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Although estimates vary, studies suggest that at least 10% of former inmates are homeless after release. In addition, sex offenders face a series of restrictions on where they can live upon their return to the community. The Federal Choice Voucher Program, which provides low-income individuals with vouchers to use for housing, bans offenders convicted of felonies. Consequences for communities When offenders are released from prison, they return to the communities from which they came-and just as prison admissions are not drawn equally from communities across the country, returning offenders do not return to all communities equally. Communities where returning individuals are concentrated tend to be disadvantaged in terms of low income and high crime, among other things. Specifically, human capital, social networks, social capital, collective efficacy, and informal social control are disrupted in ways that have deleterious effects on the offenders, the community and society at large. Human capital refers to the skills and personal resources individuals bring to their community. Social networks refer to the links individuals have with friends, family, and co-workers. Offenders tend to have strong social ties to some close friends and family members, and relatively fewer and looser social ties with others. When they return to the community, offenders are unable to access the support and assistance looser ties may provide during reentry, and may face frayed ties with family as a result of incarceration. Reentry 357 community to maintain adherence to informal norms (as opposed to laws) to engage in pro-social behavior. Current research suggests that there is no "silver bullet" that will solve every issue and thereby reduce recidivism of returning offenders-the reentry problem is multifaceted. More information is needed about offenders returning to the community, the impact of programs and policies, and the cost-effectiveness of different options for punishment. In addition, the models recognize that successful reintegration requires the willingness for society to engage in the reentry movement-it cannot be done by the justice system alone. Getting a job and education Education remains key for successful prisoner reentry, and recent suggestions have called for the development of a reentry education model. Department of Education, Tolbert outlined an education continuum that strengthens the connection between education services in the prison and community. Other recommendations include the use of cognitivebased skills training in education and workforce training, as this approach has been shown to help reduce recidivism. Reentry 359 An increasing number of inmates are now participating in post-secondary programs, often through partnerships between community colleges and prisons. To be sure, collaboration between prisons and community colleges is complex, particularly with respect to outside teachers assimilating well to the prison infrastructure and prison staff being supportive of a program that some see as special treatment. Programs directed at the demand side of the equation include transitional employment, which can be accomplished through partnerships with local faith, business, justice, and social-service organizations. More than 100 cities in 23 states have adopted such a policy as a way of leveling the playing field for people with criminal records. At this point, more evidence may be needed here, involving studies of actual job seekers-with more varied demographics on job seekers and information on actual hires-as opposed to data on "call backs" alone. Physical and mental health Collaboration between criminal justice and mental-health professionals can assist the mentally ill offender upon return. In particular, a parole agent serves as a case manager with a more therapeutic approach to reentry than traditional forms of supervision. Reentry 361 Other reentry efforts seek to connect eligible people leaving prison and jail to mental-health care and substance-use treatment. In early 2017, the Council of State Governments released guidelines for assisting people leaving prison with health-care services. In particular, some research is not methodologically rigorous enough to lead to strong conclusions. Nonetheless, several studies on prison visitation showed positive impacts on recidivism, suggesting that maintaining family bonds while an offender is incarcerated may improve successful reentry. In addition, the case manager served as an advocate for families to obtain needed services and was available to provide crisis intervention. The event brought together leading researchers who had examined the topic of families and incarceration over the previous decade. Their recommendations included providing greater educational support for children who have incarcerated parents, and building on promising intervention points for children and parents, such as including visitation support, prison nurseries, and community alternatives to prison. Difficulties in finding housing can be particularly acute for sex offenders, who face very restrictive laws as to where they can live.

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Ensure that patients with this fracture are maintained in properly sized rigid cervical collar until specialized care is available. Axis (C2) Fractures the axis is the largest cervical vertebra and the most unusual in shape. Thus it is susceptible to various fractures, depending on the force and direction of the impact. Axis fractures of note to trauma care providers include odontoid fractures and posterior element fractures. Odontoid Fractures Approximately 60% of C2 fractures involve the odontoid process, a peg-shaped bony protuberance that projects upward and is normally positioned in contact with the anterior arch of C1. Type I odontoid fractures typically involve the tip of the odontoid and are relatively uncommon. In children younger than 6 years of age, the epiphysis may be prominent and resemble a fracture at this level. In adults, the most common level of cervical vertebral fracture is C5, and the most common level of subluxation is C5 on C6. Other injuries include subluxation of the articular processes (including unilateral or bilateral locked facets) and fractures of the laminae, spinous processes, pedicles, or lateral masses. The incidence of neurological injury increases significantly with facet dislocations and is much more severe with bilateral locked facets. Note the anterior angulation and excessive distance between the spinous processes of C1 and C2 (double arrows). They are caused by flexion about an axis anterior to the vertebral column and are most frequently seen following motor vehicle crashes in which the patient was restrained by only an improperly placed lap belt. Chance fractures can be associated with retroperitoneal and abdominal visceral injuries. Due to the orientation of the facet joints, fracturedislocations are relatively uncommon in the thoracic and lumbar spine. These injuries nearly always result from extreme flexion or severe blunt trauma to the spine, which causes disruption of the posterior elements (pedicles, facets, and lamina) of the vertebra. The thoracic spinal canal is narrow in relation to the spinal cord, so fracture subluxations in the thoracic spine commonly result in complete neurological deficits. Simple compression fractures are usually stable and often treated with a rigid brace. Burst fractures, Chance fractures, and fracture-dislocations are extremely unstable and nearly always require internal fixation. Because these fractures most often result from a combination of acute hyperflexion and rotation, they are usually unstable. People who fall from a height and restrained drivers who sustain severe flexion with high kinetic energy transfer are at particular risk for this type of injury. The spinal cord terminates as the conus medullaris at approximately the level of L1, and injury to this part of the cord commonly results in bladder and bowel dysfunction, as well as decreased sensation and strength in the lower extremities. Patients with thoracolumbar fractures are particularly vulnerable to rotational movement, so be extremely careful when logrolling them. However, because only the cauda equina is involved, the probability of a complete neurological deficit is much lower with these injuries. Radiograph showing a Chance fracture, which is a transverse fracture through the vertebral body. These deficits also can result from the energy transfer associated with a highvelocity missile. Penetrating injuries of the spine usually are stable unless the missile destroys a significant portion of the vertebra. R A dio g R A phic e vA luAtioN Both careful clinical examination and thorough radiographic assessment are critical in identifying significant spine injury. Current guidelines for spinal motion restriction in the prehospital setting allow for more flexibility in the use of long spine boards and cervical collars.

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Committing crime while under the influence of drugs, being a member of a criminal gang, or being convicted of the current crime while on legal restraint. Risk Assessment in Sentencing 89 "shall give due consideration to the danger that the use of criminal-history provisions to increase the severity of sentences may have disparate impacts on racial or ethnic minorities, or other disadvantaged groups. Eighty-four percent of state prisoners age 24 and younger at release were rearrested for non-traffic offenses within five years, compared with 69% of state prisoners age 40 and older at release. The rearrest rates for any non-traffic offense within five years after release were 78% for male prisoners and 68% for female prisoners. Race the Bureau of Justice Statistics has reported that "[b]y the end of the fifth year after release from prison, white (73. The history of de jure racial discrimination in the United States, and continuing de facto discrimination, make race a highly "suspect" criterion, especially when it is used to support policies that disfavor minorities and favor whites (which is the most likely scenario in the sentencing 47. The five risk factors that the Commission categorized as "psychosocial" that were found most frequently on these existing instruments were: whether the offender was currently employed, his or her highest level of education, whether the offender had criminal friends, the degree of social or marital support available to the offender, and whether the offender had a stable residence. Michael Tonry has argued that the use of any of these as risk factors for recidivism in sentencing both "systematically disadvantages minority defendants" and "in effect punish[es] lawful life-style choices that in a free society people are 49. Similarly, a remarkable recent study of over 47,000 released prisoners in Sweden assessed the risk of conviction for a violent felony during the first two years after release. Employ risk assessment to sentence nonviolent offenders at low risk of recidivism to community sanctions or to a shortened period of incarceration. The sentencing judge should be required to state on the record a cogent reason whenever he or she disregards the sentence-lowering implications of a low-risk designation. Procedures such as those in Virginia by which a finding of high risk alone-without any finding of heightened culpability-can triple the sentence otherwise given to those convicted of sex crimes clearly violates the limits imposed by the "limiting retributivism" theory of punishment. Charge state sentencing commissions with conducting local empirical validations of any proposed risk-assessment instrument and with vigorously debating the moral and social implications of relying on the specific risk factors to be included on the instrument. In the words of the Model Penal Code, state sentencing commissions "shall develop actuarial instruments or processes to identify offenders who present an 2. In order for it to be useful in sentencing, "risk assessment must be both empirically valid and perceived as morally fair across groups. Yet as Richard Frase has argued, "with respect to low-risk assessments, can we afford to renounce any major sources of mitigation, given our inflated American penalty scales and overbroad criminal laws? In the words of another reform advocate, sentencing guidelines provided a "way of introducing policy and purpose into what has largely been a normless sanctioning system. Many reformers expressed particular concern that short-term "gettough" passions would create unavoidable political pressures upon legislatures to enact unduly severe sentences that would prove unwise and costly. Though a number of states created sentencing law only through mandatory sentencing statutes, numerous states created sentencing commissions to develop comprehensive guideline schemes. The discretionary indeterminate sentencing systems that had been dominant for nearly a century have been replaced by a wide array of sentencing laws and structures that govern and control sentencing decisionmaking. This reality is evident in state and federal criminal codes where statements of sentencing purpose and various types of sentencing law and guidelines prominently appear. Sentencing Commission have been roundly criticized for producing sentencing laws and guidelines marked by excessive complexity, rigidity, and severity. Researchers and practitioners have documented that, in practice, mandatory sentencing laws regularly produce unjust outcomes, both in the individual case and across a range of cases, because they base prison terms on a single factor and functionally shift undue sentencing power to prosecutors when selecting charges and plea terms. It is why nearly every authoritative nonpartisan law reform organization that has considered the subject, including the American Law Institute in the Model Penal Code (1962), the American Bar Association in each edition of its Criminal Justice Standards. Sentencing Commission (1991) have opposed enactment, and favored repeal, of mandatory penalties. The Sentencing Commission produced an initial set of guidelines that were lengthy and highly detailed, notable for their overall complexity. The size, structure and substance of the initial Guidelines Manual prompted many federal sentencing judges to criticize the guidelines for setting forth "a mechanistic administrative formula"34 that converted judges into "rubberstamp bureaucrats" or "judicial accountants" in the sentencing process. Alschuler, the Failure of Sentencing Guidelines: A Plea for Less Aggregation, 58 U. Sentencing Guidelines 105 and severity of its guidelines through amendments that largely overruled judicial decisions developing possible grounds for departing downward from guideline ranges.

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Topical review: a comprehensive risk model for disordered eating in youth with type 1 diabetes. Type 2 aa diabetes among persons with schizophrenia and other psychotic disorders in a general population survey. Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study. Patients and care providers should focus together on how to optimize lifestyle from the time of the initial comprehensive medical evaluation, throughout all subsequent evaluations and follow-up, and during the assessment of complications and management of comorbid conditions in order to enhance diabetes care. B Effective self-management and improved clinical outcomes, health status, and quality of life are key goals of diabetes self-management education and support that should be measured and monitored as part of routine care. C Diabetes self-management education and support should be patient centered, respectful, and responsive to individual patient preferences, needs, and values and should help guide clinical decisions. A Diabetes self-management education and support programs have the necessary elements in their curricula to delay or prevent the development of type 2 diabetes. Diabetes self-management education and support programs should therefore be able to tailor their content when prevention of diabetes is the desired goal. B Because diabetes self-management education and support can improve outcomes and reduce costs B, diabetes self-management education and support should be adequately reimbursed by third-party payers. When new complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) arise that influence self-management 4. Diabetes care has shifted to an approach that is more patient centered and places the person with diabetes and his or her family at the center of the care model, working in collaboration with health care professionals. Patient-centered care is respectful of and responsive to individual patient preferences, needs, and values. Evidence for the Benefits and have lower Medicare and insurance claim costs (16,31). This low participation may be due to lack of referral or other identified barriers such as logistical issues (timing, costs) and the lack of a perceived benefit (35). Reimbursement patterns containing nutrient-dense, highquality foods with less focus on specific nutrients. There is growing evidence for the role of community health workers (27), as well as peer (27­29) and lay (30) leaders, in providing ongoing support. Nutrition therapy has an integral role in overall diabetes management, and each person with diabetes should be actively engaged in education, self-management, and treatment planning with his or her health care team, including the collaborative development of an individualized eating plan (36,37). It is important that each member of the health care team be knowledgeable about nutrition therapy principles for people with all types of diabetes and be supportive of their implementation. To promote and support healthful eating patterns, emphasizing a variety of nutrient-dense foods in appropriate portion sizes, in order to improve overall health and specifically to: Achieve and maintain body weight goals Attain individualized glycemic, blood pressure, and lipid goals Delay or prevent the complications of diabetes 2. To address individual nutrition needs based on personal and cultural preferences, health literacy and numeracy, access to healthful foods, willingness and ability to make behavioral changes, and barriers to change 3. To maintain the pleasure of eating by providing nonjudgmental messages about food choices 4. To provide an individual with diabetes the practical tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods Weight Management Body weight management is important for overweight and obese people with type 1 and type 2 diabetes. Lifestyle intervention programs should be intensive and have frequent follow-up to achieve significant reductions in excess body weight and improve clinical indicators. There is strong and consistent evidence that modest persistent weight loss can delay the progression from prediabetes to type 2 diabetes (49,50) and is beneficial to the management of type 2 diabetes (see Section 7 "Obesity Management for the Treatment of Type 2 Diabetes"). In overweight and obese patients with type 2 diabetes, modest weight loss, defined as sustained reduction of care. E c Evidence rating A A B B B, A, E Energy balance Modest weight loss achievable by the combination of reduction of calorie intake and lifestyle modification benefits overweight or obese adults with type 2 diabetes and also those with prediabetes. A Eating patterns and macronutrient distribution c As there is no single ideal dietary distribution of calories among carbohydrates, fats, and proteins for people with diabetes, macronutrient distribution should be individualized while keeping total calorie and metabolic goals in mind. A c B B, A Micronutrients and herbal supplements There is no clear evidence that dietary supplementation with vitamins, minerals, herbs, or spices can improve outcomes in people with diabetes who do not have underlying deficiencies, and there may be safety concerns regarding the long-term use of antioxidant supplements such as vitamins E and C and carotene. C Alcohol c Sodium Adults with diabetes who drink alcohol should do so in moderation (no more than one drink per day for adult women and no more than two drinks per day for adult men). Education and awareness regarding the recognition and management of delayed hypoglycemia are warranted. Nonnutritive sweeteners are generally safe to use within the defined acceptable daily intake levels.

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A quality improvement intervention to improve inpatient pediatric asthma controller accuracy. Opportunities to improve inpatient care for children with behavioral comorbidities. The division continues its clinical work with inpatient and outpatient consult services for infectious diseases and immunology. Our volumes continue to rise, and in 2018, we enjoyed robust growth in our travel medicine program. With the national shortage of Yellow Fever Vaccine, we are the only site in the state of Connecticut offering pediatric-specific travel consult services that include provision of the Stamaril vaccine under an Expanded Access Program. Melissa Held introduced refugee resettlement clinics, performing initial medical evaluations, treatments and vaccinations as needed for refugee children newly arrived in Connecticut. This collaborative program works alongside the existing programs run by Catholic Charities and the Integrated Refugee and Immigrant Services, as well as local family medicine clinics at the University of Connecticut Health Center, and it provides a unique experience for pediatric residents interested in careers in global health. The Antimicrobial Stewardship Program implemented multiple new initiatives to improve stewardship effectiveness throughout the institution, and continues to work to optimize the clinician workflow and care provided to patients in the hospital. The new addition of Theradoc as a software solution for real-time notification and reporting for Antimicrobial Stewardship and Infection Prevention demonstrates the institutional commitment to patient safety and improved clinical outcomes. The division continues to publish cutting-edge research, as well as clinical reports and reviews. Identification of Genes Required by Leptospira interrogans for Mammalian Host Adaptation and/or Persistence in the Rat Model. Borrelia burgdorferi oligopeptide (Opp) Transporter Control of Cellular Homeostasis and Growth. Management of pediatric acute hematogenous osteomyelitis, part I: antimicrobial stewardship approach and review of therapies for methicillin-susceptible staphylococcus aureus, streptococcus pyogenes, and Kingella kingae. Ceftazidime/avibactam and ceftolozane/tazobactam: novel therapy for multidrug resistant gram negative infections in children. Sequence variation of rare outer membrane protein -barrel domains in clinical strains provides insights into the revolution of Treponema pallidum subsp. The transformational model applies population health principles and e-Registry tools to provide the highest level of care and optimal health outcomes for a population cohort comprised of over 64 genetic conditions under the care of geneticists/genetic counselors, endocrinologists, hematologists, and immunologists. In addition, it has established a foundation for the Village to become an important community partner. The office accelerates clinical transformation within an environment of intense change and growing complexity. The office sets the tone, engages, encourages, and facilitates change and transformation. The grant funding runs from July 1, 2018, to June 30, 2021, for a total award of $1,797,531. Our faculty members not only work collaboratively across these sites but also are leaders in the Connecticut Perinatal Quality Collaborative, helping to improve maternal and newborn care at the state level. This year, we have expanded our partnerships portfolio to include teleconferencing and joint education the Division of Medical Genetics resides jointly in the Department of Genetics and Genome Sciences as well as the Department of Pediatrics. The mission of the division is to provide high quality, timely and state-of-the-art genetic consultations, counseling, and treatment for patients from the prenatal period throughout childhood and into adulthood. Care throughout the lifespan is provided across two campuses by a team of clinical geneticists, genetic counselors and metabolic dieticians. The core newborn screening team is housed within the Division of Medical Genetics. Peter Benn at John Dempsey Hospital in Farmington provides genetic testing services. The division directs one of the largest and most diverse clinical services in New England and is a major perinatal regional center for Connecticut. The primary mission of the division is to provide high quality, state-of-the-art care to neonates in both our state and our region, in addition to advancing education, training, and cutting edge research. The award recognizes leaders in the field of neonatology and their dedication to teaching at the national level. Mayer committed $250,000, a sum that will be matched to create a $500,000 endowment.

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Diaphragmatic rupture, aortic transection, major tracheobronchial tears, flail chest, and cardiac contusions are also uncommon in pediatric trauma patients. Significant injuries in children rarely occur alone and are frequently a component of major multisystem injury. Penetrating trauma to the chest in children is managed the same way as for adults. Unlike in adult patients, most chest injuries in children can be identified with standard screening chest radiographs. Cross-sectional imaging is rarely required in the evaluation of blunt injuries to the chest in children and should be reserved for those whose findings cannot be explained by standard radiographs. Most pediatric thoracic injuries can be successfully managed using an appropriate combination of supportive care and tube thoracostomy. While talking quietly and calmly to the child, ask questions about the presence of abdominal pain and gently assess the tone of the abdominal musculature. Do not apply deep, painful palpation when beginning the examination; this may cause voluntary guarding that can confuse the findings. Most infants and young children who are stressed and crying will swallow large amounts of air. If the upper abdomen is distended on examination, insert a gastric tube to decompress the stomach as part of the resuscitation phase. The presence of shoulder- and/or lap-belt marks increases the likelihood that intra-abdominal injuries are present, especially in the presence of lumbar fracture, intraperitoneal fluid, or persistent tachycardia. Since gastric dilation and a distended urinary bladder can both cause abdominal tenderness, interpret this finding with caution, unless these organs have been fully decompressed. It should be immediately available and performed early in treatment, although its use must not delay definitive treatment. Early involvement of a surgeon is essential to establish a baseline that allows him or her to determine whether and when operation is indicated. Serious intra-abdominal injuries warrant prompt involvement by a surgeon, and hypotensive children who sustain blunt or penetrating abdominal trauma require prompt operative intervention. Thus, the need for accurate diagnosis of internal injury must be balanced against the risk of late malignancy. This is an uncommon occurrence, as most pediatric patients have self-limited intra-abdominal injuries with no hemodynamic abnormalities. If large amounts of intra-abdominal blood are found, significant injury is more likely to be present. However, even in these patients, operative management is indicated not by the amount of intraperitoneal blood, but by hemodynamic abnormality and its response to treatment. Clinically significant intraabdominal injuries may also be present in the absence of any free intraperitoneal fluid. For nonoperative management, children must be treated in a facility with pediatric intensive care capabilities and under the supervision of a qualified surgeon. In resource-limited environments, consider operatively treating abdominal solid organ injuries. Angioembolization of solid organ injuries in children is a treatment option, but it should be performed only in centers with experience in pediatric interventional procedures and ready access to an operating room. Nonoperative management of confirmed solid organ injuries is a surgical decision made by surgeons, just as is the decision to operate. Any patient with this mechanism of injury and these findings should be presumed to have a high likelihood of injury to the gastrointestinal tract, until proven otherwise. Penetrating injuries of the perineum, or straddle injuries, may occur with falls onto a prominent object and result in intraperitoneal injuries due to the proximity of the peritoneum to the perineum. Injuries such as those caused by a bicycle handlebar, an elbow striking a child in the right upper quadrant, and lap-belt injuries are common and result when the visceral contents are forcibly compressed between the blow on the anterior abdominal wall and the spine posteriorly. Blunt pancreatic injuries occur from similar mechanisms, and their treatment is dependent on the extent of injury. Small bowel perforations at or near the ligament of Treitz are more common in children than in adults, as are mesenteric and small bowel avulsion injuries. These particular injuries are often diagnosed late because of the vague early symptoms. Most head injuries in the pediatric population are the result of motor vehicle crashes, child maltreatment, bicycle crashes, and falls. As in adults, hypotension is infrequently caused by head injury alone, and other explanations for this finding should be investigated aggressively.

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If I ever thought that this person called Poonja was speaking to you, I have no right to sit here because whatever would come out of my mouth would be false. Poonja has Ganapati Muni 243 gone for good, but the Master remains and will always remain. On an enquiry about any other case where Sri Ramana provided physical protection to a devotee as happened in case of Papaji, David Godman, who has done extensive research about Sri Ramana and his devotees, replied that he knew no other example of this nature. He compiled Ramana Gita which is based on the replies of Sri Ramana to spiritual questions put by the Muni and his friends. Ganapati Muni, a great Siva bhakta, chose Tiruvannamalai, the holy seat of Siva, for his tapas in 1903 and briefly met Sri Ramana on the hill. In 1907, when he came again to Tiruvannamalai he found that nothing tangible had emerged from his severe tapas. Then he said in Tamil, "If a mantra is repeated and attention directed to the source from where the mantra-sound is produced, the mind will be absorbed in that. On the 18th day, when he was lying wide awake he saw the figure of the Maharshi coming in and sitting next to him. Ever since his arrival at Tiruvannamalai in September 1896, the Maharshi had never left that place. When the Muni narrated the incident to the Maharshi in 1929, the latter recollected the event in the following words: "One day some years ago, when I was lying down, I suddenly felt my body carried up higher and higher till all objects disappeared and all around me was one vast mass of white light. On his way back to the Skandasram Bhagavan said, "He told me, but to whom can I tell? Humphreys 245 the Muni by his thorough mastery of the Sanskrit language and the ease and excellence of his Sanskrit poetry must, to some extent, have influenced the Maharshi who was always receiving new ideas and learning new languages from persons and books almost unconsciously. So long as the Muni lived in Tiruvannamalai, the Maharshi consulted him on matters of importance, especially publications and other activities of the Ashram. Sundaresa Iyer records in his book At the Feet of Bhagavan: After Ganapati Muni had composed 700 out of the 1000 verses of the Uma Sahasram in praise of the Divine mother, he announced that the complete work will be dedicated on a particular day in the Arunachaleswara temple. When the Maharshi asked the Muni whether he was getting the event postponed, the Muni assured him that the task would be completed here and now. The eager disciples of the Muni watched in tense admiration the sweet flow of Sanskrit verses as they came from the lips of Kavyakantha and wrote them down. The job over, Bhagavan opened his eyes and asked the Muni whether all that he said had been taken down. The source from where the mantra-sound is produced is not merely the vocal organ but the central force from where the mind and the breath arise, that is, the Self. Humphreys came to India in January 1911 to join the Police Department as an Assistant Superintendent. His deepseated spiritual inclination resulted in his meeting Ganapati Muni (previous entry), and through the help of S. Narasimham, who was the munshi to teach him Telugu, he along with Ganapati 246 Face to Face with Sri Ramana Maharshi Muni had an audience with Sri Ramana. The following account is from his letters to a friend in England, which were later published in the International Psychic Gazette. The Maharshi spoke a few sentences of broken English and in Telugu, which conveyed worlds of meaning. The most touching sight was the number of tiny children up to about seven years of age, who climb the hill, all on their own, to come and sit near the Maharshi, even though he may not speak a word or even look at them for days together. The Maharshi is a man beyond description in his expression of dignity, gentleness, self-control and calm strength of conviction. Krishnaswami Aiyar (the District Munsif), who happened to be present, acted as interpreter. Everyone who comes to him is an open book, and a single glance suffices to reveal to him its contents. So he gave me a coconut spoon to eat with, smiling and talking during the time I ate. He knows everything, and when others pressed me to eat fruit when I had had enough he stopped them at once. Raghavachariar 247 Whilst I was eating, he was relating my past history to others and accurately too.

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Results showed no difference in negative seroconversion by day 28 or time to negative seroconversion. Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomized controlled trial. Cavalcanti et al: Adult patients in Brazil not requiring supplemental oxygen or requiring rates lower than 4 L/min were randomized 1:1:1 to receive hydroxychloroquine (n=159), hydroxychloroquine plus azithromycin (n=172), or standard of care (n=173). No significant difference was seen in primary endpoint of clinical status at day 15, or secondary outcomes of need for mechanical ventilation, duration of hospitalization, or in-hospital death. Symptoms were present for no more than 4 days in all patients and did not require hospitalization. The primary outcome of patient-reported symptom severity was no different between groups. Secondary outcomes of hospitalization or death were also not statistically significantly different. Hydroxychloroquine for early treatment of adults with mild Covid-19: a randomizedcontrolled trial. Patients in the hydroxychloroquine were sicker at baseline (median Pao2:Fio2, 223 vs. Hydroxychloroquine administration was not associated with a lowered or increased risk of intubation or death. Using adjusted cox proportional hazard modeling, there were no significant differences in in-hospital mortality between treatment arms compared to neither therapy. The authors postulate this benefit may be due to the earlier administration of the medication(s) compared to other studies, where 82% of participants received the medication(s) within 24 hours of admission and 91% within the first 48 hours, although duration of symptoms prior to hospitalization was not captured. Randomized, controlled studies do not show improvement in mortality, hospital length of stay, or prevention of mechanical ventilation. Monitoring and Toxicity 1) Hydroxychloroquine is contraindicated in epilepsy and porphyria. Evidence 1) A randomized, controlled, open-label trial assessed lopinavir-ritonavir (n=99) vs. Lopinavir/ritonavir and interferon beta-1b have shown to reduce viral load and improve lung pathology in animal models. In this trial, patients were randomized 2:1 to the combination group or the lopinavir/ritonavir group (control). Median days from symptom onset to treatment initiation was 5 days in the combination group and 4 days in the control group. Patients in the combination group demonstrated significantly better clinical and virologic response resulting in a shorter hospital length of stay (9 days [7­13] vs 14. Patients in the combination group who started treatment less than 7 days after symptom onset had better clinical and virologic outcomes than in the control group. Interim results demonstrated that lopinavir/ritonavir demonstrated little or no reduction in mortality with some associated safety signals. Confounding factors included concomitant medications being administered between groups. In addition, the open-label design, the possibility of an element of subjectivity for the primary outcome, lack of a protocolized approach to standard therapy, and variability among study centers also must be considered when interpreting the study findings. Dexamethasone as a treatment for the novel coronavirus reduced 28 day mortality rates in 36% in ventilated patients (29. Results were not statistically significant in patients not requiring mechanical ventilation or supplemental oxygen support (17. In patients receiving dexamethasone, a reduction in 28-day mortality was noted in patients who had a longer duration of symptoms (>7 days) compared to recent onset. From April18June 16, 2020, 416 patients were enrolled and 393 patients completed follow-up. No major differences in baseline characteristics were noted and a median of 10 doses were administered. In a post hoc analysis, patients >60 years of age were noted to have reduced mortality. Ventilator free days were significantly higher in the methylprednisolone group compared to the no-methylprednisolone group (6. Also seen was an increased probability of getting extubated if patients were on methylprednisolone, but no significant difference in mortality between groups. However death occurred in 3 patients during hospitalization, 2 of whom were taking methylprednisolone.

References:

  • https://www2.gov.bc.ca/assets/gov/health/forms/5364.pdf
  • https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline-Dec2019.pdf
  • https://www.accp.com/docs/bookstore/psap/p13b2_m1ch.pdf
  • https://pedclerk.bsd.uchicago.edu/sites/pedclerk.uchicago.edu/files/uploads/1-s2.0-S0268960X08000787-main.pdf
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