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By: S. Asam, M.A., M.D., Ph.D.
Deputy Director, Keck School of Medicine of University of Southern California
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The Higgs field has been used to develop a unified field theory incorporating all the fundamental interactions of matter. Experimental support for the field has been indicated in recent particle discoveries, but not all predicted particles have yet been observed. Such phenomena as non-causality and non-locality were so contrary to everyday experience that physicists, including Einstein, were forced to undergo a revolution in their thinking during the past century [39]. Nevertheless, most psychologists, neuroscientists, and philosophers of mind continue to think in terms of classical physics [50]. That is, to increase the level of awareness means to apprehend more of what is given in experience. At the lowest level (1), awareness is limited to aspects of our sexual drive, which is usually predominant in individuals with personality disorders. At the second level (2), labeled consumption, there is awareness of aspects of nutrition and growth. At the third level (3), there is awareness of the emotional attachments and aversions of oneself and others. At the fourth level (4), there is social communication and awareness of the processing and the formation of words as we try to understand experience by our individ ual intellect. The fifth level (5), integration, is the level of direct awareness or apperception of experience intuitively. Thus individual differences in ma turity are understood as individual differences in the usual level of appre hension of reality, i. Each level also has five sublevels, because each level has aspects of each of the other levels. The forces from the body associated with each of the first four non-integrated levels are called temperaments. Each temperament dimension involves information process ing in partly overlapping subdivisions of the limbic system, which are centrally integrated in the hypothalamus and supervised by neocortical association cortex according to extensive work on comparative neuroanat omy [54] and more recent brain imaging and neurophysiological research [28, 55]. The hypothalamus centrally integrates input from the limbic sub divisions and regulates the tonic opposition of sympathetic and parasympa thetic branches of the autonomic nervous system. The autonomic nervous system maintains homeostasis by the opposition of its parasympathetic functions (such as sexual arousal, feeding, digestion and storage of nutri ents, elimination, and sleep) and its sympathetic functions (such as sexual orgasm, preparation for fighting or flight, wakefulness). Accordingly, it is not surprising that each of the limbic subdivisions also regulates the tonic opposition of pairs of such psychodynamic drives, each of which has advantages and disadvantages depending on the context. In terms of func tional neuroanatomy, there are opposing drives for sexuality vs. In psychodynamic terms [56], the first level of sexuality involves the opposition of the outpouring of libidinal energy vs. Harm avoidance is manifest as shyness and fatigability whereas libido is manifest as outgoing vigor and daring.
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Interventions for fatigue and weight loss in adults with advanced progressive illness. Long-term survival in patients hospitalized for chronic obstructive pulmonary disease: a prospective observational study in the Nordic countries. Managing passengers with stable respiratory disease planning air travel: British Thoracic Society recommendations. Oxygen supplementation during air travel in patients with chronic obstructive lung disease. Air travel and chronic obstructive pulmonary disease: a new algorithm for pre-flight evaluation. Development of severe hypoxaemia in chronic obstructive pulmonary disease patients at 2,438 m (8,000 ft) altitude. Retrospective Assessment of Home Ventilation to Reduce Rehospitalization in Chronic Obstructive Pulmonary Disease. Lung-volume reduction improves dyspnea, dynamic hyperinflation, and respiratory muscle function. Lung transplantation in patients with chronic obstructive pulmonary disease in a national cohort is without obvious survival benefit. Survival after bilateral versus single lung transplantation for patients with chronic obstructive pulmonary disease: a retrospective analysis of registry data. The basis for these recommendations, which propose an organized approach to treatment, is only partially from evidence generated in randomized controlled trials. Healthcare providers are pivotal in delivering smoking cessation messages and interventions to patients. When possible, the patient should be referred to a comprehensive smoking cessation program, incorporating behavior change techniques that focus on enhancing patient motivation and confidence, patient education, pharmacologic and non-pharmacologic interventions. Recommendations 1 for treating tobacco use and dependence are summarized in Table 4. Long-acting inhaled bronchodilators are superior to short-acting bronchodilators taken as needed i. Consideration to the development of resistant organisms should be factored into decision making. A reported lack of efficacy, an elevated risk of adverse effects (including pneumonia) and evidence showing no significant harm from withdrawal supports this recommendation (see Chapter 3 for further details). However, most published studies to date provide little guidance, being inconsistent in the techniques, and lacking the necessary details. Key time points when it may be appropriate to consider referral are: (a) at diagnosis, (b) at discharge following hospitalization for an exacerbation, and (c) when symptoms are found to be progressively deteriorating. These could relate to each patient at different time points of the disease trajectory. Because benefits diminish over time if activity and other positively adaptive behaviors are not continued, patients should be offered a maintenance program, or at least supported sufficiently to increase and maintain physical activity in daily living. The components of pulmonary rehabilitation may vary but evidence-based best practice for program delivery includes: structured and supervised exercise training, smoking cessation, nutrition counseling, and self-management education.
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Prevention of venous thromboembolism in orthopedic bibliography 2004 surgery with vitamin K antagonists: A meta-analysis screened Does not address Mechanical prophylaxis of deep-vein thrombosis after total Pitto et al. Excluded Studies Considered for Prophylaxis Reason for Author Title Exclusion Narrative review, Venous thromboembolism prophylaxis: role of factor xa Turpie 2004 bibliography inhibition by fondaparinux screened Prevention of deep-vein thrombosis after total knee Does not address Wang et al. Comparison of low comparison of 2004 molecular-weight heparin and indomethacin interest Not best available Wenzl et al. Prevention of thromboembolism with low-molecular-weight evidence (case 2004 heparin in orthopedic surgery: a 5-year experience series) Charalambous Foot pump prophylaxis for deep venous thrombosis-rate of Does not examine et al. A interest randomized, double-blind study Risk of clinical pulmonary embolism after joint surgery in Not best available Dahl et al. Excluded Studies Considered for Prophylaxis Reason for Author Title Exclusion Efficacy and safety of bemiparin compared with enoxaparin Does not address Navarro-Quilis in the prevention of venous thromboembolism after total comparison of et al. Comprehensive deep venous thrombosis prevention strategy evidence (case 2003 after total-knee arthroplasty series) Not best available Reitman et al. A multimodality regimen for deep venous thrombosis evidence (case 2003 prophylaxis in total knee arthroplasty series) Does anticoagulation do more harm than good Compliance in using a pneumatic compression device after patient oriented 2003 total knee arthroplasty outcomes Systematic review, Zufferey et al. Optimal low-molecular-weight heparin regimen in major bibliography 2003 orthopaedic surgery: A meta-analysis of randomised trials screened Not best available Comparison of a nomogram and physician-adjusted dosage Anderson et al. Excluded Studies Considered for Prophylaxis Reason for Author Title Exclusion Anticoagulant effect at the time of epidural catheter removal Does not report Douketis et al. A comparison of 2002 randomized, double-blind trial interest Standardized mortality ratios and fatal pulmonary embolism Not best available Khan et al. Thromboprophylaxis dosing: the relationship between bibliography 2002 timing of first administration, efficacy, and safety screened Not best available Prevention of thromboembolic disease after non-cemented Leali et al. A multimodal approach series) Not best available Macdonald et Computerized management of oral anticoagulant therapy: evidence (case al. Prophylaxis against venous thromboembolic disease in bibliography 2002 patients having a total hip or knee arthroplasty screened Preoperative or postoperative start of prophylaxis for venous Systematic review, Strebel et al. Excluded Studies Considered for Prophylaxis Reason for Author Title Exclusion A meta-analysis of fondaparinux versus enoxaparin in the Systematic review, Turpie et al. Not specific to Prevention of pulmonary embolism by a foot sole pump 2001 elective arthroplasty Benko et al. Graduated compression stockings: Knee length or thigh Does not report 2001 length outcome of interest Systematic review, Brookenthal et A meta-analysis of thromboembolic prophylaxis in total bibliography al.
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Regarding the duration of dexamethasone therapy, European guidelines recommend a total duration of 4 days in case of pneumococcal and Hib meningitis in children [7,21] whereas American guidelines recommend the use of dexamethasone for 2 4 days in children with Hib meningitis. Other adjunctive therapies the use of osmotic agents, such as mannitol or hypertonic saline, has been proposed to reduce intracranial pressure, but they are not recommended for children with bacterial meningitis as there are not sufficient data to prove favorable outcome. On the other hand, glycer ol and therapeutic hypothermia should not be used in bacterial meningitis, as increased mortality has been associated with their use [7]. The impact of conjugate vaccines Conjugate vaccines, comprising a conjugate between an antigenic protein and a polysaccharide, have been developed against a variety of bacterial species to overcome the issues associated with the T cell-independent immunological characteristics of pure polysaccharide antigens [29]. In particular, a conjugate vaccine, depending on T cell dependent response, is expected to have benefits over a polysac charide vaccine, in terms of booster response, immunological memory and generally improved immune responses, due to the T cell dependent characteristics of the immune response. Thus, immunological memory is established and herd immunity effect is enhanced with the use of conjugate vaccines [30]. Conjugate vaccines have been developed against the main causes of paediatric meningitis in the past; pneumococcal, meningococcal serotypes and Hib. These young infants are dependent on indirect (herd) protection, and thus, delayed vaccine impact in this population could be expected [33]. To overcome this problem, new vaccines covering more serotypes including the emerging serotypes have been developed. However, no significant results were found in the hospital course or outcome, except the greater percentage of patients with subdural empyema and hemiparesis [35]. This is due to the processes of selec tion and recombination that play a critical role in the emergence of multi-resistant strains and the serotype replacement, which leads to change of serotype distribution, most frequent in serotypes before the vaccine implementation. We thus expect that the long-term use of multi-valent conjugate vaccines will contribute to serotype replacement, unless the formulation could contain all capsular types. Another way to solve this problem of serotype replacement would be to develop new types of vaccines, that will target any pneumococcal strain regardless of its capsule type [38]. Overall 13 serotypes of the meningococcus have been isolated, with only five of them associated with invasive disease (A, B, C, Y, X and W135) [39]. Four of the disease-causing serogroups (A, C, Y, and W) can be effectively prevented with available quadrivalent capsular polysaccharide protein conjugate vaccines; however, capsular polysaccharide conjugate vaccines are not effective against meningococcal serogroup B (MenB) and there is no vaccine available for serogroup X. After the implementation of MenC vaccination program, disease incidence and mortality by serogroup C have dramatically declined and this effect has been reported in both vaccinated and unvaccinated children [40,41]. However, the challenges of MenC and the rest of the conjugate meningococcal vaccines consist of the duration of protection provided and the need of repeated booster doses to provide continuing protection [42]. Meningococcal disease is hyperendemic in this region, and periodic epidemics Citation: Fani Ladomenou. Bacterial Meningitis in Childhood: Diagnosis, Management and Challenges in the Era of Conjugate Vaccines 385 during the dry season (December June) reach up to 1,000 cases per 100,000 population.
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Cholera can be treated by immediate replacement of the fluid and salts lost through diarrhea. Patients can be treated with oral rehydration solution, a prepackaged mixture of sugar and salts to be mixed with water and drunk in large amounts. Antibiotics shorten the course and diminish the severity of the illness, but they are not as important as rehydration. Epidemiology and Trends In 2012, no reported cases of cholera were reported in Indiana and only one case was reported in the six year period from 2007-2012. Healthy people recover without medical intervention, but cryptosporidiosis can be very serious or life-threatening to people with weakened immune systems. Concentrations of chlorine used in routine water treatment do not kill Cryptosporidium cysts. People become infected with Cryptosporidium by ingesting feces from an infected animal or person (fecal-oral route). The most common sources of Cryptosporidium outbreaks are contaminated drinking water, recreational water parks, pools, lakes, and contaminated beverages. Public Health Significance Symptoms of cryptosporidiosis can include watery diarrhea, stomach cramps, upset stomach, slight fever, weight loss, and vomiting (more common in children). Symptoms usually begin seven days (range of 1 12 days) after a person becomes infected. Some people with cryptosporidiosis may not have any symptoms, but they can still pass the disease to others. This may lead to prolonged disease and even death without proper medical intervention. Recovering from infection of Cryptosporidium does not provide any immunity against re-infection. Healthy People 2020 Goal There is no Healthy People 2020 Goal for cryptosporidiosis. Epidemiology and Trends In 2012, 164 cases of cryptosporidiosis were reported in Indiana, for a rate of 2. Table 1: Cryptosporidiosis Case Rate by Race and Sex, Indiana, 2012 Cases Rate* 2008 2012 Total Indiana 164 2. As shown in Figure 3, age specific rates were greatest for adults over 80 years of age (6. The incidence rates were highest among the following counties reporting five or more cases: Allen (2. Figure 4 shows counties reporting five or more cases of cryptosporidiosis in 2012.
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