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Second, PollEverywhere has greatly increased the types of questions and answer display options, now offering multiple-choice, open-ended, survey, word clouds (see. These poll questions can be shown directly from the PollEverywhere website, or each question P a g e 180 can be downloaded as a PowerPoint slide and saved as a part of a standard PowerPoint presentation. However, there are a few logistical considerations in deciding to use PollEverywhere. Thought must be given to the time participants will need to respond to questions in a live presentation, given that it is based on live Internet or cellular service. Further, if participants are texting in their answer, it is a two-step process: first, they must "join" the poll, by texting a unique numeric code and waiting for a response so that they can move to step two, which is texting that number back with their answer to the given question. That process can stall a live presentation as audience members may enter the code incorrectly, not be able to see the code from where they are sitting, or not receive a response right away. When it works, it is impressive to see words or charts appear and update in real-time. Another consideration is that presenters need to be aware of approximately how many respondents they intend to have during each presentation. The higher education, free account allows users to create as many polls as they like; however, each poll can only accept and record 40 responses, otherwise an instructor version that could accommodate up to 400 responses cost $349/semester. Interaction is an important factor affecting educational success, especially in online learning environments (Tsui & Ki, 1996). As first put forth by Moore (1989), interaction is a three-dimensional construct which includes learner-to-content, learner-to-instructor, or learner-to-learner interaction. Learner-to-teacher interaction refers to all communications between the teacher and the student (Moore, 1989). It can also refer to the curriculum development methods an instructor uses to guide learning. Learner-to-learner interaction refers to the communication between learners and includes both the cognitive and social dimensions of the interaction (Moore, 1989). Documents created with Google Docs are compatible with most word processor applications and can be accessed from just about any computer, tablet, or smart phone with an Internet connection, making it easy for anyone to create and share educational content. Whereas anything that takes place in a learning management system is usually accessible to only those enrolled in the course, a Google Doc can be made accessible to whomever the instructor wants. The document management benefits of Google Docs alone can save an instructor many headaches. How often has an instructor distributed a syllabus, only to discover an error or omission moments later? Google Docs allows an instructor to revise a work at any time without having to redistribute a second or third set. Because revisions made to a Google Doc automatically cascade to wherever its sharable link is used, instructors can make changes or updates to a document as needed. Google Docs also lends itself to collaborative knowledge building, as its commenting and editing features allow students to work together synchronously or asynchronously. For example, by allowing students to comment and ask questions directly on the syllabus (a feature controlled by the permission settings), any confusion about course objectives or assignments can be addressed by the instructor or a knowledgeable student. Instead of getting flooded with emails from many students asking the same questions, general concerns can be asked and answered directly on the syllabus. This approach to community knowledge construction can also be used to turn mundane reading assignments into collaborative reading experiences. In short, collaborative reading is a technique that encourages students to work together on a reading assignment to promote better comprehension (Klingner & Vaughn, 1999). While this is easily accomplished in face-to-face settings, the nature of online learning often isolates students from the teacher, as well from each other. By sharing a required course reading via Google Docs, the three types of interactions can be promoted. Not only can students reflect on the reading by offering their own commentary, they can also discuss divergent understandings. The instructor can also use this discourse to pinpoint systemic misunderstandings which can help shape the direction of the class. While it appears to be nothing more than a PowerPoint equivalent, Google Slides is much more than a tool for delivering presentations - it is a powerful and easy-to-use tool for delivering interactive student experiences. One of the most significant advantages of Google Slides is that it is easier to use and share than PowerPoint. Because it is cloud-based (as are the rest of the components of Google Suites), it does not need to be uploaded to a platform first, and updates/changes can be reflected immediately.
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The patient is discharged the next morning with follow up scheduled with his pediatrician in the next few days. They also found that children, unlike adults, did not have a significant difference between the foreign body being found in the right or left bronchial tree (2). The second phase is the asymptomatic period that can last from minutes to months following the incident. Airway inflammation or infection from the foreign body will cause symptoms of cough, wheezing, fever, sputum production, and occasionally, hemoptysis. On physical exam, the classic findings consist of cough, unilateral decreased breath sounds, and unilateral monophonic wheezing. Although 75% of patients have one or more of these findings, only 40% have all three (5). Since most foreign bodies are not radiopaque, one must rely on indirect findings suggestive of the presence of a foreign body such as: mediastinal shift, atelectasis, and hyperinflation. For patients who present early, radiographic studies must look for evidence of air trapping. Expiratory views rely on timing, so these are sometimes deceiving (an "expiratory view" could have been really taken during inspiration). Thus, if a decubitus view looks the same as an upright inspiratory view, this suggests air trapping on the dependent side. If the patient presents in the first clinical phase, the family and/or health care professional should be advised to follow the recommendations of the American Academy of Pediatrics and American Heart Association (7). Unless there is a complete airway obstruction, spontaneous coughing and respiration should be the only treatment encouraged. Once the patient is brought to the hospital, the patient will require rigid bronchoscopy for visualization of the airway and removal of the foreign body. Flexible bronchoscopy does not have a role in this situation because it is not the optimal tool for control of the foreign body or the safety of the patient during the removal procedure. At this point in time, clinical suspicion based on the history, exam, and ancillary studies must be used to determine the appropriate course of action. Such patients return with "recurrent pneumonia" which is actually a pneumonia or atelectasis which has never resolved because the foreign body is still there. If foreign body aspiration is suspected in this phase, the patient should undergo direct airway visualization by bronchoscopy (flexible or rigid). Even if the patient has expectorated a foreign body, direct visualization is recommended to ensure there are no additional foreign bodies present and to determine if there is any compromise of the airway from inflammation. Complications arising from foreign body aspiration depend on the location and type of foreign body aspirated (organic vs. However, the longer the foreign body remains in the airways, the more likely inflammation and thus, complications will occur. Which radiographic imaging study would be the most helpful if a foreign body aspiration is suspected in a child (<3 y. What physical exam sign/symptom is most worrisome in terms of degree of airway compromise? Tracheobronchial Foreign Bodies: Presentation and Management in Children and Adults. Organic material is worse to aspirate because it will cause a more intense inflammatory response, thereby increasing the risk for complications. A blind finger sweep may reposition the foreign body causing a complete airway obstruction. Whenever a choking episode occurs while a young child is eating nuts, the risk of foreign body aspiration is high. Review of systems reveals a slowing of growth from the 4 month routine well child visit to present. There is no family history of any respiratory disease, chronic or serious medical conditions. His abdomen is soft, non-distended with normal bowel sounds and no hepatosplenomegaly.
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This is done to minimize confusion, reduce the risk of an incorrect action being taken on the claim, and ensure any communications about the claim are directed only to the individual who is authorized as the Personal Representative of the decedent. We are committed to trying to issue some payment to the family while waiting for the deceased claim to be submitted and processed. In this situation, any open amendments on the personal injury claim will be reviewed as part of the deceased claim. To validate the Personal Representative, the Special Master evaluates the letters of administration, letters testamentary, court orders or other similar documentation issued by a court. For example, a long-form death certificate might provide the relevant cause of death. Time-Limited Court Orders/Letters of Administration: If the Letters of Administration or court order contains an expiration date that is, the documents indicate that they have expired or will expire before payment will be issued you must obtain revised Letters of Administration or a court order that extends your authority to collect assets or administer the estate. In general, states have procedures for individuals to open a simple or small estate in order to obtain an appointment. In New York, if the value of the estate is less than $10,000, you will have to pay $45. Follow the instructions here if you have received Letters of Administration with any limitations. The chart below only lists documents related to loss of pension and other benefits. As with all other claims for lost earnings, you must also submit documents establishing a disability and earnings history. You will also need to submit documentation of all information required to calculate a pension benefit under your plan. Information for victims who were employed by the City of New York or the federal government, including the military, is provided in the main policy document. Hours history report showing the number of hours worked by year and credited for pension purposes. If victim is receiving a disability or retirement pension or has received a lump-sum pension: i. Total years of vesting service/total years of continuous credited "A" membership c. Joint/survivor pension option selected and monthly pension amount with option chosen. Local 6 New York Hotel Trades Council "History of pension credits and years of vesting service" which includes: hours worked each year (or functions served in the case of banquet waiters) pension credits, year by year and total vesting years for each year job category A document or letter showing: Membership date Type of employment. Banquet Waiter, Checkroom/Washroom Attendant, or Hours-Members) If a pension has been received: type. Pension option letter, if available, and indication of the final option chosen the Central Pension Fund "Calculation Worksheet" showing how the pension was calculated. If victim does not receive a pension from the Central Pension Fund: the final Semi-Annual Benefit statement the victim received from the Central Pension Fund Local 30 International Union of Operating Engineers Benefit Fund Pension Benefit Statement yearly history which includes: Employer contribution amounts, by year Hours worked by year Pension credits by year Total pension credits Pension calculation worksheet, if available Pension option letter, if available, and indication of the final option chosen A document or letter showing: Start date with Union If receiving a pension: type of pension. Pension option letter, if available, and indication of the final option chosen If victim does not receive a pension from the Central Pension Fund: the final Semi-Annual Benefit statement the victim received from the Central Pension Fund Updated: December 2019 Version 5. For the related pension credit entries on the statement, the "plan code" field typically will be blank/not filled in. It is the sixth leading cause of death overall and is a major cause of morbidity and mortality. New organisms had emerged and development of resistance had increased over time among respiratory pathogens. Theinfluxandeffluxofantimicrobialagentsusedinthe treatment had likewise posed a threat to the rapid rise of antimicrobial resistance. The use, misuse, abuse and overuse had also shaken the market of antimicrobial agents. There is a need to standardize care by providing management strategies based on best available evidences. The evidences may be the same; however, regional differences, causative agents, antibiotic resistance rates, drug licensing, healthcare structure and available resources may vary. Although therapy within 4 hours of arrival to the hospital has been associated with reduced mortalities in some studies, undue emphasis on early therapy could lead to unnecessary use of antibiotics and associated complications. For these reasons, the present guideline maintains its position to not recommend a specific time interval between diagnosis and antibiotic administration for patients. Early administration of the first antimicrobials should be considered a marker of optimal care of patients with community-acquired pneumonia rather than a predictor of outcomes.
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Which parenteral vaccine should not be characterized as an attenuated live virus vaccine? Which passive or active immunization is specifically recommended for women in the second or third trimester of pregnancy? Intussusception among recipients of rotavirus vaccine - United States, 19981999. It should be noted that the current parenteral influenza vaccine is not a live attenuated virus. However, a non-parenteral intranasal live attenuated influenza vaccine is available. The most critical period for the development of hearing and speech occurs in the first 6 months of life. Deafness is more prevalent than any other disabling condition for which mandated neonatal screening programs exist (2). The Joint Committee on Infant Hearing, Year 2000 Position Statement also illustrates specific risk indicators associated with progressive or delayed-onset hearing loss (1,4): - Parental or caregiver concern regarding hearing, speech, language, or developmental delay. Children who had mild or moderate hearing losses often were not identified until entering school. Studies have shown that even targeted screening of high-risk groups can identify only up to 50% of children who have significant hearing impairments prior to the development of speech (1). These screening techniques reveal whether specific stimulus levels elicit a response. This emission can be detected by placing a microphone in the ear canal connected to a computer specially designed to analyze this emission. Higher false-positive rates may lead to a variety of unnecessary negative effects, including emotional trauma, disease labeling, iatrogenic adverse events from unnecessary testing, and increased expense in terms of time and money. Sokol and Hyde report that a maximum false-positive rate of 3% is generally acceptable for hearing screening programs (1). It is important to recognize that screening tests in high- and lowrisk groups will yield different results due to variation in the presentation and distribution of hearing disorders within these groups and the fact that it is easier to achieve ideal testing conditions and results in babies who are sleeping, less distressed, and in low-risk groups (1). The behavior of the child and environmental noise levels may affect the results of hearing screening in infants. If this is not possible, mild sedation or light general anesthesia may provide a better testing environment in these children (1). Screening preschool-aged children under a Early Hearing Detection and Intervention program may identify preschoolers who have developed hearing deficits that have presented following birth, are progressive, or associated with diseases. Middle ear conditions are common in 3 to 5 year old children, and it is important for health care professionals to screen for both hearing loss and middle ear problems. Screening failures in this group should also be followed by full audiologic assessment (1). Failing an objective screen in a child should alert health care professionals to determine whether the failure is caused by middle ear disease. Tympanometry is used to detect middle ear conditions by utilizing varied air pressures to assess the compliance of the tympanic membrane. For example, an acute otitis media will result in low compliance indicating a stiff tympanic membrane because the space behind the tympanic membrane is filled with fluid. An abnormal tympanogram suggests that the screening failure is probably a result of a middle ear disorder. One should remember that abnormal tympanograms do not necessarily rule out a sensorineural component of hearing loss (1). He drinks about two to three glasses of milk a day and maybe one glass of fruit juice per day. He has used the toilet for both bowel movements and urination, but he will not consistently tell his mother when he has to go. These children and families face poor nutrition, poor access to health care, violence and neglect. There are many children who live with foster families because of neglect, abuse, parental substance abuse or domestic violence. Pediatricians and other child health providers emphasize prevention, early detection, and management of various behavioral, developmental, and social functioning problems (2). A major aspect of preventing and managing such problems includes concise and effective discussions with parents and other caregivers; what is commonly called anticipatory guidance.
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This project allows students to develop resource guides for this population that are then shared on a public website. P a g e 262 Developing a resource guide (whether for a website or for a community agency to distribute) is an additional example of a service learning project that could occur entirely online. Recommendations for implementation include allocating time to thoroughly describe expectations for the project, including milestones and due dates, and identifying community partners for the projects. This identification can occur either through the instructor making the connections with community partners who could benefit from student assistance, or through the students independently making connections with organizations in their own communities. Groups can be assigned by the instructor, giving consideration to factors such as student interests, demographics, and location. The former should include a problem statement, the goal of the project, and how the project connects to course content, while the latter should include the specific steps that will be undertaken to complete the project, the responsibilities of each group member, and any data that will be collected as a part of the project. In addition, the action plan portion of the project should involve students in learning more about the problem they are trying to solve via online research and communication with related organizations. A 5-point Likert scale is the suggested format for the rubrics used to assess student submissions. The instructor should also involve other entities in the evaluation process, such as community members, other faculty members or students, or the community partners. The involvement of multiple sources in the evaluation process can allow for richer feedback and a more authentic project assessment. Finally, because students are working in groups, an online survey that allows students to provide feedback on their other group members should be included. Because students in online courses are likely to be geographically dispersed, the authors make recommendations for staying connected via course technology (Helms et al. For example, the instructor may post a video to the course of him/herself explaining the project. Online discussion boards should be used to reflect on the projects and to receive feedback from the instructor and from peers. Webinar technology, such as Skype, can be used for group meetings, as could conference calls. Because students may not have easy access to the university librarian, the librarian could be enrolled in the course in order to provide research assistance. Web links related to research and course content could be posted in the online course, as well. As we conclude this chapter, we intend to provide resources and tips that will help psychology instructors, in addition to those tips suggested by Helms et al. As past literature demonstrates, students in online courses can participate in face-to-face service learning (Bossaller, 2016; Guthrie & McCracken, 2010). With respect to service learning in general, professional journals for service learning include: Journal for Civic Commitment, Journal for Civic Engagement, Journal of Community Engagement and Higher Education, Journal of Community Engagement and Scholarship, Journal of Higher Education Outreach and Engagement, Michigan Journal of Community Service Learning, and Partnerships: A Journal of Service-Learning and Civic Engagement. Another significant service learning resource is the Campus Compact coalition ( Campus Compact is comprised of almost 1,100 colleges and universities across the country, with the purpose of supporting its member institutions with improving their local communities and educating their students to be socially responsible citizens. One of the priorities of Campus Compact is to "establish meaningful, reciprocal community partnerships" (Campus Compact, 2015, Strategic Plan, para. Resources available on the Campus Compact website include books and publications for purchase, blogs, news articles, links to other web resources, videos and presentations (including slides addressing topics such as engaged scholarship and community-based participatory research), and a searchable database of syllabi for service-oriented courses offered by other colleges and universities. Additional resources specifically related to service learning include a guide for incorporating structured reflection into service learning courses and a service learning toolkit for administrators that includes information on planning for and measuring community engagement. Campus Compact contains both general information and discipline-specific information for psychology. Another excellent resource for service learning in psychology is the book Service Learning in Psychology: Enhancing Undergraduate Education for the Public Good (Bringle et al. The Society for Teaching of Psychology also maintains a listserv and public Facebook discussion group where instructors of psychology could explore online service learning opportunities and seek feedback and collaboration from other instructors at various institutions. Finally, examples of service learning projects for various psychology courses are discussed by Bringle et al.
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The transaction price consisted of an upfront cash payment of approximately $430 million. On November 22, 2016, we announced the closing of our acquisition of EndoChoice Holdings, Inc. The transaction price consisted of an upfront cash payment of approximately $213 million, or $8. In addition, we completed other individually immaterial acquisitions during 2016 for total consideration of $189 million in cash at closing plus aggregate contingent consideration of up to $125 million. The components of the aggregated purchase prices are as follows: (in millions) Payment for acquisitions, net of cash acquired Fair value of contingent consideration Fair value of debt repaid $ 365 50 43 458 $ the following summarizes the aggregated purchase price allocations for our 2016 acquisitions: (in millions) Goodwill Amortizable intangible assets Other assets acquired Liabilities assumed $ 204 228 83 (57) 458 $ We allocated a portion of the purchase prices to specific intangible asset categories as follows: Amount Assigned (in millions) Amortizable intangible assets Technology-related Customer relationships Other intangible assets $ 176 51 1 228 9 - 13 9 - 13 4 11% - 20% 11% - 12% 11% Weighted Average Amortization Period (in years) Risk-Adjusted Discount Rates used in Purchase Price Allocation $ For our 2018, 2017 and 2016 acquisitions, our technology-related intangible assets consist of technical processes, intellectual property and institutional understanding with respect to products and processes that we will leverage in future products or processes and will carry forward from one product generation to the next. We used the multi-period excess earnings method, a variation of the income approach and relief from royalty approach to derive the fair value of the technology-related intangible assets and are amortizing them on a straight-line basis over their assigned estimated useful lives. Other intangible assets primarily include acquired customer relationships and tradenames. Customer relationships represent the estimated fair value of non-contractual customer, payor and distributor relationships. Customer relationships are direct relationships with physicians and hospitals performing procedures with the acquired products, payor relationships are contracts and relationships with healthcare payors relating to reimbursement of services and distributor relationships are relationships with third parties used 77 to sell the acquired products, all as of the acquisition date. These relationships were valued separately from goodwill because there is a history and pattern of conducting business with customers and distributors. We used the income approach or the replacement cost and lost profits methodology to derive the fair value of the customer relationships. The customer relationships intangible assets are amortized on a straight-line basis over their assigned estimated useful lives. Tradenames include brand names that we expect to continue using in our product portfolio and related marketing materials. The tradenames are valued using a relief from royalty methodology and are amortized on a straight-line basis over their assigned estimated useful lives. We believe that the estimated intangible asset values represent the fair value at the date of acquisition and do not exceed the amount a third party would pay for the assets. Goodwill was established due primarily to synergies expected to be gained from leveraging our existing operations as well as revenue and cash flow projections associated with future technologies and has been allocated to our reportable segments based on the relative expected benefit. Based on preliminary estimates, the goodwill recorded related to our 2018 acquisitions is not deductible for tax purposes. The goodwill recorded related to our 2017 acquisitions is not deductible for tax purposes. Of the goodwill recorded related to our 2016 acquisitions, $116 million is deductible for tax purposes. Refer to Note C - Goodwill and Other Intangible Assets for more information related to goodwill allocated to our reportable segments. Contingent Consideration Changes in the fair value of our contingent consideration liability were as follows: (in millions) Balance as of December 31, 2016 Amounts recorded related to current year acquisitions Contingent consideration expense (benefit) Contingent consideration payments Balance as of December 31, 2017 Amounts recorded related to current year acquisitions Purchase price adjustments related to prior year acquisitions Contingent consideration expense (benefit) Contingent consideration payments Balance as of December 31, 2018 $ 204 94 (80) (48) 169 248 (22) (21) (28) 347 $ $ As of December 31, 2018, the maximum amount of future contingent consideration (undiscounted) that we could be required to pay was approximately $873 million. The maximum amount of future contingent consideration (undiscounted) decreased approximately $447 million compared to the amount as of December 31, 2017 due primarily to the expiration of certain contingent consideration arrangements in 2018. The recurring Level 3 fair value measurements of our contingent consideration liabilities include the following significant unobservable inputs: Contingent Consideration Liabilities R&D, Regulatory and Commercialization-based Milestones Revenue-based Payments Fair Value as of December 31, 2018 $189 million Valuation Technique Discounted Cash Flow Discounted Cash Flow Unobservable Input Discount Rate Probability of Payment Projected Year of Payment Discount Rate Probability of Payment Projected Year of Payment Range 3% - 4% 17% - 100% 2019 - 2022 11% - 15% 60% - 100% 2019 - 2026 $158 million 78 Projected contingent payment amounts related to some of our R&D, commercialization-based and revenue-based milestones are discounted back to the current period using a Discounted Cash Flow model. Projected revenues are based on our most recent internal operational budgets and strategic plans. Increases or decreases in projected revenues, probabilities of payment, discount rates or the time until payment may result in materially different fair value measurements. Strategic Investments the aggregate carrying amounts of our strategic investments were comprised of the following categories: As of (in millions) Equity method investments Measurement alternative investments Publicly-held securities Notes receivable $ December 31, 2018 303 94 - 26 424 $ December 31, 2017 209 81 15 47 353 $ $ these investments are classified as Other long-term assets within our accompanying consolidated balance sheets, in accordance with U. In addition, we verified the classification as indefinite-lived assets continues to be appropriate. The following represents our goodwill balance by global reportable segment: (in millions) Balance as of December 31, 2016 Impact of foreign currency fluctuations and other changes in carry amount Goodwill acquired Balance as of December 31, 2017 Impact of reportable segment revisions Impact of foreign currency fluctuations and other changes in carry amount Goodwill acquired Balance as of December 31, 2018 MedSurg $ 2,875 Rhythm and Neuro $ 290 1 126 417 1,379 Cardiovascular $ 3,513 $ 9 182 3,704 - Total 6,678 12 308 6,998 - (29) 942 7,911 $ 2 - 2,877 $ (1,379) (3) 568 2,063 $ $ $ $ (22) 150 1,924 $ (3) 224 3,925 $ We did not have any goodwill impairments in 2018, 2017 or 2016. We operate these programs pursuant to documented corporate risk management policies and do not enter into derivative transactions for speculative purposes. Our derivative instruments do not subject our earnings to material risk, as the gains or losses on these derivatives generally offset losses or gains recognized on the hedged item. We manage concentration of counterparty credit risk by limiting acceptable counterparties to major financial institutions with investment grade credit ratings, limiting the amount of credit exposure to individual counterparties and by actively monitoring counterparty credit ratings and the amount of individual credit exposure. We also employ master netting arrangements that limit the risk of counterparty non-payment on a particular settlement date to the net gain that would have otherwise been received from the counterparty.
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Occasionally, prolonged exposure to topical eye medications can cause conjunctivitis, especially the aminoglycosides, such as gentamicin and tobramycin, and certain glaucoma medications. Additionally, patients may have allergic reactions to other topical antibiotics such as sulfonamides. A three-year old boy presents with an acute red lump in his right upper eyelid, the pediatrician diagnoses that it is an acute chalazion. A four month old male has congenital tear duct obstructions and has symptoms of chronic tearing and mucus. His primary care physician prescribes topical sulfacetamide drops three times a day to clear up the mucus, but after using the drops for one month, his eyelids are more erythematous than ever and the conjunctiva is more swollen and he constantly rubs his eyes. A dental infection involving the upper teeth can easily spread itself into the orbit. The baby is probably developing an allergic reaction to the long-term use of topical sulfacetamide. The eyedrops should be discontinued right away and patient can be treated with tear duct massage and another antibiotic eyedrop on an as-needed basis. A single drop of a cycloplegic agent (such as homatropine) is instilled into his left eye. Injuries to the stroma and endothelium usually result in permanent scarring of the cornea, and reduced vision for the eye. Cornea has a high density of neuronal pain receptors, making injury to the cornea very painful. The most common cause is external blunt trauma, such as foreign objects scratching the cornea. It is very important to document visual acuity when examining a patient with an eye injury. A topical anesthetic, such as proparacaine or tetracaine, can be instilled to decrease pain for the patient to facilitate the examination. Take note of any periorbital injuries, such as eyelid trauma, or possible orbital wall fractures. Fluorescein is applied topically, and using cobalt blue light, the size, shape and location of the abrasion should be documented. The cycloplegic reduces the pain due to ciliary muscle spasm and the topical antibiotics provide prophylaxis against infection developing in the abrasion. A second gauze eye patch is applied over the first eye patch, making sure the eye is completely closed. This type of treatment ensures that the epithelium can regenerate without having the eyelid abrading further on the corneal abrasion. If infiltrates are observed at any time, patching is discontinued and the patient needs to be treated for a corneal ulcer by an ophthalmologist. A pressure patch is not recommended for abrasions which are at significant risk for infection, such as scratches from a tree branch, from a dirty fingernail, and abrasions in a contact lens wearer. Just as in a sunburn, patients with ultraviolet corneal burns do not notice much discomfort initially, but after 1 to 2 hours have passed, the burning sensation becomes very painful. Fluorescein examination reveals multiple, tiny pitting defects of the corneal surface, called superficial punctate keratopathy. If only confined to the cornea, and not involving the retina, this problem is generally self limited. The management of hyphema remains controversial, but most experts agree that children should be placed on bed rest with bathroom privileges for at least 5 days and refrain from strenuous activities for 10 days. A fox shield (a metal shield) is also recommended to decrease the chance of further blunt injury in the early days. Topical corticosteroids, oral corticosteroid, and aminocaproic acid (antifibrinolytic agent) have all be advocated to decrease the incidence of re-bleeds. Occasionally, surgical evacuation of a blood clot is necessary to decrease complications, such as uncontrollable intraocular pressure, and corneal blood staining (permanent opacification of the cornea from infiltration of hemoglobin and hemosiderin). A 10 year old boy presents to the pediatrician with a red and teary eye for a day. He had been to a soccer practice on the day before presentation and the red eye began after that. She had forgotten to take off her soft contact lenses the night before because she was too tired. A 4 year old boy presents to the emergency room with a red and painful right eye after a swing had accidentally hit the eye on the playground.
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A peak flow meter can consistently record airflow readings compared against normal values for sex and age. The ultimate objective measurement for asthma is by body plethysmography (body box), which can measure the end expiratory residual lung volume as well as resistance to airflow. For those patients unable to perform peak flow measurements, clinical history is all you may have to base your conclusions. The identification of the role of allergic diseases in asthma relies heavily on patient history. Soft signs indicating that asthma is out of control include: frequent overt wheezing episodes, increasing frequency of using rescue medications. This is based on the patient understanding the principles of: triggers and aggravators, bronchodilation, inflammation, airway hyper-reactivity and healing. Should there be an unanticipated episode of wheezing, immediate activation of the action plan and consultation with the physician for additional treatment schemes is the next step. Obviously, recurrent wheezing episodes, even if reversed easily might indicate the presence of an unstable condition requiring an Page - 298 adjustment in the basic asthma management plan. Step 2 (mild persistent): Day symptoms greater than two times per week, but less than once per day or night symptoms greater than nights per month. The major goal is to allow the child to express and achieve his or her maximum natural potential by not allowing the asthma to control him or her. Along the way, it is crucial to cradle the impressionable self image so that the child does not have a negative view of himself or herself. Bronchodilators In 1896 Solis-Cohen published, "The use of adrenal substances in the treatment of asthma" (adrenalin or epinephrine is a fast and potent bronchodilator). Epinephrine (most commonly administered subcutaneously, but it could be inhaled as well) was the first line of treatment for acute asthma from the 1950s through the 1970s and early 1980s. Although methylxanthines such as theophylline are effective bronchodilators, they have been largely replaced by beta-2 agents. Anti-Inflammatory Drugs Based on the biphasic mechanism, an anti-inflammatory drug. They have an array of impressive and undesirable side-effects, which cause hesitation in their use by physicians as well as patients. They have less potent anti-inflammatory properties, but they have minimal side effects. Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations. Step 3 (moderate persistent) recommends a low dose inhaled corticosteroid plus a long acting beta-2 agonist (salmeterol or formoterol). Step 4 (severe persistent) recommends a high dose inhaled corticosteroid, plus a long acting beta-2 agonist. In addition to the above chronic (long-term) recommendations, acute exacerbations are treated with quick relief (or rescue) medications, which is most commonly prn albuterol and optional short bursts of systemic corticosteroids. If the patient is on inhaled corticosteroids, these should be resumed once systemic corticosteroids are stopped or tapered. Some physicians continue inhaled corticosteroids during systemic corticosteroid bursts to avoid the confusion caused by modifying their chronic medications. All patients should have a written asthma management plan that describes their chronic medications and a plan for the initiation of a rescue plan based on their symptoms and peak flow (if age >5 years). More detailed plans can include recommendations to step up or step down their chronic medications as their chronic symptoms worsen or improve. Inhaled beta-2 agonists can be given continuously for severely ill patients, or serially based on severity. Parenteral corticosteroids do not have an onset time advantage over oral corticosteroids; however, very ill children have a higher likelihood of vomiting oral prednisolone. The decision to start systemic corticosteroids is based on their response to beta-2 agonists and their previous history which indicates their severity level. Those who do not respond well to beta-2 agonists should be started on systemic corticosteroids because, poor response indicates the presence of significant bronchial Page - 300 inflammation Those who have required systemic corticosteroids in the past or who have other markers of more severe asthma should also be started on systemic corticosteroids.
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Prediction of resting metabolic rate in critically ill patients at the extremes of body mass index. A comparison of predictive equations of energy expenditure and measured energy expenditure in critically ill patients. The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies. The prognostic inflammatory and nutritional index in traumatized patients receiving enteral nutrition support. Recognizing malnutrition in adults: definitions and characteristics, screening, assessment, and team approach. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Preoperative immunonutrition in patients at nutritional risk: results of a double-blinded randomized clinical trial. Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Description and prediction of resting metabolic rate after stroke and traumatic brain injury. A reappraisal of nitrogen requirements for patients with critical illness and trauma. Compared with parenteral nutrition, enteral feeding attenuates the acute phase response and improves disease severity in acute pancreatitis. Importance of the early increase in intestinal permeability in critically ill patients. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials. A randomized trial of isonitrogenous enteral diets after severe trauma: an immune-enhancing diet reduces septic complications. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Effect of early compared with delayed enteral nutrition on endocrine function in patients with traumatic brain injury: an open-labeled randomized trial. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Early enteral feeding, compared with parenteral, reduces postoperative septic complications: the results of a meta-analysis. Parenteral vs enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial. Total enteral nutrition vs total parenteral nutrition in patients with severe acute pancreatitis. Gut failurepredictor of or contributor to mortality in mechanically ventilated blunt trauma patients? Influence of different routes of nutrition on respiratory muscle strength and outcome of elderly patients in respiratory intensive care unit. Enteral versus parenteral feeding: effects on septic morbidity after blunt and penetrating abdominal trauma. Visceral protein response to enteral versus parenteral nutrition and sepsis in patients with trauma. Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization.
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