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Developmental Disabilities: Manifest before the person reaches 22 years of age (or 18 in some states), which constitutes a substantial disability to the affected individual, and is attributable to mental retardation or related conditions which include cerebral palsy, epilepsy, autism or other neurological conditions when such conditions result in: Impairment of general intellectual functioning or adaptive behavior similar to that of a person with mental retardation. Unless otherwise specifically stated, the federal definition of "Developmental Disability" found in 42 U. Developmental Delay: the slowed or impaired development of a child who is under 5 years old and who is at risk of having a developmental disability because of the presence of one or more of the following: Chromosomal conditions, Congenital syndromes, Metabolic disorders, Prenatal and prenatal infections and significant medical problems, low birth weight, postnatal-acquired problems. Di George Syndrome: A rare but often complex genetic abnormality caused by a deletion of chromosome 22 with prevalence estimated at 1:4000 live births. The most common presentation in the neonatal period begins with the diagnoses of a cardiac defect. Late presentations of Di George Syndrome can occur in children between the ages of 3-6 who show developmental delays, moderate to severe behavioral problems and recurrent airway infection. Digitized Speech: Human speech that is recorded onto an integrated circuit chip and which has the ability to be played back. Direct Deposit: the standard way to receive Social Security benefits and Supplemental Security Income payments. Your money is sent electronically to an account in a financial institution (a bank, trust company, savings and loan association, brokerage agency or credit union). Discouraged Worker: Persons who had no employment during the survey week, want a job, have looked for work during the past year, and are available to work, but did not look for work in the last four weeks because they believed that no jobs were available to them. They are not counted as unemployed because they have not made specific efforts to find work. Discrimination: the act of treating a person differently in a negative manner based on factors other than individual merit. Dislocated Worker: An employee who has been laid off from his/her job because of a business cutback or plant closure. Dispute Resolution: An umbrella term for processes people can utilize to address their problems or conflicts. Documents (Proofs): Forms and papers such as birth certificates, marriage certificates, W2 forms, tax returns, deeds, etc. We can accept 268 only originals or copies certified by the agency that has the original document. Down Syndrome: A genetic condition caused by extra genetic material (genes) from the 21st chromosome. Individuals with Down Syndrome also have all the other genes given to them by their parents. As a result, they have a combination of features typical of Down Syndrome on top of the individual features from their parents. This can include some degree of mental retardation, cognitive disability and other developmental delays. Duration of Unemployment: the length of time during which a person classified as unemployed has been continuously looking for work. Dyslexia is a learning disability that alters the way the brain processes written material. The range of services include marriage and family problems, stress related problems, financial and legal difficulties, and psychological and workplace conflict. They are the outer ear (the part we see along the sides of our head behind the temples), the middle ear, and the inner ear. Hearing thus involves all parts of the ear as well as the auditory cortex of the brain. The external ear helps concentrate the vibrations of air on the ear drum and make it vibrate. These vibrations are transmitted by a chain of little bones in the middle ear to the inner ear. There they stimulate the fibers of the auditory nerve to transmit impulses to the brain. Early Retirement: You can start getting Social Security retirement benefits as early as age 62, but your benefit amount will be less than you would have gotten at full retirement age. If you take retirement benefits early, your benefit will be permanently reduced, based on the number of months you received checks before you reached full retirement age.

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To subscribe, leave the subject line blank and send the following to dbaction-subscribe-request@home. Usher Syndrome Mailing List this listserv is an Internet forum for people with Usher Syndrome, their parents, friends, spouses, and service providers. Deaf-Blind Techies Mailing List the topic of this listserv is adaptive technology. The purpose of this list is to discuss all types of adaptive technologies related to deafblindness, to exchange information, inquiries, ideas, and opinions about how adaptive technology helps deafblind people. This list is open to deafblind people, professionals, families/friends, and manufacturers. To subscribe to this list, leave the subject line blank and send the following to: dbtechies subscribe request@tr. Paperless Braille Displays Mailing List the topic of this listserv pertains to paperless or refreshable braille displays. The purpose of this list is to discuss all types of refreshable braille displays including notetakers with braille displays, to exchange information, inquiries, ideas, and opinions about all the features offered by each brand of braille display. This list is open to those who use braille displays or those who want to learn to use them, professionals, families/friends, and manufacturers. To subscribe to this list, leave the subject line blank and send the following to: listserv@icors. Ingraham Melinda Couslin Deidre Dockery Like many students exiting secondary programs, deafblind students often lack proper preparation for life after high school. The exact factors that lead to clear-cut positive post-school outcomes have yet to be identified; however, a compilation of the frequently cited skill sets that determine the need for training have been gathered, and will be discussed in this chapter. Due to the demanding academic course load required to obtain a high school diploma, many independent living and life-skills, essential for the deafblind student to live independently, are eliminated from daily school schedules. Parents and educators report that, like all secondary students, deafblind pupils are unable to pack any additional time into their already challenging educational programs (Ingraham, 2001). As a result, deafblind students are often forced to utilize time at the end of the school day, summer vacation or extended holiday breaks to address skill deficits related to independent living skills. In rare instances deafblind students have extended time at the secondary level to allow for adequate training in independent living and other essential life skills. Defining Independence While still in high school, or even during the middle school years, students who are deafblind should have access to secondary and post-secondary resource personnel who can offer a clear understanding of what life after high school will require (Ingraham & Anderson, 2001). These key service providers can be transition coordinators, education team leaders or advocates with specialized skills in deafblindness. The specific services available can and often do include: orientation and mobility instruction, print-to-Braille transcription services, notetaking services, interpreter support services, adaptive technology evaluations and 87 training, funding resources for equipment acquisition, and vocational assessments to determine academic and employment potential. In addition, the student, if not already assigned, should be given chores related to personal needs and household routines. Assuming as much responsibility for personal attire, grooming, organization and social activities as early as possible will help the deafblind student gain more self-assurance and life-experience prior to entering high school. Also, in some states, vocational rehabilitation agencies have lists of Rehabilitation Instructors who can be accessed on a contractual basis for students who may require independent living skills training in the home. Though essential to a successful education placement for deafblind students, many students are naive about how services such as those listed above are typically coordinated. Often students exit the school system uninformed about the wide array of service options, frequency, practicality or rationale for why access to these services may help to make the educational experience both possible and positive. Even though many deafblind students have reached the age of maturity by the time the initial college semester begins, many have not been afforded the opportunity to engage in practical life experiences that involve problem solving or time management. As a result, after arriving on the college campus or entering the adult service system, scores of deafblind students often report feeling lost and before long have squandered significant time trying to figure out all the policies associated with the new academic, residential environment and new level of responsibility (Ingraham & Anderson, 2001). The more time deafblind students are given to exercise self-determination while still in high school, the better equipped they will be upon graduating from the secondary program and taking on primary responsibility for the direction of their adult lives. Yet, for many deafblind students who are entering college, exercising this level of self-determination based on clear and thoroughly researched options may be a very new and frightening concept. This is especially true when students are not accustomed to independently making critical life decisions or problem solving. One very engaging approach to teaching critical thinking and problem solving skills to deafblind students is through the use of board games.

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Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. In immature rats and dogs, the oral and intravenous administration of levofloxacin resulted in increased osteochondrosis. Histopathological examination of the weight-bearing joints of immature dogs dosed with levofloxacin revealed persistent lesions of the cartilage. Other fluoroquinolones also produce similar erosions in the weight-bearing joints and other signs of arthropathy in immature animals of various species [see Animal Toxicology and/or Pharmacology (13. Drug therapy should be discontinued if photosensitivity/phototoxicity occurs [see Adverse Reactions (6. The population studied had a mean age of 50 years (approximately 74% of the population was < 65 years of age), 50% were male, 71% were Caucasian, 19% were Black. Treatment duration was usually 3­14 days, and the mean number of days on therapy was 10 days. The most common adverse drug reactions leading to discontinuation with the 250 and 500 mg doses were gastrointestinal (1. The most common adverse drug reactions leading to discontinuation with the 750 mg dose were gastrointestinal (1. The most common adverse drug reactions (3%) are nausea, headache, diarrhea, insomnia, constipation, and dizziness. Table 6: Postmarketing Reports Of Adverse Drug Reactions System/Organ Class Adverse Reaction pancytopenia Blood and Lymphatic System aplastic anemia Disorders leukopenia hemolytic anemia [see Warnings and Precautions (5. Tablets with antacids containing magnesium, aluminum, as well as sucralfate, metal cations such as iron, and multivitamin preparations with zinc or didanosine may substantially interfere with the gastrointestinal absorption of levofloxacin, resulting in systemic levels considerably lower than desired. Similarly, no apparent effect of warfarin on levofloxacin absorption and disposition was observed. Patients should also be monitored for evidence of bleeding [see Adverse Reactions (6. Therefore, careful monitoring of blood glucose is recommended when these agents are co-administered [see Warnings and Precautions (5. Similarly, no apparent effect of theophylline on levofloxacin absorption and disposition was observed. However, concomitant administration of other fluoroquinolones with theophylline has resulted in prolonged elimination half-life, elevated serum theophylline levels, and a subsequent increase in the risk of theophylline-related adverse reactions in the patient population. Adverse reactions, including seizures, may occur with or without an elevation in serum theophylline levels [see Warnings and Precautions (5. However, elevated serum levels of cyclosporine have been reported in the patient population when co-administered with some other fluoroquinolones. Levofloxacin Cmax and ke were slightly lower while Tmax and tЅ were slightly longer in the presence of cyclosporine than those observed in other studies without concomitant medication. Levofloxacin absorption and disposition kinetics were similar in the presence or absence of digoxin. Confirmation of positive opiate screens by more specific methods may be necessary. Levofloxacin was not teratogenic in rats at doses as high as 810 mg/kg/day which corresponds to 9. The oral dose of 810 mg/kg/day to rats caused decreased fetal body weight and increased fetal mortality. No teratogenicity was observed when rabbits were dosed orally as high as 50 mg/kg/day which corresponds to 1. Inhalational Anthrax (Post-Exposure) Levofloxacin is indicated in pediatric patients 6 months of age and older, for inhalational anthrax (post-exposure). The risk-benefit assessment indicates that administration of levofloxacin to pediatric patients is appropriate. The safety of levofloxacin in pediatric patients treated for more than 14 days has not been studied [see Indications and Usage (1. Plague Levofloxacin is indicated in pediatric patients, 6 months of age and older, for treatment of plague, including pneumonic and septicemic plague due to Yersinia pestis (Y.

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Lung transplantation remains the final treatment option over the course of the disease. In addition, even among those who undergo a transplant, median survival is only 4. Discussion with patients as to goals of therapy, expected benefits, and potential adverse effects and interventions to mitigate these are imperative before initiating treatment with specific therapeutic agents. It is essential, therefore, that all members of the healthcare team, from the primary care physicians to the pharmacy benefits managers, understand the course and evolution of the disease, the range of comorbidities, and the potential for acute exacerbations. Furthermore, there is a significant potential for drug interactions with increasing polypharmacy as treatment evolves and comorbidities appear. Through drug utilization reviews, prescriptions should be monitored to ensure that old medications that are no longer needed or do not appear to be effective will not continue to be used in error; in addition healthcare professional should ensure compliance with medications to promote optimal well-being. Funding source: this activity is supported by educational grants from Genentech and Boehringer Ingelheim Pharmaceuticals, Inc. Authorship information: Analysis and interpretation of data; drafting of the manuscript; and critical revision of manuscript for important intellectual content. Mortality from pulmonary fibrosis increased in the United States from 1992 to 2003. Incidence and prevalence of idiopathic pulmonary fibrosis: review of the literature. Idiopathic pulmonary fibrosis: a disease with similarities and links to cancer biology. Familial pulmonary fibrosis is the strongest risk factor for idiopathic pulmonary fibrosis. Inhalation of inorganic particles as a risk factor for idiopathic pulmonary fibrosis-elemental microanalysis of pulmonary lymph nodes obtained at autopsy cases. Serial development of pulmonary hypertension in patients with idiopathic pulmonary fibrosis. Impact of pulmonary hypertension on gas exchange and exercise capacity in patients with pulmonary fibrosis. Depression is a common and chronic comorbidity in patients with interstitial lung disease. Prognosis of patients with advanced idiopathic pulmonary fibrosis requiring mechanical ventilation for acute respiratory failure. Outcome of patients admitted to the intensive care unit for acute exacerbation of idiopathic pulmonary fibrosis. Ventilator settings and outcome of respiratory failure in chronic interstitial lung disease. Lung transplantation in idiopathic pulmonary fibrosis: a systematic review of the literature. The course of illness is complicated by multiple comorbidities that impact prognosis and quality of life and adversely affect survival. Therefore, it is important for healthcare professionals to understand the range of therapeutic options, as well as the appropriate use of agents and interventions. Unfortunately, not all patients are eligible for lung transplantation, and while conferring a survival benefit, the median survival of 4. Treatment focuses on both disease- and symptom-centered management with emphasis shifting from disease-centered to symptom-centered, as the disease progresses. These treatments however, have safety concerns and should not be administered concurrently with certain medications. In addition, recent clinical trials have shed new light on other treatment approaches. This results in scarring of the lung, remodeling of the lung architecture, and irreversible loss of function. The search for an effective treatment was directed at compounds targeting the wound-healing cascade and fibrogenesis, but due to the vast number of mediators, growth factors, signaling pathways, and redundancy of systems involved in the process, finding effective treatments has been challenging. As was the standard practice, guidelines were developed based on a consensus approach. Lung transplantation is the only treatment that has shown improved survival in a select patient population despite a median survival of only 4. Patients with a high risk of death should be considered for lung transplantation, while a limited group of patients may be eligible for pharmacologic treatment, as long as they are willing to accept the potential adverse events compared with unknown potential benefits.

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However, monitoring the response to those changes may require novel approaches such as monitoring of shallow groundwater near streams, because it may take years before changes in water quality can be observed in the stream itself. These models account for erosion and/or deposition of sediment from different land uses and in stream channels, and can be accessed and manipulated (in the case of Schwarz, 2008) through a new decision support system cida. These models conclude that stream banks represent a significant source of sediment loads. Existing spatial datascts have also been used to characterize the relative importance of stream bank erosion to downstream water bodies. While the analysis of existing sediment and spatial data can provide information on long-term, average sediment contributions from stream banks, understanding the mechanisms and causes of stream bank erosion requires more intensive data collection and/or modeling efforts. Wilson and his colleagues, whose work is referenced in the question, have published on various processes that affect streambank failure. Compilation of sediment budgets through surveys and through the collection of physical and geochemical sediment tracers have allowed researchers to quantify the relative importance of various sediment sources (Walling, 2005; Gellis and Walling, 2011). Question 9: Some areas of the country have extensively modified streams and rivers, which were channelized into concrete lined flood control channels Should nutrients in concrete linedflood control channels be regulated the same as natural streams? Response: States have some degree of flexibility under the Clean Water Act regarding how they apply Clean Water Act standards to a specific waterbody. Concrete-lined flood control channels may or may not meet the statutory and regulatory definition of"watcrs of the United States" and therefore may or may not be subject to the provisions of the Clean Water Act. If a specific waterbody such as a heavily modified stream is jurisdictional under the Clean Water Act, States have some flexibility under the Clean Water Act in how they apply water quality standards to that waterbody. For example, states may be able to tailor the specific designated uses of a particular waterbody to its characteristics. If a State analysis supports a change in the designated use, States may change the designated use in their Water Quality Standards regulations. A change in designated use can often result in a change to the water quality criteria that must be met. If the State determines that the designated use for an altered habitat is not achievable, then the State can conduct a use attainment analysis. Many of our waters do not meet the aquatic life or recreation water quality goals envisioned by Section 101 (a)(2) of the Clean Water Act. Accomplishing these tasks would require substantial rebuilding and enhancements of current monitoring and assessment activities to address these critical public issues. The National Research Council (2011) has reviewed the plans and supports the recommendations. However, at present, agency resources are insufficient to fully address these needs. The fourth action is a critical information requirement; but should be addressed by those agencies responsible for nutrient management programs. States allocate some of the Nonpoint Source Program grants under Section 319 of the Clean Water Act to monitoring the localized effectiveness of best management practices, including those aimed at reducing nonpoint source nutrient loads. Nutrient enrichment and fisheries exploitation: interactive effects on estuarine living resources and their management. Land-based Lidar mapping-a new surveying technique to shed light on rapid topographic change. Committee on Environment and Natural Resources, 2010 Scientific assessment of hypoxia in U. Coastal Waters, Interagency Working Group on Harmful Algal Blooms, Hypoxia, and Human Health of the Joint Subcommittee on Ocean Science and Technology, Washington D. Elser, James, and Bennett, Elena, 2011, Phosphorus: a broken biogeochemical cycle: Nature, v. In: Oxygen depletion and associated benthic mortalities in New York Bight, 1976, R. The need for sediment surrogate technologies to monitor fluvial-sediment transport.

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Differences between groups were determined with the Chi-square at level of significance (p<0. Ethical considerations the study was carried out from December 2015 to august 2016 after due permission from the Institutional Ethics Committee and after getting consent (in written form) from all the participating subjects. Highest incidence is seen in Primigravida and lowest incidence is seen in multigravida. The highest incidence seen in <25 yrs (60%) and lowest incidence is seen in >30yrs (4%). Multigravida has an increased risk factor of developing bacteriuria among pregnant women according to various studies. In ourstudy highest incidence is seen in Primigravida (60%) and lowest incidence is in Multigravida (19%) the result of our study is not significant at (p<0. Present study showed higher number of pus cells >20/ hpf in 60% of cases and 10-20/hpfin 40% of cases. The increased incidence during third trimester may relate to increased mechanical obstruction due to gravid uterus. Prevalence of Urinary Tract Infection among pregnant women and its complications in their newborns during the birth in the hospitals of Dezful city, Iran, 2012-2013. Prevalenceof Urinary Tract Infection among pregnant women at Bugando Medical Center, Mwanza, Tanzania. Detection Of Urinary Tract Infection Among Pregnant Women In Oluyoro Catholic Hospital,Ibadan,South-Western Nigeria. Prevalence of Asymtomatic Bacteriuria among Pregnant Women Attending Antenatal in Port Harcourt Township, Nigeria and Antibiogram of Isolated Bacteria. Bacterial profile of Urinary Tract Infection and Anti microbial Susceptibility Pattern among Pregnant attending women at Antenatal clinic in DilChora referral Hospital,DireDawa,EasternEthiopia. Associated Risk Factors of Urinary Tract Infection among Pregnant women at SelegeHiwot referral Hospital, BahirDar,North West Ethiopia. Detection of Urinary Tract Infection among Pregnant women in a Tertiary care Hospital. AsymptomaticBacteriuria among Antenatal care women in a Tertiary hospital in Benin, Nigeria. Rising Prevalence of Antimicrobial Resistance in Urinary Tract Infections during Pregnancy:Necessity for Exploring Newer Treatment Options. Incidence of Urinary Tract Infection among Pregnant women attending Antenatal clinic at Federal Medical Centre,Bida,Niger-State, North Central Nigeria. Incidence of Urinary Tract Infections and its Aetiological Agents among Pregnant women in Karnataka Region. Prevalence and Screening: International Journal of Current Microbiology and Applied Sciences. A Preliminary Assessment of Asymptomatic Bacteriuria of Pregnancy in Brunei Darussalam. PregnancyOutcomes:A Comparison of women with Symptomatic and Asymptomatic Bacteriuria in Cape Coast,Ghana. Asymptomatic Bacteriuria in Antenatal Patients Attending State Hospital, Ado-Ekiti,Ekiti State,Nigeria. Prevalence of Asymptomatic Bacteriuria and its Antibacterial Susceptability Pattern among Pregnant women Attending the Antinatal Clinic at Kanpur,India. Asymptomatic Bacteriuria among Pregnant women refer to Outpatient Clinics in Sanandaj, Iran. Bacterial Profile and Drug Susceptibility Pattern of Urinary Tract Infection in Pregnant women at University of Gondar Teaching Hospital,Northwest Ethopia. Urinary Tract Infection during Pregnancy and Mental Retardation and Developmental Delay. Prevalence of Urinary Tract Infection, Microbial Aetiology, and Antibiotic Sensitivity Pattern among Antenatal Women Presenting with Lower Abdominal Pains at Kenyatta National Hospital,Nairobi, Kenya. Isolation and Identification of Bacteria causing Urinary Tract Infections in Pregnant women in Vidarbha and their drug Susceptibility Patterns in them. Pregnant women admitted with Urinary Tract Infections to a Public Sector Hospital in South Africa. The Prevalence of Urogenital Infections in Pregnant Women Experiencing Preterm and Full-Term Labor: Infect Dis Obstetrics Gynecol.

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Adults with sore throat and 2 (3 if 45 yo) or more of the following features should get a rapid test: 1. See references for additional treatment options and other important information especially if early pyelonephritis is suspected. Appropriate antibiotic use for acute respiratory tract infection in adults: Advice for high-value care from the american college of physicians and the centers for disease control and prevention. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Diagnosis, microbial epidemiology, and antibiotic treatment of acute otitis media in children: A systematic review. Principles of judicious antibiotic prescribing for upper respiratory tract infections in pediatrics. American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. See references for more details, additional treatment options, including re-treatment after initial treatment failure, supportive care, and other important information. Streptococcal pharyngitis is primarily a disease of children 5-15 yo and is rare in preschool children. Children with sore throat plus 2 or more of the following features should undergo a rapid test: 1. Diagnosis Usually nasal discharge begins as clear and changes throughout the course of the illness. These substances are among the top 20 substances leading to death in children <5 yo. Unless hospitalized, neither albuterol nor nebulized racemic epinephrine should be administered to infants and children with bronchiolitis. There is no role for corticosteroids, ribavirin, or chest physiotherapy in the management of bronchiolitis. See references for more details, additional treatment options, and other important information. Urine testing for all children 2-24 mo with unexplained fever is no longer recommended. Management Initial antibiotic treatment should be based on local antimicrobial susceptibility patterns. A report from May 2016 Antibiotic Use in Outpatient Settings Health experts create national targets to reduce unnecessary antibiotic prescriptions the Pew Charitable Trusts Susan K. Although they have reviewed the report, neither they nor their organizations necessarily endorse its findings or conclusions. We would further like to thank those who participated on the expert panel that developed the antibiotic reduction targets that serve as the foundation for this report: Eva Enns, Thomas File, Jonathan Finkelstein, Jeffrey Gerber, Adam Hersh, Jeffrey Linder, Ruth Lynfield, David Margolis, Larissa May, Daniel Merenstein, Joshua Metlay, Jason Newland, Jay Piccirillo, Daniel Shapiro, Katie Suda, Ann Thomas, and Teri Moser Woo. Additionally, the project team would like to thank the following Pew colleagues for their assistance in the development of this report. Thanks to Tia Carter, a former colleague, for help in coordinating and convening the expert panel; and to Sarah Despres for lending her expertise to this effort. Finally, thanks to Heather Cable, Katie Portnoy, Laurie Boeder, Demetra Aposporos, Bailey Gregory, and Dan Benderly for providing valuable feedback and production assistance on this report. Pew applies a rigorous, analytical approach to improve public policy, inform the public, and invigorate civic life. Contents 1 2 Overview Background Importance of improved antibiotic stewardship2 3 5 Establishing a baseline of outpatient antibiotic use Establishing national targets for reducing unnecessary antibiotic use in outpatient settings Overarching recommendations for reduction8 Acute respiratory conditions8 Sinus infections9 Middle ear infections10 Pharyngitis11 Viral upper respiratory infections12 Bronchitis and bronchiolitis13 Asthma and allergy13 Influenza14 Pneumonia15 Other conditions16 17 Reaching national targets for improved antibiotic use: the role of antibiotic stewardship Outpatient antibiotic stewardship: What does it look like? These drugs should be used only to treat bacterial infections and, when needed, the right antibiotic should be prescribed at the most appropriate dose and duration. Yet antibiotics are often prescribed inappropriately across health care settings in the United States. Antibiotic stewardship efforts, which aim to ensure that these drugs are prescribed appropriately, are critical for combating the public health threat posed by antibiotic-resistant pathogens.

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Interventions with proven effect for prevention are clustered in the preconception, between pregnancy and pregnancy periods as well as during preterm labor (Figure 3). Interventions to reduce death and disability among premature babies can be applied both during labor and after birth. If interventions with proven benefit were universally available to women and their babies. While requiring a long-term investment, risks for preterm birth and the solutions needed to reduce these risks during each stage of the reproductive, maternal, newborn and child health continuum, are becoming increasingly evident (Chapters 3-5). However, for many of these risks such as genital tract infections, we do not yet have effective program solutions for prevention. For premature baby care, the greatest emphasis should be on development and delivery research, learning how to implement what is known to be effective in caring for premature babies, and this has a shorter timeline to impact at scale (Chapter 6). Some examples include adapting technologies such as robust and simplified devices for support for babies with breathing difficulties, or examining the roles of different health care workers. A global action agenda for research Preterm birth has multiple causes; therefore, solutions will not come through a single discovery but rather from an array of discoveries addressing multiple biological, clinical, and social-behavioral risk factors. The dual agenda of preventing preterm birth and addressing the care and survival gap for premature babies requires a comprehensive research strategy, but involves different approaches along a pipeline of innovation. The pipeline starts from describing the problem and risks more thoroughly, through discovery science to understanding causes, to developing new tools, and finally to research the delivery of these new tools in various health system contexts. Research capacity and leadership from low- and middle-income countries is critical to success and requires strategic investment. After the publication of this report, a technical expert group will be convened to establish a goal for reduction of preterm birth rate by 2025 for announcement on World Prematurity Day 2012. Photo: Ritam Banerjee for Getty Images/Save the Children Primary role Secondary role: supporting effort Invest Ensure preterm interventions and research given proportional focus, so funding is aligned with health burden Plan and implement preterm birth strategies at global and country level and align on preterm mortality reduction goal Introduce programs to ensure coverage of evidence-based interventions, particularly to reduce preterm mortality Perform research to support both prevention and treatment agendas Implement Innovate Pursue implementation research agenda to understand how best to scale up interventions Significantly improve preterm birth reporting by aligning on consistent definition and more consistently capturing data Raise awareness of preterm birth at all levels as a central maternal, newborn and child health issue Continue support for Every Woman Every Child and other reproductive, maternal, newborn and child health efforts, which are inextricably linked with preterm birth Ensure accountability of stakeholders across all actions Inform G o po ver lic nm ym en a ts D an on ker an s d d or ph c ou ila nt nt hr rie U m N a op s y ul n til d at ot er he al r C s iv il so ci et y Bu co m sin m es H un s ea ity & lth as ca so re ci w Ac a o re ade tion rke se m s rs ar ic ch s er an s d Figure 4: Shared actions to address preterm births P r e t e r m B i r t h m at t e r s Photo: © March of Dimes 9 Chapter 1. Prematurity is now the second-leading cause of death in children under 5 years and the single most important cause of death in the critical first month of life (Liu et al. Given its frequent occurrence, it is likely that most people will experience the challenge, and possible tragedy, of preterm birth at some point in their lives, either directly in their families or indirectly through friends. Born Too Soon presents the first published country-level estimates on preterm birth. These estimates show that prematurity is rising in most countries where data are available (Blencowe et al. The reasons for the rise in prematurity, especially in the later weeks of pregnancy, are varied and are discussed in later chapters of the report. The implications of being born too soon extend beyond the neonatal period and throughout the life cycle. Babies who are born before they are physically ready to face the world often require special care and face greater risks of serious health problems, including cerebral palsy, intellectual impairment, chronic lung disease, and vision and hearing loss. This added dimension of lifelong disability exacts a high toll on individuals born preterm, their families and the communities in which they live (Institute of Medicine, 2007). The Millennium Development Goals and beyond the substantial decline in high-income countries in maternal, newborn and child deaths in the early and middle 20th century was a public health triumph. Much of this decline was due to improvements in socioeconomic, sanitation and educational conditions and in population health, most notably a reduction in malnutrition and infectious diseases (Howson, 2000; World Bank, 1993). These advances in public health also resulted from strengthened political will prompted by public pressure, often by health professionals, who demanded attention to and investment in the necessary sanitary measures, drugs and technologies that were responsible for the decline in maternal and child mortality in industrialized countries in the 20th century (de Brouwere et al. Many low- and middle-income countries are now experiencing a similar "health transition," defined as an "encompassing relationship among demographic, epidemiologic and health changes that collectively and independently have an impact on the health of a population, the financing of health care and the development of health systems" (Mosley et al. Low- and middle-income countries are sometimes referred to as developing and high-income economies as industrialized. Although convenient, these terms should not imply that all developing countries are experiencing similar development or that all industrialized countries have reached a preferred or final stage of development (World Bank, 2012). The need to monitor progress has also led to improved and more frequent use of health metrics and to collaboration and consensus on how to strengthen primary health care systems from community-based interventions to the first referral-level facility at which emergency obstetric care is available (Walley et al. Child survival programs have primarily focused on important causes of death after the first 4 weeks of life such as pneumonia, diarrhea, malaria and vaccine-preventable conditions (Martines et al.

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Repeated failures to replicate do lead to reconsideration of the original findings. Eventually, we may conclude that the original results were a fluke-a Type I error was made in the statistical analysis. This is especially likely when unsuccessful attempts to replicate employ not only the original procedures but different procedures as well. The Importance of Replications Conceptual Replications the use of different procedures to replicate a research finding is called a conceptual replication. Conceptual replications are even more important than exact replications in furthering our understanding of behavior. In most research the goal is to discover whether a relationship between conceptual variables exists. This conceptual replication has been conducted by researchers at the University of California, Irvine (Rauscher et aI. Preschoolers who took piano lessons once a week for a year scored 34% higher on puzzle-solving tests than children in a control group who received computer lessons, singing lessons, or no special instruction. This is an important extension of the original findings, underscoring the potential value of musical instruction in schools. Chisholm and her colleagues (Chisholm, 1997; Chisholm, Carter, Ames, & Morison, 1995) investigated the development of attachment in Romanian orphans who were adopted early in infancy (before age 4 months) and later in infancy (after spending at least 8 months in an orphanage). The children adopted later in infancy were more likely to show atypical forms of insecure attachment (52% of later adoptees vs. The timing of adoption appears to be critical in the development of a secure attachment to a caregiver. A conceptual replication of this study was conducted by other attachment researchers (Dozier & Stovall, 1997) who evaluated attachment in children placed in foster care at varying ages during infancy. The pattern of findings is consistent with the work on adopted children; the most severe attachment problems occurred with infants who entered foster care at 8 months or older. In a conceptual replication, the same independent variable is manipulated in a different way (and possibly the dependent variable is measured in a different way also). Such conceptual replications are extremely important in the social sciences because the specific manipulations and measures are usually operational definitions of complex variables. A crucial generalization question is whether the relationship holds when other ways of manipulating or measuring the variables are studied. Do different types of alternate caregiver relationships such as adoption or foster care by relatives lead to the same disruption in attachment reported by Chisholm (1997) and Dozier and Stovall (1997)? When conceptual replications produce similar results, our confidence in the generalizability of relationships between variables is greatly increased. In sum, replication, exact or conceptual, provides important evidence about the generalizability of a finding. The ability to precisely replicate the findings of a study or to extend the findings of a study by employing different procedural approaches enhances the theoretical importance of a finding. Replication studies are a fruitful avenue for research, adding substantially to our knowledge about development. A researcher interested in breaking the cycle of teen pregnancy is unlikely to test all pregnant teenagers. Results obtained on the sample of girls are then generalized to the larger population. This extension of the findings is possible only if the sample is, in fact, representative of the larger group. Random sampling from the population is the best way to ensure that a representative sample has been employed, yet researchers almost never use random sampling to select from the general population. As we noted in earlier chapters, individuals who participate in research are usually selected because they are available. This nonrandom selection of participants creates a "convenience" sample rather than a random sample. Such a convenience sample may differ on important participant characteristics that limit the generality of results and limit our ability to make rational conclusions about development. Important participant characteristics include volunteer status, educational level, age, and diversity issues such as gender, ethnicity, race, and social status. Volunteers One important way that participants differ from nonparticipants is that most research participants are volunteers. Volunteers differ in important ways from nonvolun- 277 teers (Rosenthal & Rosnow, 1975).

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Gross Pathology: Irregularly shaped, but welldemarcated, coalescing nodules (2 to >10 cm in diameter) of firm, pale tan tissue were distributed through all lobes of the lung. Histopathologic Description: Lung: the pulmonary nodules are well-demarcated from unaffected lung and are the result of interstitial fibrosis. Within the nodules, -alveolar septa are thickened up to 100 µm or more by fibrous tissue composed of birefringent, orderly collagen fibers with low to moderate cellularity (well-differentiated fibroblasts) and light infiltration by lymphocytes, plasma cells and fewer neutrophils. Alveolar spaces are lined by cuboidal epithelial cells with pale vacuolated cytoplasm, and are partially filled with macrophages, neutrophils, exfoliated epithelial cells, and debris. Intranuclear eosinophilic to amphophilic inclusion bodies are easiest to find in alveolar macrophages. Bronchi and bronchioles within the nodules are filled with similar exudate and surrounded by increased fibrous tissue. Irregularly shaped, but well-demarcated, coalescing nodules (2 to >10 cm in diameter) of firm, pale tan tissue were distributed through all lobes of the lung. Photograph courtesy of Purdue University, Animal Disease Diagnostic Laboratory, Alveolar macrophages occasionally contain an eosinophilic intranuclear inclusion body that marginates chromatin (arrow). Salient gross lesions were restricted to the lungs and bronchial lymph nodes, and usually appeared as numerous coalescing fibrotic nodules that involved most of the lung. A less common macroscopic presentation was as multiple discrete and larger fibrotic nodules, separated by unaffected pulmonary parenchyma. Histologically, well-organized, mature fibrous tissue expand the interalveolar septa with preservation of alveolar architecture. Alveolar spaces are lined by cuboidal cells, and contain neutrophils and macrophages. Multinodular pulmonary fibrosis is histologically distinct from the pulmonary interstitial fibrosis of silicate pneumoconiosis, which is associated with granulomatous inflammation, and from idiopathic pulmonary fibrosis, which more commonly affects foals than adults and is attributed to diffuse alveolar damage. Inappetance, weight loss, fever, cough, and respiratory distress were common to all 5 cases in that study. There is marked lymphadenomegaly of the bronchial lymph nodes resulting from lymphoid hyperplasia with sinus histiocytosis. An interstitial pneumonia of donkeys has been reported which is associated with asinine herpesvirus. Conference participants noted that pleural arteries were often hypertrophied and surrounded by abundant collagen. This is likely due to increased intrapulmonary blood pressure due to the diffuse fibrosis, which inhibits adequate blood flow through large portions of the affected lung. Conference participants also discussed a differential diagnosis that included paraquat and diquat toxicosis, which causes fulminant pulmonary fibrosis, although due to the dwindling availability of these compounds, this differential is becoming exceedingly rare. Another possibility is exercise-induced pulmonary hemorrhage, which also has large areas of pulmonary fibrosis, but is characterized by numerous hemosiderophages, and lacks intranuclear inclusion bodies. This histologic finding is expected with interstitial pneumonias in which there is abundant protein exudation, as well as viral-induced leukocyte chemotaxis. Association of two newly recognized herpesviruses with interstitial pneumonia in donkeys (Equus asinus). Equine multinodular pulmonary fibrosis: a newly recognized herpesvirus-associated fibrotic lung disease. History: this dog, submitted by a Humane Society that had received several complaints from residents that the dog was neglected and left outdoors during the winter, was found dead and frozen in an outdoor enclosure. Gross Pathology: the dog was thin (body condition score = 2/5) with easily palpable ribs and only a small amount of subcutaneous fat. There were small amounts of visceral fat and no evidence of serous fat atrophy in the bone marrow. The lungs had dark red mottling with lobes on the right side appearing darker than those on the left. Additionally, there were multifocal to coalescing tan-white areas (~10% of overall lung volume) that were firmer than the surrounding lung tissue and were slightly collapsed. These areas were mainly distributed along the margins of the lung with the largest area (2 cm X 2 cm) having a dark red center. The stomach was filled with food and had a roughly 2 X 3 cm area of congestion on the serosal and mucosal surfaces.

References:

  • https://wa.kaiserpermanente.org/static/pdf/public/bariatric/plans.pdf
  • https://www2.ed.gov/admins/lead/academic/ells/e28-03.pdf
  • https://www.thoracic.org/statements/resources/tb-opi/idsaats-cap.pdf
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