature of the procedure; (3) length of time the patient has been fasting; and (4) pref- erences of the surgeon and the patient. General anesthesia should be accomplished through a balanced technique using nitrous oxide, oxygen, thiopental, succinylcholine, and a halogenated agent.

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Summarized version of proposal: efectve implementaton of a structured psychoeducaton programme among caregivers of schizophrenia patents in the community purchase lamisil uk. Those caregivers’ of patients with uncontrolled or unstable medical illness requiring admission i order 250mg lamisil otc. Data on demography of caregiver discount 250mg lamisil with mastercard, patient and staff will be recorded in the Caregivers demographic data form (Appendix A) discount lamisil 250mg mastercard, Patient’s demographic data form (Appendix B) and in the Staff demographic data (Appendix F). Questionnaire on the Feasibility of the Psychoeducation Program (Appendix E) will be used to assess the opinion of the staff conducting the Psychoeducation Modules. Data on pretest and post test results will be recorded using the Pre & post-test report form (Appendix G). Data on Readmission rate and default on follow up will be recorded at the end of the study using the initial demography form (Appendix C), which will be flled up by the staff. Plan for data analysis & interpretation The raw data will be processed and entered for data analysis according to the different phases, starting as soon as the patients are recruited, until end of study. Summarized version of proposal: efectve implementaton of a structured psychoeducaton programme among caregivers of schizophrenia patents in the community. Effects of a mutual support group for families of Chinese people with schizophrenia: 18 month follow-up. Psychoeducation: A Basic Psychotherapeutic Intervention for Patients with Schizophrenia and Their Families. Eugino Aguglia et al: Psychoeducational intervention and prevention of relapse among schizophrenic disorders in the Italian community psychiatric network. Evidence Based Practices, Shaping Mental Health Services Toward Recovery Draft Version 2003. Li Z, Arthur D: Family education for people with Schizophrenia in Beijing, China: randomized controlled trial. Psychoeducation and compliance in the treatment of schizophrenia: results of the Munich Psychosis Information Project Study. Bangsa/Race  Melayu/Malay  Cina/Chinese  India/indian  Lain-lain/Others Nyatakan/specify………………………………… Summarized version of proposal: efectve implementaton of a structured psychoeducaton programme among caregivers of schizophrenia patents in the community. Taraf Perkahwinan/Marital status  Bujang/Single  Kahwin/Married  Cerai/Divorced  Janda/Duda/Widow/Widower 6. Taraf pendidikan/educational level  Tidak bersekolah/no formal education  Rendah/Primary  Menengah/Secondary  Diploma/Teknikal  Universiti/Tertiary 9. Summarized version of proposal: efectve implementaton of a structured psychoeducaton programme among caregivers of schizophrenia patents in the community. All of them may not apply to (Name), but please try to answer them to the best of your knowledge. During the past 30 days, how often did you help (Name) with, or remind (Name) to do things like grooming, bathing or dressing? During the past 30 days, how often did you help, remind or encourage (Name) to take (his/her) medicine? During the past 30 days, how often did you try to prevent or stop (Name) from doing something embarrassing? During the past 30 days, how often did you try to prevent or stop (Name) from doing excessive demands for attention? Was it: 1 2 3 4 not at all very little some a lot Summarized version of proposal: efectve implementaton of a structured psychoeducaton programme among caregivers of schizophrenia patents in the community. This may produce an unsatisfactory immune response, incapable of protecting the recipient from life threatening infections (Lewis, Reimer & Dixon, 2001). Poor vaccine storage could lead to an increase in the morbidity and mortality rates of the diseases preventable by vaccination. Very little information is available about the extent to which private physician clinics in Malaysia meet quality assurance needs for vaccine storage. Faulty handling and storage may occur and maybe are more common than is generally believed. This study aims to evaluate vaccine storage practices and the effectiveness of an intervention package among private physician clinics in Malaysia. Correct placement of the vaccine refrigerator Summarized version of proposal: vaccine storage in Private Practce. To develop a practical intervention package to improve vaccine storage practices among private health clinics that is sustainable. To evaluate the intervention package to improve vaccine storage practices among private health clinics including: a. To use the fnding from the study to improve vaccine storage among private health clinics in Malaysia. Registered nurses from the public health clinics will be identifed as research assistants as they are well versed with vaccine storage practices and had contacts with private clinics when they obtained monthly feedback on vaccination returns from the clinics. The trial consisted of four audits with the implementation of the intervention package carried out concurrently with the audits. Researchers target that the baseline audit is completed within a week of commencement to reduce bias (communication between the private clinics). In the event there are problems in obtaining consent, research nurses will contact research team members from the respective states who will then personally contact the private practitioner by phone. Once consent is obtained, the intervention package will be handed over to the clinic staff and the audit carried out using the audit checklist (refer Appendix A). Feedback will be given simultaneously if any discrepancies were noted during audit process. Obtain list of private clinics offering vaccinations in each region Selection of private clinics for study in each region (minimum n = 110) Obtain consent from Doctor-in-charge Evaluation of vaccine storage at clinic Phase 1: First audit Implementation of Intervention Package (Baseline) Evaluation of vaccine storage at clinic Phase 2: Second audit Implementation of Intervention Package (1 month post intervention) Evaluation of vaccine storage at clinic Phase 3: Third audit Implementation of Intervention Package (3 months post intervention) Evaluation of vaccine storage at clinic Phase 4: Forth audit Implementation of Intervention Package (12 months post intervention) Figure Y: Flow chart of study design Following the audit, the research nurses will answer any queries by clinic staff pertaining to good vaccine storage practice and will reinforce the six essential messages by showing the power point presentation. They will then give a copy of audit checklist to the participating clinic after it has been signed by a named personnel, thank clinic staff and remind them of subsequent visit (but not to mention any dates). Fidelity test is to monitor quality of implementation of the intervention by research nurses. A random sample of one-third of all participating clinics will be selected for the conduct of this fdelity test by supervisors. Phase 2: Second Audit (1 Month Post intervention) In the second audit, a tool to address the value of survey will be circulated to private practitioners (refer Appendix C). This asks questions on practicality of survey to the private practitioner to obtain feedback/ suggestions for improvement of the intervention package. The research nurses will hand-deliver this questionnaire to the private practitioner at the end of the second audit and collect it back from the clinic staff within 2 days. The rest of the audit process will not differ from fow of the baseline audit except the fdelity test will be conducted on every third clinic in the list of participating clinics, excluding the clinics that already had the fdelity test done in phase 1. Phase 3 & 4: Third and Forth Audit The schedule for all audits will be prepared in advance. The work fow for these audits will be similar to that of the second audit, except that the fdelity and value of survey tools will not be administered. Intervention package The research team emphasized practicality, sustainability and the provision of incentives in the development of the intervention package. Additional incentives include two stickers, for the refrigerator and a certifcate of vaccine storage status. The training session on recommended vaccine storage practice for private physician clinics’ staff requires research nurses to give immediate feedback to all accompanying staff during the audit process and advice on temperature charting and maintenance. To reinforce learning, research nurses will show a power point presentation on recommended vaccine storage practice followed by a question and answer session with all clinic staff. Study type This is a quasi-experimental study (non-controlled community trial) conducted in four administrative regions in Malaysia. There is no randomization nor a control group as researchers felt that it would not be ethical not to intervene in the event there are problems in vaccine storage. Ethical considerations Researchers applied for approval prior to conduct of this study. Consent will be obtained from practitioners at the selected clinics prior to the study. This was to ensure that this proposed incentive does not contravene any ethical or medico-legal issues. Variables Scale of Variables Operational Defnition Measurement Yes/No Two door/top loading refrigerator Appropriate type of refrigerator to store vaccines (nominal/categorical) Yes/No Dedicated refrigerator for vaccine Availability of a dedicated refrigerator for vaccines. Availability of a dedicated refrigerator for vaccines Yes/No Fulflled all 6 criteria# 3. Daily monitoring of internal refrigerator temperature This consisted of criterion #1 to #6 and also allowed the Yes/No Fulflled all 6 criteria & drug@ refrigerator to also store drugs together with vaccines.

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