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The chest x-ray in a left-to-right shunt lesion will demonstrate congested pulmonary vessels vasodilator drugs erectile dysfunction buy viagra plus 400 mg fast delivery. Untreated defects with large shunts will eventually result in injury to the pulmonary arterioles erectile dysfunction doctor nyc order cheap viagra plus, vascular obstruction erectile dysfunction exercise viagra plus 400 mg mastercard, and pulmonary hypertension erectile dysfunction which doctor to consult purchase viagra plus toronto. The intracardiac defects can be closed by primary suturing of the edges of the defect if small impotence with diabetes cheap viagra plus online visa, or by covering with a patch material if large erectile dysfunction doctor toronto buy viagra plus 400 mg otc. The knowledge of the location of the conduction system in relationship to the defect now makes this a rare complication. The mortality rate in experienced hands should be less than 5% if all ages are considered, with infants carrying a higher mortality rate especially if pulmonary hypertension is present. True/False: Equal blood pressures in the right arm and left leg rule out the diagnosis of coarctation of the aorta. True/False:the presence of palpable femoral pulses rules out the diagnosis of aortic coarctation. Anomalous origin of the right subclavian artery and its relation to coarctation of the aorta. Other congenital heart disease lesions may remain occult for longer period of time. An aberrant right subclavian artery originating below a coarctation will produce equal pressures in the right arm and leg. Development of collateral vessels to the lower body can produce palpable femoral pulses. If the hypoxia is severe enough, visible cyanosis will result, although this can be overcome with oxygen and other treatments for pulmonary edema and congestive heart failure. He was born at 41 weeks of gestation by C-section because of failure to progress to a 23 year old mother G1P0. He was discharged from the hospital and followed in the office until this episode. He subsequently undergoes palliative surgery with improved oxygenation and appearance of a continuous murmur. He is discharged in stable condition to be followed on an outpatient basis and to undergo further corrective surgery at a later date. Cyanosis can be secondary to cardiac, respiratory, hematologic and metabolic causes. Methemoglobinemia, decreased alveolar hypoventilation secondary to depressed respiratory center or obstruction of the respiratory passages, polycythemia, and hypoglycemia, shock, and sepsis may also cause cyanosis, or at least something that resembles cyanosis. Peripheral cyanosis is secondary to low cardiac output, in which acrocyanosis usually occurs with cool extremities and small pulse volume with bluish discoloration at the tip of the nose and fingers, and less in the mucous membranes. It is often difficult to differentiate pulmonary from cardiac causes of cyanosis in the newborn. A hyperoxy test may be helpful, whereby an arterial pO2 is measured in room air, which is then compared to a arterial pO2 measured in an FiO2 of about 90%-100% for about 10-15 minutes. Respiratory problems with alveolar hypoventilation usually improve with paO2 measurements well above 100-150 mmHg, whereas in right-to-left shunt cardiac lesions, the improvement in arterial pO2 is very minimal. Classifying cyanotic congenital heart defects into those with increased vascularity with an accentuated second heart sound and those with decreased blood flow with a diminished second heart sound, can simplify the differential diagnosis to an extent. Lesions with increased or normal blood flow with accentuated second heart sounds include transposition of the great vessels, truncus arteriosis, total anomalous pulmonary venous return, single ventricle, single atrium, and hypoplastic left heart. Transposition of the great vessels is the most common cyanotic congenital heart disease in the newborn infant (tetralogy of Fallot is more common overall, but many tetralogy of Fallot cases present after the newborn period). The aorta arises from the right ventricle and pulmonary artery from the left ventricle, with the aorta positioned anterior and to the right of the pulmonary artery. It is incompatible with life unless a communication exists between systemic and pulmonary circulation, as the two circulations are in parallel (and independent). On auscultation, the second heart sound is greater in intensity, as the aortic valve is anterior. Chest x-ray shows increased pulmonary vascular markings and a narrow mediastinal shadow secondary to a small thymus, sometimes giving the appearance of "egg on side" or "apple on a string" appearance. Echocardiography confirms the diagnosis and delineates the other associated lesions. Inadequate mixing between systemic and pulmonary circuits represents a medical emergency and a prostaglandin E1 infusion which maintains ductus arteriosus patency (to preserve mixing) may be lifesaving, followed by balloon atrial septostomy (Rashkind procedure). Surgical management consists of an arterial switch procedure (aorta and pulmonary artery are anastomosed to the correct ventricle), which is the operation of choice. The atrial switch (atrial baffling) such as Senning or Mustard procedures are no longer done because of the development of later complications. The arterial switch procedure offers the best prognosis with a mortality of about 5%. Tetralogy of Fallot constitutes 4%-9% of congenital heart disease and is the most common cyanotic congenital heart disease when considering all age groups together. Tetralogy of Fallot and pulmonary atresia with ventricular septal defect consist of: a) ventricular septal defect, b) pulmonary stenosis, c) overriding of the aorta, and d) right ventricular hypertrophy. Approximately 25% have a right sided aortic arch, and about 4% have a coronary artery anomaly. This is quite variable, from a slight obstruction, to severe obstruction with pulmonary atresia. Pulmonary atresia constitutes about 18% of the children with tetralogy of Fallot (3). The major right ventricular outflow obstruction in tetralogy of Fallot is infundibular stenosis. With mild stenosis, there may be congestive heart failure in infancy, also known as "pink tetralogy of Fallot. During these episodes (called "Tet" spells), there is increased right-to-left shunting (with less pulmonary flow), and decreased systemic vascular resistance. Older infants and children may assume a squatting position during playtime or long walks which increases systemic vascular resistance and decreases right to left shunting, increasing their oxygenation. Clinical examination shows a loud systolic ejection murmur from the right ventricular outflow obstruction at the left sternal border conducted to the upper sternal border towards the suprasternal notch. The second pulmonary sound may be diminished, but the aortic component may be loud, as the aorta is anterior. Page 276the electrocardiogram shows the non-specific right ventricular hypertrophy. Chest x-ray shows decreased pulmonary vascular markings (reduced pulmonary perfusion) and right ventricular hypertrophy with a leftward apex. There is an absence or decreased main pulmonary artery segment, which may give the appearance of a "boot shaped heart. Cardiac catheterization is done in cases in which the anatomy of the defect is not clear on echocardiogram. Management during the newborn period consists of administration of prostaglandin E1 when the infant is markedly cyanotic and pulmonary blood flow is ductus dependent. This is followed by a systemic artery to pulmonary artery shunt (Blalock-Taussig shunt). Treatment of hypercyanotic spells is directed towards improving pulmonary blood flow. These include oxygen, knee/chest position, morphine, intravenous fluids, sodium bicarbonate, propranolol (beta-blocker), or increasing systemic vascular resistance by administration of drugs, such as phenylephrine. Total surgical correction of the defect is performed under cardiopulmonary bypass, and it can now be performed in young infants from 3-6 months of age or earlier (4). However, the majority of them still have residual defects and some of them may need reoperation and life long medical follow up. Truncus arteriosus consists of a single arterial vessel arising from the heart, positioned over a ventricular septal defect, supplying systemic, coronary and pulmonary circulations. With increased blood flow, symptoms of congestive heart failure such as tachypnea, cyanosis, retractions, etc. There may be a systolic murmur at the left sternal border or an apical aortic ejection click. A diastolic murmur of truncal insufficiency may be heard along the left sternal border. Cardiac catheterization may be indicated when the anatomic features are not clear on echocardiography. After surgery, they will need long term follow up as they will eventually need to have the conduit graft replaced. In the cardiac type, the common pulmonary veins drain into the right atrium directly or via the coronary sinus. In the infracardiac type, the common pulmonary vein courses downward through the diaphragm into the portal vein, which then drains via hepatic veins into the inferior vena cava. An atrial septal defect is necessary for survival, since the oxygenated blood (from the pulmonary veins) must somehow reach the left side of the heart. Symptomatology depends on the amount of mixing and whether or not the pulmonary veins are obstructed. Cyanosis and signs and symptoms of congestive heart failure develop and progress rapidly. There may be a grade 2/6 systolic ejection flow murmur heard along the left sternal border, or it may be absent. The electrocardiogram shows right ventricular hypertrophy and right atrial hypertrophy. Chest x-ray shows increased pulmonary vascular markings or even edema, and the heart may be normal in size or minimally enlarged. The echocardiogram may show right ventricular volume overload, and a color-flow Doppler study may help in locating the common pulmonary venous channel and its drainage. If the resolution is poor, cardiac catheterization and angiocardiography may help in delineating the anomaly further. If surgery is delayed and there is inadequate mixing, palliative balloon septostomy may be performed. Tricuspid atresia consists of an absence or atretic tricuspid valve and a hypoplastic right ventricle. Blood from the right atrium enters the left atrium through an atrial septal defect or foramen ovale. Chest x-ray may show increased or decreased pulmonary blood flow depending on the shunt and a normal or mildly increased heart size. Echocardiography usually delineates these abnormalities and very rarely a cardiac catheterization may be needed. Prostaglandin E1 may be life saving in infants with low oxygen saturation with duct dependent pulmonary blood flow. Surgical correction initially consists of a bilateral Glenn procedure (superior vena cava to right pulmonary artery shunt) followed by an inferior vena cava anastomosis to the right pulmonary artery through an intra or extra cardiac baffle (modified Fontan procedure). Prognosis is good after surgery but patients will need multiple surgeries with associated morbidity such as pleural effusion, ascites, arrhythmia and mortality. Ebstein anomaly is characterized by downward displacement of the septal and posterior leaflets of the tricuspid valve which are attached to the right ventricular septum. The anterior leaflet is elongated and is displaced downward within the right ventricular cavity causing "atrialization of the right ventricle". Auscultation may reveal a triple or quadruple gallop rhythm and a split second heart sound. Echocardiography reveals the lesions of Ebstein anomaly and only rarely is cardiac catheterization needed. In older patients, tricuspid annuloplasty and rarely tricuspid valve replacement may be performed. Prognosis is good with mild lesions and poor with severe lesions with other associated anomalies/malformations. Hypoplastic left heart syndrome consists of a combination of mitral stenosis or atresia, severe aortic stenosis or atresia, and a small left ventricle. Surgery consists the Norwood surgical procedure and a few centers perform cardiac transplantation for this lesion. A "tet spell" or "blue" spell of tetralogy of Fallot is treated with all of the following except: a. Midline one-stage complete unifocalization and repair of pulmonary atresia with ventricular septal defect and major pulmonary collateral. Cyanotic congenital heart-disease with decreased pulmonary blood flow in children (cardiology). The shortness of breath occurs with walking, but he is now unable to walk because of the joint pain. He also has some shortness of breath with lying down flat when he is trying to sleep. Heart sounds are tachycardic with a holosystolic murmur 3/6 heard at apex with radiation to axilla. He has difficulty with range of motion but can flex his knee 30 degrees passively. Due to the significant cardiac disease with elements of congestive heart failure he is switched to corticosteroids and improves. His heart size decreases over the next 2 weeks, and when it normalizes he is switched back to salicylates for a total treatment duration of 8 weeks. He is started on intramuscular benzathine penicillin, which is given every 4 weeks for streptococcal prophylaxis. The terms of Acute Rheumatic Fever and Rheumatic Heart Disease are sometimes confused. Proper use of these terms requires some knowledge of the disease entities even though their pathogenesis and relation to streptococcal infection is nearly identical.

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Primary lactose intolerance such as lactase deficiency and galactosemia impotence thesaurus buy viagra plus with mastercard, occurs approximately in 1:1000 infants erectile dysfunction doctor miami order cheap viagra plus on-line. Secondary lactose intolerance by contrast is far more common and often presents with protracted diarrhea impotence at 50 cheap viagra plus 400mg with amex. The lactase enzyme is located at the villous tip of the intestine and appears to be more vulnerable than sucrase that is found deeper in the crypt erectile dysfunction surgery cost buy cheap viagra plus line. An infectious diarrhea may cause denuding and the lactase enzyme may take up to a week to fully recover erectile dysfunction doctor boston purchase 400mg viagra plus fast delivery. A low lactose or lactose free formula may reduce carbohydrate malabsorption (and subsequent exacerbation of diarrhea by an osmotic mechanism) during the illness erectile dysfunction jelqing cheap viagra plus 400 mg overnight delivery. The lactose free cow-milk based formulas are designed to treat primarily secondary lactase deficiency. The contrast to lactose containing formulas is the substitution of its carbohydrate source. Soy formulas support the growth of normal term infants through the first year of life. Soy formulas may be used in lieu of cow milk formula and in formula fed infants whose parents want their children to adhere to a vegetarian diet. Phytate in soy formula in addition to the absence of lactose diminish the absorption of divalent cations such as iron, calcium and zinc in the intestinal lumen. Supplementation of soy formula with iron, calcium and zinc has largely overcome these issues (8,9). Phytogens in soy formulas have the potential for hormonal action at critical points in development. Soymilk based formulas: Indications: Lactose deficiency or galactosemia, strict vegetarians, IgE mediated reaction to cow milk protein. Bioavailability of iron in soy-based formula and its effect on iron nutriture in infancy. Breastfeeding is regarded first and foremost except when it is not practical, desired or medically contraindicated. From a practical standpoint, whether it is breast milk or infant formula, a healthy term infant is the best regulator of the frequency and quantity of their nutritional intake. However, since we are scientists at heart; during the first 6 months of life approximately 95-115 kcal/kg/day is recommended. To compensate for the depletion of iron stores by growth, dietary iron must be provided to exclusively breastfed infants. Please refer to the text to review the clinical significance of this profile difference. The clinical significance of the difference in whey:casein ratio between human and bovine milk is illustrated when unmodified casein-predominant cow milk enters the acidic environment of the human stomach and forms a relatively hard curd of casein and minerals. Lactose is added to most standard infant formula to achieve the concentration of human milk. Soy formulas do not contain lactose; they contain sucrose, glucose polymers, or a mixture of the two. He has had 10 episodes of vomiting (clear then yellow tinged) and 8 episodes of diarrhea with some mucusy material in the first few episodes. His parents gave him a sports drink (red color), and then they tried clear Pedialyte. His overall color is slightly pale, his capillary refill time is 2 seconds over his chest, and his skin turgor feels somewhat diminished. They indicate that he still has some diarrhea, but only about two episodes per day and his vomiting has stopped. However, vigorous hand washing and hygiene regarding dishes/utensils for all family members is recommended. She is also permitted to eat and drink small amounts, so a low fat diet without fruit juice is ordered for her. Since children are small, critical attention must be paid to fluid and electrolyte balance. An fluid administration could result in clinically significant overhydration, underhydration, or electrolyte imbalance. However, in pathologic conditions such as gastroenteritis, burns, neurologic dysfunction, etc. The purpose of this chapter is to familiarize the reader with normal fluid and electrolyte requirements. Much of this chapter consists of numbers, some of which should be memorized for personnel who provide medical care to children frequently. These will be called everyday basic numbers and are summarized in a table at the end of this chapter. These numbers are estimates because body fat variations will modify these percentages as well (obese individuals have lower body water percentages). Of the extracellular fluid, 3/4 is interstitial and 1/4 is circulating as plasma (1). There is also a small percentage known as transcellular water (about 2%) which consists of synovial fluid, pericardial fluid, pleural fluid, bowel secretions, cerebral spinal fluid, etc. This can be summarized below as: Total body water: 60%-75% of body weight Intracellular: 30%-40% of body weight Extracellular: 20%-25% of body weight Interstitial: 15% of body weight Plasma: 5% of body weight However, total blood volume is actually 8% to 9% of body weight for children and 7% of body weight for adults (2). This is because the red blood cell elements of blood are not considered to be "body water". Thus, if plasma consists of 5% of the body weight, a few more percentage points would account for the circulating blood volume (which is larger than the circulating plasma volume). Fluid losses occur routinely through urine, stools, respiratory vapor and insensible skin losses. Maintenance fluid volume for 24 hours can be calculated as follows: 100 cc/kg for the first 10 kg of body weight, 50 cc/kg for the next 10 kg of body, then 20 cc/kg thereafter. Thus, the maintenance fluid volume 40 kg patient would be calculated as: 10kg X 100 cc/kg + 10kg X 50 cc/kg + 20kg X 20 cc/kg = 1000cc + 500cc + 400cc = 1900cc per day. A shortcut for patients over 20 kg is to take 1500 cc and then add 20 cc/kg for additional weight above 20 kg. Maintenance electrolytes are calculated using maintenance fluid volumes as 3 mEq Na (sodium) and 2 mEq K (potassium) per 100cc of maintenance fluid. Thus, the 40 kg patient above would require 57 mEq Na (3 X 19) and 38 mEq K (2 X 19) per day. Therefore, half of its osmolar particles must be Na (sodium) and the other half must be Cl (chloride) to give a total osmolarity of about 300. I could provide you with a table with the exact numbers, but no one can remember these. By calculating the maintenance fluid volume for a 75 kg average adult, the maintenance volume would be 1500 cc + 55 kg X 20 cc/kg = 3000 cc. As an average busy adult, I normally do not drink this much, yet I do not become dehydrated. Normal kidneys are able to compensate for wide ranges of fluid and electrolyte intake. Excess fluid and electrolyte intake is urinated out as excess, while inadequate intake results in renal retention of fluid and/or electrolytes to maintain normal fluid volumes and electrolyte balance. The Page 64 kidney has to do some work to remove excess substances or to retain substances which are in short supply. Thus, maintenance volumes and electrolytes are beneficial because this results in minimizing the stress and workload on the kidneys. This is not very important in healthy individuals going about their everyday lives, but it becomes more important in very ill patients whose bodily functions are under great stress. Maintenance calculations using the formula provided are only valid under the assumption of the "average hospital patient". Thus, the "maintenance" calculations provide a basic guide to determine the fluid and electrolyte intake that minimizes work stress on the kidneys of average hospital patients. Although oral electrolyte solutions are commonly utilized for rehydration, they are actually maintenance electrolyte solutions. The most commonly recommended oral electrolyte solution known as Pedialyte contains 45 mEq Na per liter and 20 mEq K per liter. When a fluid deficit state is encountered, assessment of the severity is usually categorized as percent dehydration, which is really the volume of fluid loss as a percentage of body weight. Ideally, one could use their baseline body weight to determine the percentage of fluid loss, but this is almost never useful because growing children almost never have a known baseline body weight just prior to becoming ill. Additionally, factors such as anorexia and the duration of illness may lead to loss of lean body mass as well which adversely affects the weight calculation. Clinical and laboratory criteria have been developed to estimate dehydration percentage categories, but these are similarly flawed. Criteria for 5% dehydration include: no tears when crying, oliguria, sticky (tacky) oral mucosa, less active than usual. Criteria for 15% dehydration include obvious shock (tachycardia, hypotension, cool extremities) and skin tenting. It should be noted that early signs of shock may appear as early as the 5% dehydration level. All of these clinical criteria have some flaws and they are not universally agreed upon. It is often not possible to estimate the urine output because of frequent diarrhea. A ketotic odor to the breath may signify ketosis due to poor oral intake which somewhat correlates with dehydration. The serum bicarbonate is a measure of metabolic acidosis, but this can be misleading as well since sodium bicarbonate can be lost directly from diarrhea. However, an increased anion gap (calculated as Na minus Cl minus bicarb, which should be less than 12) is almost always present in clinically significant dehydration since lactic acid is produced in a dehydrated state (due to cellular hypoperfusion and a relative increase in anaerobic metabolism). For example, in vomiting patients, their bicarbonate initially increases (because of gastric acid loss resulting in a metabolic alkalosis); however, as fluid loss continues, they become dehydrated and a metabolic acidosis would indicate the presence of dehydration. In a patient with diarrhea, the bicarbonate value may be low from diarrheal losses of bicarbonate. So if the serum bicarbonate is relatively low and an increased anion gap is not present, this may not signify dehydration. However, the presence of an increased anion gap would indicate the presence of lactic acid production and dehydration. Similarly in diabetic ketoacidosis, the production of ketoacids and lactic acid results in an increased anion gap. Other clinical situations could affect the bicarbonate value and the anion gap in unusual ways, but this discussion is beyond the scope of this chapter. Oral hydration is generally preferable since this can be done at home, it is less invasive and it requires less costly resources. Oral rehydration has been demonstrated to be successful in most (or perhaps nearly all) cases of gastroenteritis. Glucose in excess of sodium may remain in the bowel lumen as an unabsorbed osmotic particle which retains fluid in the bowel and inhibits fluid absorption. Giving 5 cc every 1 to 2 minutes reduces the volume remaining in the stomach at any given time. Since the stomach is similar to a bag, it is difficult for the stomach to vomit if only a small fluid volume is present. Giving 5 cc every minute results in a maximum fluid administration rate of 300 cc per hour, but this is very labor intensive for parents who must do this continuously for it to work. More commonly, 30 cc (1 ounce) is given every 15 minutes which results in a maximum fluid administration rate of only 120 cc per hour. It should be noted that a major difference between the clinical utilization of oral rehydration in the U. While parents in other countries may be willing to administer 5 cc every 1 to minutes, while the child continues to have a few emesis episodes, American parents are not likely to be this persistent. Children in poorer countries do not have this option and despite sustaining greater degrees of dehydration, they are satisfactorily rehydrated via the oral route. It can be said that oral rehydration usually works for parents who are willing to persevere. Children with mild dehydration can be placed on near normal diets (avoiding fat and excessive sugar), with good results in most instances. For severe dehydration, this should be given as a rapid bolus (over less than 10 minutes), but for mild dehydration this can be given over one hour. Since fluid follows osmotic particles, the fluid volume will go, where the osmotic particles go. These ions stay within the circulating plasma and thus, the fluid volume expands the intravascular space preferentially. This might promote cellular edema under some circumstances, but at the very least, the fluid does not effectively expand the intravascular space. The 2% is determined by 400 cc divided by 20 kg (20,000 gms), or by 20 cc/kg (20 cc per 1000 cc = 2%). Another way to appreciate the truly small size of this fluid volume infusion is to equate this to soft drink cans, which are 12 ounce cans. Since 1 ounce equals 30 cc, a typical 12 ounce soft drink can contains 360 cc, which is similar to the 400 cc fluid infusion. Most 4 year olds can drink 3 or 4 soft drink cans on a hot day after a soccer game. For severe dehydration in the range of 15%, the patient would actually need 150 cc/kg to fully replace the fluid deficit. For a patient with 5% dehydration, the patient would actually need 50 cc/kg to fully replace the fluid deficit. In most instances, fully rehydrating the patient very rapidly is not necessary and this may be harmful if excessive fluid shifts occur. Once satisfactory fluid resuscitation has stabilized the patient, continued rehydration and maintenance fluids can be administered more gradually. Oral rehydration requires more work on the part of parents and some uncertainty exists as to whether it will be successful.

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Tianyou Hospital Affiliated to Wuhan University of Science and Technology erectile dysfunction at the age of 18 buy discount viagra plus 400mg line, Wuhan impotence with prostate cancer purchase viagra plus visa, Hubei 430065 erectile dysfunction homeopathic drugs cheap viagra plus 400 mg with visa, China 23 best erectile dysfunction doctors nyc buy viagra plus canada. Guan erectile dysfunction treatment chandigarh generic 400 mg viagra plus with visa, Ni erectile dysfunction jacksonville fl viagra plus 400 mg overnight delivery, Hu, Liang, Ou, He, Liu, Shan, Lei, Hui, Du, Li, Zeng and Yuen contributed equally to the article. State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health,the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, Guangdong, China. On admission, ground-glass opacity was the typical radiological finding on chest computed tomography (50. Significantly more severe cases were diagnosed by symptoms plus reverse-transcriptase polymerase-chain-reaction without abnormal radiological findings than non-severe cases (23. Severe pneumonia was independently associated with either the admission to intensive care unit, mechanical ventilation, or death in multivariate competing-risk model (sub-distribution hazards ratio, 9. Conclusions:the 2019-nCoV epidemic spreads rapidly by human-to-human transmission. Normal radiologic findings are present among some patients with 2019-nCoV infection. Key words: 2019 novel coronavirus; acute respiratory disease; transmission; mortality; risk factor Abstract: 249 words; main text: 2677 words Funding: Supported by Ministry of Science and Technology, National Health Commission, National Natural Science Foundation, Department of Science and Technology of Guangdong Province. Running head: 2019-nCoV in China Introduction In early December 2019, the first pneumonia cases of unknown origins were identified in Wuhan city, Hubei province, China [1]. Evidence pointing to the person-to-person transmission in hospital and family settings has been accumulating [4-8]. The World Health Organization has recently declared the 2019-nCoV a public health emergency th of international concern [9]. As of February 5, 2020, 24,554 laboratory-confirmed cases have been documented globally. Given the rapid spread of 2019-nCoV, an updated analysis with significantly larger sample sizes by incorporating cases throughout China is urgently warranted. This will not only identify the defining epidemiological and clinical characteristics with greater precision, but also unravel the risk factors associated with mortality. The initial cases were diagnosed as having pneumonia of unknown etiology, based on the clinical manifestations and chest radiology after exclusion of the common bacteria or viruses associated with community-acquired pneumonia. Suspected cases were identified as having fever or respiratory symptoms, and a history of exposure to wildlife in Wuhan seafood market, a travel history or contact with people from Wuhan within 2 weeks [13]. The incubation period was defined as the duration from the contact of the transmission source to the onset of symptoms. The study was approved by the National Health Commission and the institutional board of each participating site. Written informed consent was waived in light of the urgent need to collect clinical data. The epidemiological characteristics (including recent exposure history), clinical symptoms and signs and laboratory findings were extracted from electronic medical records. Laboratory assessments consisted of complete blood count, blood chemistry, coagulation test, liver and renal function, electrolytes, C-reactive protein, procalcitonin, lactate dehydrogenase and creatine kinase. Secondary endpoints comprised mortality rate, the time from symptom onset to the composite endpoint and each of its component. All medical records were copied and sent to the data processing center in Guangzhou, under the coordination of the National Health Commission. If the core data were missing, requests of clarification were immediately sent to the coordinators who subsequently contacted the attending clinicians. Categorical variables were summarized as the counts and percentages in each category. Wilcoxon rank-sum tests were applied to continuous variables, chi-square tests and Fishers exact tests were used for categorical variables as appropriate. The risk of composite endpoints among hospitalized cases and the potential risk factors were analyzed using Fine-Gray competing-risk models in which recovery is a competing risk. The candidate risk factors included an exposure history, greater age, abnormal radiologic and laboratory findings, and the development of complications. The statistically significant risk factors, sex, and smoking status were included into the final models. Results Demographic and clinical characteristics th Of all 1,324 patients recruited as of January 29, 222 (16. A history of contact with wildlife, recent travel to Wuhan, and contact with people from Wuhan was documented in 1. On admission, 926 and 173 patients were categorized into non-severe and severe subgroups, respectively. Moreover, any underlying disorder was significantly more common in severe cases as compared with non-severe cases (38. There were, however, no marked differences in the exposure history between the two groups (all P>0. Radiologic and laboratory findings at presentation Table 2 shows the radiologic and laboratory findings on admission. The most common patterns on chest computed tomography were ground-glass opacity (50. Severe cases yielded more prominent radiologic abnormalities on chest X-ray and computed tomography than non-severe cases (all P<0. Most patients demonstrated elevated levels of C-reactive protein, but elevated levels of alanine aminotransferase, aspartate aminotransferase, creatine kinase and D-dimer were less common. Treatment and complications Overall, oxygen therapy, mechanical ventilation, intravenous antibiotics and oseltamivir therapy were initiated in 38. All these therapies were initiated in significantly higher percentages of severe cases (all P<0. Significantly more severe cases received mechanical ventilation (non-invasive: 32. Moreover, extracorporeal membrane oxygenation was adopted in 5 severe cases but none in non-severe cases (P<0. Severe cases yielded significantly higher rates of any complication as compared with non-severe cases (94. Results of the univariate competing risk model are shown in Table E1 in Supplementary Appendix. Around only 1% of patients had a direct contact with wildlife, while more than three quarters were local residents of st Wuhan, or had contacted with people from Wuhan. These findings echoed the latest reports, including the outbreak of a family cluster [4], transmission from an asymptomatic individual [6] and the three-phase outbreak patterns [8]. Our findings have provided evidence from a much larger sample size to guide the duration of quarantine for close contacts. Importantly, the routes of transmission might have contributed considerably to the rapid spread of 2019-nCoV. In a case with severe peptic ulcer after symptom onset, 2019-nCoV was directly detected in the esophageal erosion and bleeding site (Hong Shan and Jin-cun Zhao, personal communication). Collectively, fomite transmission might have played a role in the rapid transmission of 2019-nCoV, and hence hygiene protection should take into account the transmission via gastrointestinal secretions. These findings will, by integrating systemic protection measures, curb the rapid spread worldwide. Our findings advocate shifting the focus to identifying and managing patients at an earlier stage, before disease progression. Consistent with two recent reports [1,12], lymphopenia was common and, in some cases, severe. However, based on a larger sample size and cases recruited throughout China, we found a markedly lower case fatality rate (1. Our findings were consistent with the national official statistics, reporting the mortality of 2. Early isolation, early diagnosis and early management might have collectively contributed to the marked reduction in mortality in Guangdong. These findings will inform the mass public, clinicians and policy makers the true transmissability of 2019-nCoV which has resulted in a major social panic. The risk factors indicated the importance of taking into account the disease severity, laboratory findings, chest imaging findings in practice. Table E5 in Supplementary Appendix highlights the defining characteristics of these viruses, enabling clinicians to differentiate these diagnoses. First, some cases had incomplete documentation of the exposure history, symptoms and laboratory testing given the variation in the structure of electronic database among different participating site and the urgent timeline for data extraction. Some cases were diagnosed in out-patient settings where medical information was briefly documented and incomplete laboratory testing was applied. There was a shortage of infrastructure and training of medical staff in non-specialty hospitals, which has been aggravated by the burn-out of local medical staff in milieu of a surge of cases. Second, because many patients still remained in the hospital, we did not compare the 28-day rate of the composite endpoint. To mitigate the potential bias, we have applied the competing-risk model for analysis. However, there were a minority of patients who had no apparent radiologic manifestations, suggesting that we had included patients at the early stage of disease. Last, we took reference on the existing international guideline to define the severity of 2019-nCoV because of its global recognition [15]. In summary, 2019-nCoV elicits a rapid spread of outbreak with human-to-human transmission, with a median incubation period of 3 days and a relatively low fatality rate. Absence of fever and radiologic abnormality occurs in a substantial proportion of patients on initial presentation while diarrhea is uncommon. Stringent and timely epidemiological measures are crucial to curb the rapid spread. Acknowledgment: We thank the hospital staff (see Supplementary Appendix for a full list of the staff) for their efforts in recruiting patients. Zong-jiu Zhang, Ya-hui Jiao, Bin Du, Xin-qiang Gao and Tao Wei (National Health Commission), Yu-fei Duan and Zhi-ling Zhao (Health Commission of Guangdong Province), Yi-min Li, Zi-jing Liang, Nuo-fu Zhang, Shi-yue Li, Qing-hui Huang, Wen-xi Huang and Ming Li (Guangzhou Institute of Respiratory Health) which greatly facilitate the collection of patients data. Dong Han, Li Li, Zheng Chen, Zhi-ying Zhan, Jin-jian Chen, Li-jun Xu, Xiao-han Xu (State Key Laboratory of Organ Failure Research, Department of Biostatistics, Guangdong Provincial Key Laboratory of Tropical Disease Research, School of Public Health, Southern Medical University). We also thank Li-qiang Wang, Wei-peng Cai, Zi-sheng Chen, Chang-xing Ou, Xiao-min Peng, Si-ni Cui, Yuan Wang, Mou Zeng, Xin Hao, Qi-hua He, Jing-pei Li, Xu-kai Li, Wei Wang, Li-min Ou, Ya-lei Zhang, Jing-wei Liu, Xin-guo Xiong, Wei-juna Shi, San-mei Yu, Run-dong Qin, Si-yang Yao, Bo-meng Zhang, Xiao-hong Xie, Zhan-hong Xie, Wan-di Wang, Xiao-xian Zhang, Hui-yin Xu, Zi-qing Zhou, Ying Jiang, Ni Liu, Jing-jing Yuan, Zheng Zhu, Jie-xia Zhang, Hong-hao Li, Wei-hua Huang, Lu-lin Wang, Jie-ying Li, Li-fen Gao, Jia-bo Gao, Cai-chen Li, Xue-wei Chen, Jia-bo Gao, Ming-shan Xue, Shou-xie Huang, Jia-man Tang, Wei-li Gu, Jin-lin Wang (Guangzhou Institute of Respiratory Health) for their dedication to data entry and verification. Genomic characterization and epidemiology of 2019 novel coronavirus: implications of virus origins and receptor binding. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: A modeling study. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Clinical management of severe acute respiratory infection when Novel coronavirus (nCoV) infection is suspected: interim guidance. Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Disease Society of America. Enteric involvement of severe acute respiratory syndrome-associated coronavirus infection. Prevalence of gastrointestinal symptoms in patients with influenza, clinical significance, and pathophysiology of human influenza viruses in faecal samples: what do we know L ymph openia denoted th e lymph ocyte countofless th an 1,500 per cubicmillimeter. Th rombocytopenia denoted th e plateletcountoflessth an150,000 percubicmillimeter. PaO 2:F iO 2 wasdefined asth e ratio ofth e partialpressure ofarterialoxygen to th e fractionofinspired oxygen. Patient recruitment flowchart and the distribution of patients across China Figure 1-A. The distribution of laboratory-confirmed cases throughout China Shown are the official statistics of all documented laboratory-confirmed cases throughout China th according to the National Health Commission (as of February 4, 2020). Shown are the stratification by age, Sex, disease severity, smoking status, underlying disease, alanine or aspartate aminotransferase levels, blood leukocyte count, blood lymphocyte count, blood platelet count, ground-glass opacity on chest X-ray on admission, local patchy shadowing on chest X-ray on admission, diffuse patchy shadowing on chest X-ray on admission, interstitial abnormality on chest X-ray on admission, interstitial abnormality on chest computed tomography on admission. Although creatinine clearances can be calculated from urine creatinine concentration measured in a 24-hour urine collection and * Corresponding author. Patients with stage 3 or 4 disease progress to end-stage renal disease or stage 5 at a rate of 1. The World Health Organization denes anemia as a hemoglobin level less than 13 g/dL in men and postmenopausal women, and less than 12 g/dL in premenopausal women [6]. Erythropoietin is a glycoprotein secreted by the kidney interstitial broblasts [9] and is essential for the growth and dieren tiation of red blood cells in the bone marrow. Normalization of hemoglobin levels is no longer considered the goal of ther apy since these target levels have been associated with higher mortality [13]. Enrolled subjects were randomly assigned to epo therapy treatment protocols designed to achieve a target hemoglobin level of either 13. The study was terminated prematurely because of higher mortality rates and adverse events in the group with higher targeted Hgb levels [14].

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The pat tern of psychological illness and premorbid characteristics in four skills and in the importance of stress management impotence cure cheap viagra plus 400mg without a prescription, and chronic pain populations erectile dysfunction treatment michigan order viagra plus canada. Dying from cancer in devel oped and developing countries: lessons from two qualitative interview behavioral therapy impotence kit purchase viagra plus 400mg visa, relaxation techniques erectile dysfunction prevention cheap generic viagra plus uk, and so on royal jelly impotence viagra plus 400mg cheap. Pain in the aftermath of trauma is a risk factor for posttraumatic stress disorder erectile dysfunction after 70 generic viagra plus 400 mg with mastercard. Common chronic pain conditions in developed and de veloping countries: gender and age dierences and co morbidity with depression-anxiety disorders. Guide to Pain Management in Low-Resource Settings Chapter 47 Insights from Clinical Physiology Rolf-Detlef Treede Insights on acute pain Practical consequences Ask each patient about movement-evoked pain, and Aside from alleviating suffering, one of the major treat with eective, multimodal analgesics. One of the funda Insights on cancer pain mental mechanisms in the nociceptive system is in terfering with these aims is called central sensitiza One of the most painful conditions in a patient with tion. Sensitization is a basic learning mechanism that advanced cancer is bone metastasis. This well-known describes an increased neural response when stimuli clinical reality is in conict with traditional basic sci of constant intensity are simply repeated. In central sensitization, the increased tend into the periosteum should be painful. But ex neural response is due to enhanced efficacy of the perience teaches otherwise: fortunately, painful bone synaptic connections within the nociceptive system. Tus, when they are treated causally by radia chanical stimuli, whereas peripheral sensitization al tion or chemotherapy, the stability of the bone is still most exclusively increases heat pain sensitivity. It is also well known that aspiration of makes central sensitization highly relevant in the bone marrow is very painful, in spite of local anesthe postoperative setting. When sensitization occurs in the nociceptive sys Tus, the bones interior structures are densely in tem, the patient perceives more pain in response to nervated by nociceptive aerents, probably very similar relatively mild stimuli such as moving around in bed to the innervation of teeth. Fortunately, eective pain gene-related peptide), where they appear to have con treatment. Physiologically, there is also some recent evidence that Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. This material may be used for educational 345 and training purposes with proper citation of the source. This increased sensitivity appears to be related to a de Practical consequences ciency in habituation. For example, evoked cerebral Tissue damage restricted to the bone marrow can be potential studies have shown that the normal response a source of intense nociceptive input. Hence, patients decrement upon repetitive application of visual stimuli with pain in such conditions do need treatment. More recently, such de ever, treatment here does not necessarily have to be by cits have also been shown for pain habituation, by using analgesics; instead, radiation or chemotherapy may ac laser-evoked potentials (here an infrared laser applies tually eliminate the cause of this pain. Tere is some evidence that decits in pain habituation occur in other chronic pain conditions as well, such as Insights on neuropathic pain in cardiac syndrome X. Tere has been a long-standing debate on how to de Practical consequences ne neuropathic pain. Pain is perceived when this system rings leviate chronic pain conditions by treatment modalities an alarm. As with any other alarm system, there are two that enhance habituation without being directly analgesic. The usual pain infants and children after tissue damage is a case of true alarm by the noci ceptive system. Tese electrical brain signals suggest that con damaged, consider neuropathic pain as a possibility. To scious perceptions such as pain may be present before verify this clinical hypothesis, evidence should be sought birth. However, the nervous system is immature at birth to demonstrate the underlying damage to the nocicep and undergoes substantial changes postnatally. Sensory testing must include either a whereas cortical stimulus responses increase (detect painful test stimulus such as pinprick, or a thermal stim able by near-infrared spectroscopy, for example). As soon as a child is able to understand verbal neuropathic pain correctly, pain specialists need to have instructions, faces pain scales can be used in a similar some level of neurological training. Practical consequences Insights on chronic pain It is dicult to judge the level of pain and discomfort Migraine is a frequent headache syndrome that has in infants due to their strong reex responses that may a major impact on quality of life. Special special observer-based scales have been developed regimens apply, and most medications are being used and validated to allow assessment of pain and suer olabel. Tere is some evidence that the placebo eect is less ecacious in demented people. Decline in liver and kidney function, on the Insights on pain in other hand, makes dosage adjustments necessary for old age and dementia many medications. Pain thresholds and pain-evoked brain potentials have Practical consequences been studied in healthy volunteers up to the age of 100 years. Pain thresholds and evoked potential latencies Many people maintain normal functions of their no slightly increase and evoked potential amplitudes de ciceptive system way into old age. In many cases, however, present, pain assessment relies increasingly on the ob verbal communication skills may deteriorate in old age, servation of pain-related behavior. In this situation, pain sumed that the level of pain in demented patients is un assessment becomes dicult. Guide to Pain Management in Low-Resource Settings Chapter 48 Herbal and Other Supplements Joel Gagnier What is the denition Other activities followed, including international con ferences and research exchanges. Natural health products include vitamins, minerals, What supplements are herbal medicines, homeopathics and other naturally de best for acute pain Surgical procedures and acute trauma may be ad In the developing world, it would be advis dressed by several natural health products. For exam able to consult local elders or healers to determine lo ple, the homeopathic remedies Arnica and Hypericum cal plants or foods that may be used. Traditional ticularly useful for decreasing pain, bruising discolor knowledge from a respected elder, healer, or tribal chief ation, and discomfort in the patient. Always think about the pericum is very useful to heal incisions and eliminate risk/benet ratio, since natural health products might pain. For acute trau products depends on mutual trust between the care ma to muscles, ligaments, and tendons, topical creams giver and the healer, since there are few evidence-based or ointments containing Harpagophytum procumbens data and standardized products available. For example, in 1998 a task force was set up by the What supplements are best Ministry of Health in Ghana to identify the credible Na for neuropathic pain Tese associations came together to Peripheral neuralgias, if caused by malnutrition, may form the nucleus of the Ghana Federation of Traditional be treated by supplementation with vitamins. E, B1, B3, B6, and B12 are essential for adequate nerve Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. This material may be used for educational 349 and training purposes with proper citation of the source. A diet with regular fruit and vegetable intake with oral glucosamine sulfate at 1500 mg per day to would include these vitamins, or alternatively a simple gether with oral chondroitin sulfate at 1200 mg per day; multivitamin mineral formula would be sucient. Tese supplements containing a combination of camphor, glucosamine may be used together. The selection reects rec is an issue to be considered when selecting a drug: the ommendations of the Essential Drug List for Cancer possible positive eects must always be balanced against from Makarere University and the health ministry in possible side eects. A good recommendation would be Uganda for the treatment of cancer patients, which ap to think, when prescribing a drug, whether you would pear to be a reasonable drug selection for treatment prefer the same drug when in a comparable situation, of the most common pain syndromes encountered by since it is your decision to select pharmacological treat nonspecialists in a low-resource setting. This overview explains the mode of action as Pharmacological treatment should be explained well as typical side eects of drugs. A valuable tool to avoid misunderstandings tioned in desk references the ones that are most impor and incompliance by the patient is the use of a simple tant for the therapist and the patient to know about. Metoclopramide 40 droplets: Prevents nausea caused by Should be taken for 10 days. This material may be used for educational 351 and training purposes with proper citation of the source. Even though acetaminophen is classied as an uli, thus provoking a decreased pain threshold. Cen antipyretic drug, it has mild anti-inammatory prop trally active prostaglandins enhance the perception and erties. Acetaminophen is a safe alternative medication transmission of peripheral pain signals. However, and rightly so, acetamin ment of acute or chronic pain conditions, espe ophen is often used for minor to moderate pain post cially where inflammation is present. In pain of low operatively, as well as in headache and cancer patients, to moderate intensity, they may give sufficient pain because it is free of any gastrointestinal and renal side control as a single therapy, but in moderate to severe eects when the dose recommendations are observed. A less common but serious side worry about renal function and gastrointestinal side ef effect is anaphylactic reaction with development of fects and that it is generally cheap. Like acetaminophen, severe bronchospasm and/or cardiovascular depres dipyrone may also be used for long-term treatment. Renal failure is a more frequent and serious indications are acute and chronic pain of mild to mod complication and is mostly associated with long-term erate intensity, as well as colicky pain. The topic of idio Note the contraindications: gastrointestinal ul syncratic drug reactions has been reopened after some ceration, hemophilia, hypersensitivity to aspirin, young Scandinavian publications, and a number of countries children because of the possibility of developing Reyes have therefore made dipyrone unavailable. But several syndrome, pregnancy especially the last trimester, countries, including Germany, Spain, and most Latin breastfeeding, and advanced renal impairment. Unfortunately, chronic noncan may be associated with hypotension, which should not cer pain, like chronic nonspecic back pain or head be mistaken for a allergic response, which in fact occurs ache, is only rarely a good indication for opioids. Contraindications include porphyria, glucose liative care, opioids may also be used to control dyspnea 6-phosphate dehydrogenase deciency, pregnancy (espe very eectively. The reason is that when opioids are used for control of pain, the regular dosing avoids major changes in serum levels, therefore preventing the activa Opioid analgesics tion of our dopaminergic reward system (as opposed to For legal reasons, opioids may be classied into weak drug addicts experiencing a high after sudden blood and strong ones. For dependence (as with a number of other classes of drugs, clinical practice, this distinction is probably irrelevant, such as beta blockers or anticonvulsants), and patients because there are no data indicating that equianalgesic will develop symptoms of withdrawal if they discontinue doses of weak and strong opioids have a dierent opioids without tapering down the dose. Terefore, opioid thera Weak opioids py may be started with low doses of a strong opioid, if weak opioids are not available. The analgesic eect of opioids is me analgesics are insucient to control the pain. The analgesic eect is a result ing eect, meaning that there is a maximum dose above of the reduced presynaptic opening of calcium channels which there is no further increase of analgesia. The risk and glutamate liberation as well as the increase of post for respiratory depression is very low with weak opioids. The best clinical indications for opioids are the The standard dose for tramadol is 50 to 100 mg symptomatic treatment of moderate to severe acute t. Tramadol is also available Neuropathic pain may be an indication, too, especially in an intravenous application formulation. A safe protocol would be to in severe pain in cancer and postoperative pain as taper down the dose in several steps over about 10 well as in cancer-related dyspnea. They may also days, which safely prevents withdrawal syndromes work to a lesser extent in neuropathic pain, but they (tearing, restlessness, tachycardia, and hypertension, are generally not indicated for use in chronic nonspe among other symptoms). If slow-release formulations are available, once pain, because they can improve the patients qual or twice-daily doses may be chosen. There is no maximum dose for diate-release and slow-release formulations are avail morphine and its derivates. For example, in a patient taking 20 mg morphine diction, but reflect progressive tissue damage most of q. Other causes of increasing dose demands should be allowed as an extra dose to be taken on de are a change in pain quality (development of neuro mand in situations of increased pain (breakthrough pathic pain instead of nociceptive pain) or concomi pain). The other causes interval of 30 to 45 minutes before using another de mentioned have to be diagnosed correctly to be able mand dose. According to the number of daily demand to treat them specifically with coanalgesics or non doses, the caregiver may change the constant basal pharmacological interventions. In a patient needing no demand Nausea and vomiting, drowsiness, dry mouth, doses at all, the basal dose may be reduced by 25%, in a miosis, and constipation occur very frequently in pa patient requiring one to four doses the scheme should tients taking strong opioids. If nausea and vomiting stay unchanged, and in a patient requiring more than persist, or delirious symptoms develop, a change to four demand doses the basal opioid dose should be another opioid (opioid rotation) usually controls the increased.

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Boston: Office of Instructional Development and Evaluation erectile dysfunction 60784 discount viagra plus 400mg fast delivery, Northeastern University impotence due to diabetic peripheral neuropathy cheap viagra plus 400mg on-line, 1989 erectile dysfunction doctors in maine buy viagra plus 400mg amex. Ann Arbor: National Center for Research to Improve Postsecondary Teaching and Learning erectile dysfunction causes natural treatment discount viagra plus 400mg, University of Michigan erectile dysfunction treatment food buy 400 mg viagra plus fast delivery, 1989 erectile dysfunction causes ppt buy discount viagra plus line. Chicago: Educational Development Unit, Michael Reese Hospital and Medical Center, 1978. It is natural for both students and instructors to feel anticipation, excitement, anxiety, and uncer tainty. Check any audiovisual equipment (microphone, slide or overhead projector) you will be using. Find out how to obtain help if a bulb burns out or a piece of equipment malfunc tions. In general, students learn more and work harder in classes that spark their intellectual curiosity and allow for active involvement and participation. For the first day, plan an activity that provides opportunities lor students to speak to one another or solve problems. Students also tend to work harder and respond more positively if they believe the instructor views them as individuals rather than as anonymous faces in the crowd (Wolcowitz, 1984). From the start, then, make an effort to get to know your students and express your interest in working with them during the semester. Students enter a new class with several questions: Is this the right course for me Use the first day to help your students understand how the class will serve their needs, and demonstrate your commitment to help them learn. Stay after class to answer questions, or invite students to walk with you back to your office. This signals to students that you are serious about making their time worthwhile and that you expect progress to be made at each session. All teachers, especially beginning instructors, feel a twinge of apprehension before the first class. Keep in mind that to your students your nervousness is likely to be perceived as energy and enthusiasm. Arriving early on the first day of class and talking informally to students may help you relax. This message will alert any students who are in the wrong classroom to leave before you begin. Check with your department to see whether policies exist for preferential enrollment. Others make certain that students have the prerequisites anil then select enrollment by lottery. If your course is an elective, plan on admitting a few more students than you can comfortably accommodate; a small number will end up dropping your course. If your course has sections, make sure that all students know which section they are enrolled in, who their graduate student instructor is, and when and where the section meets. Describe the relationship between the course and its sections and how sections will be run. Let students know what skills or knowledge they are expected to have and whether alternate experience or course work will be accepted. Besides turning in all written assignments and taking exams, what do you expect of students during class State your expectations, and let students know what you regard as cheating and imper missible collaboration. One faculty member has students read the syllabus and then form groups to identify questions about the course or the instructor {Serey, 1989). Be sure students know where your office is and encourage them to stop by with questions and course-related problems. Make a special point of asking students who feel they may need academic accommodations for a physical or learning disability to see you so that appropriate arrangements can be made. If your course requires lab work or fieldwork, review safe practices for using equipment and supplies and discuss emer gency procedures. Let students know what to do in case of fire, tornado, earthquake, evacuation, or other emergency. This way you do not have to keep repeating the material as new students join your class. If taping is impractical, ask students who enroll after the first day to obtain notes from someone who attended that session. In addition to telling students how you wish to be addressed, say something about your background: how you first became interested in the subject, how it has been important to you, and why you are teaching this course. Have students indicate their name, campus address, telephone number, electronic mail address, year in school, and major field. You might also ask them to list related courses they have taken, prerequisites they have completed, other courses they are taking this semester, their reasons for enrolling in your course, what they hope to learn in the course, tentative career plans, and something about their outside interests, hobbies, or current employment. Make sure that students who later enroll in the course complete an introduction card. As you call roll, ask for the correct pronunciation and how the student prefers to be addressed. If your course enrolls fewer than forty students, call the roll for several class meetings to help you learn names. During the term, call students by name when you return homework or quizzes, and use names frequently in class. The act of posing for a picture breaks the ice and creates an informal, relaxed environment. Circulate the photo graphs and have students write their name underneath their picture. Photographs are helpful in recalling a student before an appointment, or later on, when you are asked to write a recommendation for a student, you can refer back to the picture to jog your memory. Or block out on a piece of paper general locations within the room and write the names of students inside the appropriate blocks, instead of labeling exact seats. The second person gives the name of the first person and his own name, and the third person gives the names of the first two people followed by her own name. The chain continues until it returns to the first person, with the instructor preferably near the end. Ask students to divide themselves into groups of three to five and introduce themselves. Or have students group themselves by residence halls or living groups so that they can identify nearby classmates to study with (Heine and others, 1981). If your course has a writing component, you might ask students to write a brief description of their partner. The class could agree on the interview questions beforehand, or each student could devise his or her own items. The statements should be relevant to students in your class and can be a mix of personal and academic attributes: "Someone who works and goes to school," "Someone who has taken (a related course)," "Someone who has already purchased the textbooks," "Someone who is left-handed," "Someone who knows the order of the planets" (or other content-related question). An English professor divides the class into groups of six and gives each member of the group one line of a six-line poem. A sociology professor asks groups of students to come up with a list of the ten most important events (or people) in history. It all students agree, ask them to write their name, telephone number, and electronic mail address on a plain sheet of paper and make copies of this roster for them. Encourage students to call their classmates about missed classes, homework assign ments, and study groups. Or have students complete 3" x 5" cards and exchange cards with two or three classmates. As specifically as possible, tell your students what you wish to accomplish and why, but also ask for what they want to learn from you and what sorts of problems they would like to tackle. Students can also rank their goals in terms of how difficult they may be to achieve. Will a specific time be set aside for questions, or may students ask questions as they arise Give examples of questions students might wish to think about or strategies for approaching the material. Tell students how much time they will need to study for the course, and let them know about campus academic support services. Explain that this "test" will not be graded but is designed to give you information on topics students have mastered and areas in which they need additional review. You could present a list of key concepts, facts and figures, or major ideas and ask students to indicate their familiarity with each. Select a key word from the course title and have students generate word associations or related ideas. Put their responses on the board and use the list to give a thematic overview of the course. Engaging students in actual work during the first class session gives them an idea of what your class will be like. You might make a brief presentation of a core idea, pose a typical problem, or ask students to form working subgroups. By moving immediately into the first topic, you are indicating to students that the course is worth while, well organized, and well paced. Make sure that the assignment is ungraded, however, because students may be adding or dropping your course during the first week or so. Take two minutes at the end of class to have students jot down unsigned comments about what 26the First Day of Class went well and what questions they have about the course. Diversity and Complexity in the Classroom: Considerations of Race, Ethnicity, and Gender 6. Reentry Students Teaching Academically Diverse StudentsAcademic Accommodations for Students with Disabilities Students who have a disability, particularly a learning disability, are a rapidly growing population on college campuses. Such accommodations are neither difficult to provide nor distracting to the rest of the class. In fact, many of these accommodations may make learning easier for all your students. At the beginning of each semester, you might make a general announcement: "Any student who feels that he or she may need accommodations for any sort of physical or learning disability, please speak to me after class, make an appointment to see me, or see me during my office hours. Students are usually their own best advocates, and they know the techniques and adaptations that best suit their needs. It is natural for able-bodied people to feel hesitant or uneasy when first meeting people who are disabled. But disabled people are neither more or less emotionally fragile than able-bodied people. Students who are blind "see" ideas or concepts, just as students who are deaf "hear" what someone means and wheelchair users "walk" to class. Offer physical assistance only if a student requests help or if the need is immediately obvious. Students who use wheelchairs may encounter physical barriers in getting to class on time (broken elevators, late van transportation). Other students may sometimes feel fatigued or have diflicultv concentrating as a result of their disability or their medication. Dyslexic students, for example, have a perceptual deficit that prevents them from unerringly interpreting sequences of letters or numbers. In general, using a variety of instructional modes enhances learning for such students, as it does for all students, by allowing them to master material that may be inaccessible in one particular mode. Most college students will know which forms or modalities of learning work best for them. The attendance and performance of affected students may be erratic, and they may need flexibility in the scheduling of assignments. Staff members can answer questions and provide helpful information about disabilities and academic accommodations. Most buildings on your campus should have entrances that are accessible to students who use mobility aids (wheelchairs, 32 Accommodations for Students with Disabilities canes, crutches, and walkers). Contact your room scheduling office for assistance in obtaining an accessible classroom. Students who use canes, crutches, or walkers appreciate having a chair or desk that is close to the door. Wheelchair users need flat or ramped access, and classroom tables or desks must have enough clearance for them to get their legs underneath. Lab tables and computer consoles should be set up so that wheelchair users can comfortably reach the equipment. Students who are-disabled usually locate and hire their own aides (note takers, lab assistants, readers), often through referrals from the campus disabled students program. You can help, at times, by announcing to your class that a note taker is needed or by referring qualified tutors and lab assistants to students who are disabled. The student and aide will reach their own arrangements about the type of help needed. Be sensitive to questions of access when planning field trips, assigning lab and computer work, and recommending visits to museums, attendance at off-campus lectures and dramatic presentations, and the like. Many techniques that will help students who have sensory or learning disabilities will also benefit all the students in your class.

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