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He points across the room at a boy sitting in the doorway with his legs dangling out of the car. In a second, her serious expression is gone, but I still feel rattled by what she said, half confused by the idea of Four being "nice" and half wanting to punch her for no apparent reason. The other members follow her, a stream of black-clothed, pierced people not much older than I am. So I jump, hitting the ground hard and stumbling forward a few steps before I regain my balance. Uriah and I jog to catch up to the members, along with the other initiates, who barely look in my direction. The Hub is behind us, black against the clouds, but the buildings around me are dark and silent. South of the bridge, Michigan Avenue is a busy street, crawling with people, but here it is bare. I step through it instead of opening it and follow the members through an eerie, dark entryway, crunching broken glass beneath my feet. The ladder creaks and sways beneath his feet, but he keeps climbing, whistling as he does. When he reaches the roof, he turns around and holds the top of the ladder for the next person. It reminds me of climbing the rungs on the Ferris wheel with Four close at my heels. I remember his fingers on my hip again, how they kept me from falling, and I almost miss a step on the ladder. Biting my lip, I make it to the top and stand on the roof of the Hancock building. At first, all I see is the marsh, wide and brown and everywhere, touching the horizon, devoid of life. In the other direction is the city, and in many ways it is the same, lifeless and with limits I do not know. Attached to one of the poles on top of the tower is a steel cable as thick as my wrist. On the ground is a pile of black slings made of tough fabric, large enough to hold a human being. I follow the cable down, over the cluster of buildings and along Lake Shore Drive. She wriggles forward on her stomach until most of her body is supported by black fabric. Then Zeke pulls a strap across her shoulders, the small of her back, and the top of her thighs. He pulls her, in the sling, to the edge of the building and counts down from five. The members whoop and pump their fists and form a line, sometimes shoving one another out of the way to get a better place. The next member, a young-looking boy with hair down to his shoulders, jumps into the sling on his back instead of his stomach. But when I look over my shoulder, I see that most of the initiates look pale or worried, even if they talk excitedly to one another. What happens between initiation and membership that transforms panic into delight? A tall, thick boy jumps up and down like a child before climbing into the sling and lets out a high screech as he disappears, making the girl in front of me laugh. She hops into the sling face-first and keeps her hands in front of her as Zeke tightens her straps. The straps tighten around my midsection, and Zeke slides me forward, to the edge of the roof. And a fool for enjoying the feeling of my heart slamming against my sternum and sweat gathering in the lines of my palms. It holds, which is fortunate, because if it breaks, my death will be swift and certain. He looks down at me and says, "Ready, set, g-" Before he can finish the word "go," he releases the sling and I forget him, I forget Uriah, and family, and all the things that could malfunction and lead to my death. I hear metal sliding against metal and feel wind so intense it forces tears into my eyes as I hurtle toward the ground. Ahead of me the marsh looks huge, its patches of brown spreading farther than I can see, even up this high. I pick up speed and a shout of exhilaration rises within me, stopped only by the wind that fills my mouth the second my lips part. Held secure by the straps, I throw my arms out to the side and imagine that I am flying. I plunge toward the street, which is cracked and patchy and follows perfectly the curve of the marsh. I can imagine, up here, how the marsh looked when it was full of water, like liquid steel as it reflected the color of the sky. The ground grows and bulges beneath me, and I can see the tiny people standing on the pavement below. I should scream, like any rational human being would, but when I open my mouth again, I just crow with joy. I yell louder, and the figures on the ground pump their fists and yell back, but they are so far away I can barely hear them. I look down and the ground smears beneath me, all gray and white and black, glass and pavement and steel. I hang about twenty feet above the ground, but that height seems like nothing now. Wrist bones and forearms press into my back, and then palms wrap around my arms and pull me to my feet. They look as windblown as I feel, the frenzy of adrenaline in their eyes and their hair askew. I think of climbing the stairs with the Abnegation, our feet finding the same rhythm, all of us the same. I follow the pointed finger toward a small dark shape sliding down the steel wire. For the second after I walk in, I stand among a crowd of Dauntless, and I feel like one of them. Then Shauna waves to me and the crowd breaks apart, and I walk toward the table where Christina, Al, and Will sit, gaping at me. I caught sight of myself in a window on the way into the compound, and my cheeks and eyes were both bright, my hair tangled. The Dauntless-born initiates and the transfers were separated during stage one, but we will be training together from now on. If I was still Abnegation, her comment would be rude and out of place, but among the Dauntless, challenges like that seem common. I hear only muttering from the room at the end of the hallway, and I suspect this is another part of the game they like to play with us. In the room is a reclining metal chair, similar to the one I sat in during the aptitude test. The simulation will teach you to control your emotions in the midst of a frightening situation. It takes all the willpower I have for me to steer myself toward the chair and sit down in it again, pressing my skull into the headrest. The Dauntless or the Candor, maybe, because bravery and honesty make people do strange things, but the Abnegation? Four holds a syringe with a long needle in one hand, his thumb against the plunger. You stay in the hallucination until you calm down-that is, lower your heart rate and control your breathing.

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They present society itself in a perfected form, or else society turned upside down, but in any case these Utopias are fundamentally unreal spaces. There are also, probably in every culture, in every civilization, real places - places that do exist and that are formed in the very founding of society - which are something like counter-sites, a kind of effectively enacted Utopia in which the real sites, all the other real sites that can be found within the culture, are simultaneously represented, contested, and inverted. Places of this kind are outside of all places, even though it may be possible to indicate their location in reality. Because these places are absolutely different from all the sites that they reflect and speak about, I shall call them, by way of contrast to Utopias, heterotopias. I believe that between Utopias and these quite other sites, these heterotopias, there might be a sort of mixed, joint experience, which would be the mirror. But it is also a heterotopia in so far as the mirror does exist in reality, where it exerts a sort of counteraction on the position that I occupy. From the standpoint of the mirror, I discover my absence from the place where I am, since I see myself over there. Starting from this gaze that is, as it were, directed toward me, from the ground of this virtual space that is on the other side of the glass, I come back toward myself; I begin again to direct my eyes toward myself and to reconstitute myself there where I am. The mirror functions as a heterotopia in this respect: it makes this place that I occupy at the moment when I look at myself in the glass at once absolutely real, connected with all the space that surrounds it, and absolutely unreal, since in order to be perceived it has to pass through this virtual point which is over there. As for the heterotopias as such, how can they be described, what meaning do they have? As a sort of simultaneously mythic and real contestation of the space in which we live, this description could be called heterotopology. Its first principle is that there is probably not a single culture in the world that fails to constitute heterotopias. But the heterotopias obviously take quite varied forms, and perhaps no one absolutely universal form of heterotopia would be found. In the so-called primitive societies, there is a certain form of heterotopia that I would call crisis heterotopias, i. In our society, these crisis heterotopias are persistently disappearing, though a few remnants can still be found. But these heterotopias of crisis are disappearing today and are being replaced, I believe, by what we might call heterotopias of deviation: those in which individuals whose behaviour is deviant in relation to the required mean or norm are placed. Cases of this are rest homes and psychiatric hospitals, and of course prisons; and one should perhaps add retirement homes that are, as it were, on the borderline between the heterotopia of crisis and the heterotopia of deviation since, after all, old age is a crisis, but is also a deviation since, in our society where leisure is the rule, idleness is a sort of deviation. It is a space that is however connected with all the sites of the city-state or society or village, etc. Until the end of the eighteenth century, the cemetery was placed at the heart of the city, next to the church. There was the charnel house in which bodies lost the last traces of individuality, there were a few individual tombs, and then there were the tombs inside the church. These latter tombs were themselves of two types, either simply tombstones with an inscription, or mausoleums with statues. On the contrary, from the moment when people are no longer sure that they have a soul or that the body will regain life, it is perhaps necessary to give much more attention to the dead body, which is ultimately the only trace of our existence in the world and in language. In any case, it is from the beginning of the nineteenth century that everyone has a right to her or his own little box for her or his own little personal decay; but on the other hand, it is only from the start of the nineteenth century that cemeteries began to be located at the outside border of cities. The dead, it is supposed, bring illnesses to the living, and it is the presence and proximity of the dead right beside the houses, next to the church, almost in the middle of the street, it is this proximity that propagates death itself. This major theme of illness spread by the contagion in the cemeteries persisted until the end of the eighteenth century, until, during the nineteenth century, the shift of cemeteries toward the suburbs was initiated. The heterotopia is capable of juxtaposing in a single real place several spaces, several sites that are in themselves incompatible. Thus it is that the theater brings onto the rectangle of the stage, one after the other, a whole series of places that are foreign to one another; thus it is that the cinema is a very odd rectangular room, at the end of which, on a two-dimensional screen, one sees the projection of a three-dimensional space; but perhaps the oldest example of these heterotopias that take the form of contradictory sites is the garden. W e must not forget that in the Orient the garden, an astonishing creation that is now a diousand years old, had very deep and seemingly superimposed meanings. As for carpets, they were originally reproductions of gardens (the garden is a rug onto which the whole world comes to enact its symbolic perfection, and the rug is a sort of garden that can move across space). The garden is the smallest parcel of the world and then it is the totality of the world. The garden has been a sort of happy, universalizing heterotopia since the beginnings of antiquity (our modern zoological gardens spring from that source). Heterotopias are most often linked to slices in time - which is to say that they open onto what might be termed, for the sake of symmetry, heterochronies. The heterotopia begins to function at full capacity when men arrive at a sort of absolute break with their traditional time. This situation shows us that the cemetery is indeed a highly heterotopic place since, for the individual, the cemetery begins with this strange heterochrony, the loss of life, and with this quasi-eternity in which her permanent lot is dissolution and disappearance. From a general standpoint, in a society like ours heterotopias and heterochronies are structured and distributed in a relatively complex fashion. First of all, there are heterotopias of indefinitely accumulating time, for example museums and libraries. Museums and libraries have become heterotopias in which time never stops building up and topping its own summit, whereas in the seventeenth century, even at the end of the century, museums and libraries were the expression of an individual choice. By contrast, the idea of accumulating everything, of establishing a sort of general archive, the will to enclose in one place all times, all epochs, all forms, all tastes, the idea of constituting a place of all times that is itself outside of time and inaccessible to its ravages, the project of organizing in this way a sort of perpetual and indefinite accumulation of time in an immobile place, this whole idea belongs to our modernity. The museum and the library are heterotopias that are proper to Western culture of the nineteenth century. Opposite these heterotopias that are linked to the accumulation of time, there are those linked, on the contrary, to time in its most fleeting, transitory, precarious aspect, to time in the mode of the festival. These heterotopias are not oriented toward the eternal, they are rather absolutely temporal [chroniques]. Quite recently, a new kind of temporal heterotopia has been invented: vacation villages, such as those Polynesian villages that offer a compact three weeks of primitive and eternal nudity to the inhabitants of the cities. You see, moreover, that through the two forms of heterotopias that come together here, the heterotopia of the festival and that of the eternity of accumulating time, the huts of Djerba are in a sense relatives of libraries and museums. For the rediscovery of Polynesian life abolishes time; yet the experience is just as much the rediscovery of time, it is as if the entire history of humanity reaching back to its origin were accessible in a sort of immediate knowledge. Heterotopias always presuppose a system of opening and closing that both isolates them and makes them penetrable. Either the entry is compulsory, as in the case of entering a barracks or a prison, or else the individual has to submit to rites and purifications. Moreover, there are even heterotopias that are entirely consecrated to these activities of purification - purification that is partly religious and partly hygienic, such as the hammam of the Moslems, or else purification that appears to be purely hygienic, as is Scandinavian saunas. There are others, on the contrary, that seem to be pure and simple openings, but that generally hide curious exclusions. Everyone can enter into these heterotopic sites, but in fact that is only an illusion: we think we enter where we are, by the very fact that we enter, excluded. I am thinking, for example, of the famous bedrooms that existed on the great farms of Brazil and elsewhere in South America. The entry door did not lead into the central room where the family lives, and every individual or traveler who came by had the right to open this door, to enter into the bedroom and to sleep there for a night. This type of heterotopia, which has practically disappeared from our civilizations, could perhaps be found in the famous American motel rooms where a man goes with his car and his mistress and where illicit sex is both absolutely sheltered and absolutely hidden, kept isolated without however being allowed out in the open. The last trait of heterotopias is that they have a function in relation to all the space that remains. Either their role is to create a space of illusion that exposes every real space, all the sites inside of which human life is partitioned, as still more illusory (perhaps that is the role that was played by those famous brothels of which we are now deprived). O r else, on the contrary, their role is to create a space that is other, another real space, as perfect, as meticulous, as well arranged as ours is messy, ill constructed, and jumbled. This latter type would be the heterotopia, not of illusion, but of compensation, and I wonder if certain colonies have not functioned somewhat in this manner. In certain cases, tiiey have played, on the level of the general organization of terrestrial space, the role of heterotopias. I am thinking, for example, of the first wave of colonization in the seventeenth century, of the Puritan societies that the English had founded in America and that were absolutely perfect other places. I am also thinking of those extraordinary Jesuit colonies that were founded in South America: marvelous, absolutely regulated colonies in which human perfect i o n w a s effectively achieved. The Jesuits of Paraguay established colonies in which existence was regulated at every turn.

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These factors should be carefully excluded before considering crying as a sign of pain. But this could be her behavioral expression for coping with pain (by distracting her attention from pain and attempting to enjoy a favorite activity). Even when they have adequate communication skills, there are some reasons children may not report pain. Children may be frightened of (1) talking to doctors, (2) finding out they are sick, (3) disappointing or bothering their parents or others, (4) receiving an injection or medication, (5) returning to hospital or delaying discharge from hospital, (6) having more invasive diagnostic procedures, or (7) having medication side effects. And after all, children just may not think it is necessary to tell health professionals about their pain. So even in children whose cognitive development should allow them to report How can you assess pain in infants and toddlers? Loud scream; rising, shrill, continuous (note: silent cry may be scored if baby is intubated, as evidenced by obvious mouth and facial movements). Analgesics for mild to moderate pain (such as post-traumatic pain and pain from spasticity). Especially avoid giving aspirin to children with chicken pox, dengue fever, and other hemorrhagic disorders. If the child and parents agree and if it helps, the following additional methods (for local adaption) can be combined with pain medications. Transmucosal, intraoral, or intranasal opioids might become an interesting alternative for breakthrough pain in children, since they generally accept this form of application well. Parenteral route the traditional route of parenteral administration used to be intramuscular, which should be avoided nowadays because of the fear, anxiety, and distress it produces in children. The traditionally recommended dose is the antipyretic dose, which is too conservative for pain relief. This maximum daily dose should not be given longer than 48 hours in infants under 3 months, and not longer than 72 hours in children over 3 months old. If a suppository is used, it should not be cut, because drug distribution might be uneven. Often, rectally applied paracetamol does not provide therapeutic drug serum levels. Opioids are the first line of systemic therapy in moderate to severe pain, with morphine being the most frequently used. For the use of morphine and fentanyl in the pediatric patient, and especially in neonates and infants, no strong correlation between dose/serum plasma levels and analgesic effects has been shown, due to the high variability in individual opioid metabolism. Fentanyl can be used as a substitute for morphine in children who have hemodynamic instability and who cannot tolerate histamine release. For remifentanil, which may only be used intraoperatively, adequate analgesia is achieved with a loading dose of 1 g/kg/hr followed by maintenance infusion of 0. Alfentanil is effective at a dose of 50 g/ kg followed by an infusion of 1 g/kg/min. Table 3 Common regional blocks practiced in children Caudal epidural Lumbar epidural Ilioinguinal/iliohypogastric Dorsal nerve of penis Axillary Femoral/iliac Hernia repair, orchidopexy, urethro plasty, circumcision All upper and lower abdominal surgery, thoracotomy Hernia repair Circumcision, advancement of prepuce Surgery of hand and forearm Thigh and femur surgery Pain Management in Children Note: wound infiltration can be as good for a hernia, or caudal block with bilateral drug administration providing complete blockade. The catheters may even be advanced-always without resistance-up to the thoracic segments in infants because their more compact and globular fat makes it easy to pass the catheter. Bupivacaine should not exceed 2 mg/kg or 8 mg/day; it is commonly used in concentrations of 0. Planning an analgesic strategy It is important to have a plan for pain relief from the beginning of the perioperative period until such time as the pediatric patient is pain free (see. A premature or young infant who may have problems with central respiratory drive may benefit from techniques that minimize the use of opioids, which have central respiratory depressant drug effects. Surgical considerations the degree of pain is often associated with the type of surgery. For surgeries in areas that are moved regularly, such as the chest and upper abdomen, the pain relief measure required would be intense. A catheter placed in the epidural space can provide continuous analgesia for a long period of time (if tunneled for periods of more than 1 week). Two hours after surgery, oral paracetamol 300 mg or a combination of paracetamol and ibuprofen (300 mg) is given 8-hourly until the pain score allows reduction or stopping of the medication. In single-injection regional nerve blocks, postoperative analgesia is limited to 12 hours or less. Plan 2 A newborn baby with an anorectal anomaly is scheduled for an emergency colostomy. Plan 3 A 5-year-old boy is admitted to the emergency ward with acute burns and severe pain. If it comes to surgery, local infiltration with local anesthetics of the donor area or a regional block would be beneficial. Routine monitoring and recording of pain score, sedation score, and respiratory rate is important in all moderately to severely painful conditions, and for all Pain Management in Children patients on infusion. A monitoring frequency of check-ups every 4 hours is considered to be safe to detect increasing sedation. Oxygen saturation is a better monitor than apnea/respiratory rate monitors as it would detect airway obstruction earlier, but for the average situation and patient outside the intensive care ward, there is no indication that regular sedation control would be inferior to pulse oximetry. Pharmacological management must be combined with supportive measures and integrative, nonpharmacological treatment modalities such as massage, acupuncture, relaxation, and physiotherapy. Cognitive-behavioral techniques include guided imagery, hypnosis, abdominal breathing, distraction, and storytelling. Nonpharmacological treatment options should be integrated into the analgesia plan. Assessment of chronic pain should establish not only the site, severity, and other characteristics of pain, but also the physical, emotional, and social impact of pain. Treatment should include specific therapy directed to the cause of pain and associated symptoms such as muscle spasms, sleep disturbance, anxiety, or depression. Pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. Andreas Kopf If adequate pain medication is provided for elderly patients, why might they still not receive sufficient pain control? Impaired vision and motor skills, combined with xerostomia (dry mouth) and disturbances of memory, may make an adequate treatment a complete failure. It has to be noted that the average geriatric patient in industrialized countries has a prescription for seven different drugs, and only a minority of patients have been prescribed fewer than five daily drugs, making noncompliance and drug interactions highly likely. Also, due to reduced hepatic function, plasma protein levels are generally lower in elderly patients. This effect may be most pronounced for drugs that are eliminated through the kidneys, since glomerular filtration rate is generally reduced, too, and for drugs with high plasma protein binding, where unpredictable serum levels of free substance may result. Studies show that unrelieved pain is one of the most important predictive factors for physical disability. Other important pain etiologies include polyneuropathy and postherpetic neuralgia. Therefore the conclusion has to be that pain perception and analgesic interactions are unpredictable. Shehu was still in relatively good general condition, being an important and active member of St. Do patients with impaired communication, such as those with Alzheimer disease, receive insufficient analgesia? All reported pain should be taken seriously; it is the patient who has the pain, and the pain is what the patient tells you it is. In Filipoje, he found a used walking stick and an elastic bandage, which helped with ambulation. Shehu was not satisfied with the pain reduction from the paracetamol, since he needed to make his way to and from the church daily, although when sitting or lying down the pain intensity was acceptable. Frasheri was reluctant to prescribe opioids, because they are not easy available in Albania. Activity, drinking an extra liter of water, the healthy Mediterranean diet, and milk sugar helped against constipation, but nausea could not be avoided due to the lack of metoclopramide.

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Rarely, some children with this illness later develop rheumatic fever (abnormalities of the heart valves and inflammation of the joints); treatment with antibiotics can usually prevent this. The symptoms of illnesses caused by bioterrorism agents are similar to symptoms of many infectious diseases. If a number of children become ill at the same time, notify the Delaware Division of Public Health, Office of Infectious Disease Epidemiology immediately at 1888-295-5156. Creating Written Emergency Plans for Natural and Man-made Disasters In the past, practicing fire drills and having a basic plan to evacuate your program or family childcare home seemed adequate preparation for an emergency. Especially in relation to recent world events, we are becoming increasingly aware of the need for more in-depth emergency planning. Your plans should include procedures for the following: Training staff or helpers about disaster preparedness Assigning staff or helpers specific responsibilities during a disaster Accounting for all children, staff or helpers Having a relocation process, when appropriate Remaining at the facility or "sheltering-in-place," when appropriate Having necessary emergency supplies, food and water Contacting appropriate emergency response activities Contacting the parents/guardians of the children Your plan should be individualized to the particular needs of the children, staff, or helpers in your facility or family childcare home. Please take time to think through how you would respond to various types of emergencies and begin to write your facilities emergency plans. Share your plans with parents and guardians of the children in your care to let them know you are doing all you can to keep their children safe and sound. The Wesley program utilizes the accredited National Training Institute of Childcare Health Consultant Curriculum developed by the University of North Carolina at Chapel Hill, School of Public health-Maternal and Child Health. The health consultant should be a pediatrician, family health physician, pediatric nurse practitioner, pediatric/community health nurse, or health professional with expertise in: Mental Health Nutrition Health education Oral Health Environmental Health Emergency management Infectious diseases Issues relation to caring for children with special health care needs Although some state regulations require a health consultant, others do not. The health consultant should have knowledge and expertise in the following areas: Routines Conditions and constraints for caregivers/teachers Pediatric health care and early brain development Community, state, and national resources and regulations Principles of consultation Working with diverse populations Oral, written and electronic communication Communication with non-health-related personnel and local health authorities Techniques to teach health and safety to adult learners who are not health professionals 131 Childcare Manual What Does a Health Consultant Do? Assessment: An in-depth appraisal conducted to diagnose a condition or determine the importance or value of a procedure. Organisms that may be responsible for localized or generalized diseases and can survive in and out of the body. They are much larger than viruses and usually can be treated effectively with antibiotics. Body Fluids: Urine, feces, saliva, blood, nasal discharge, eye discharge, and injury or tissue discharge. Bronchitis: Most often a bacterial or viral infection that causes swelling of the tubes (bronchi) leading to the lungs. Chronic: Adjective describing an infection or illness that lasts a long time (months or years). The membrane can make swallowing and breathing difficult and may cause suffocation. Plantlike organisms such as yeasts, molds, mildew, and mushrooms that get their nutrition from other living organisms or dead organic matter. Group care setting: A facility where children from more than one family receive care together. Health consultant: A physician certified pediatric or family nurse practitioner, registered nurse, or environmental, oral, mental health, nutrition, or other health professional that has pediatric and childcare experience and is knowledgeable in pediatric health practice, childcare, licensing, and community resources. The health consultant provides guidance and assistance to childcare staff on health aspects of the facility. Immune globulin (gamma globulin, immunoglobulin): An antibody preparation made from human plasma. Incubation period: Time between exposure to an infectious microorganism and beginning of symptoms. Infant: A child between the time of birth and age of ambulation (usually between birth & 12 months). Ingestion: the act of taking material (whether food or other substance) into the body through the mouth. It occurs as a symptom of various diseases such as hepatitis that affect the processing of bile. Mantoux intradermal skin test: Involves the intradermal injection of a standardized amount of tuberculin antigen. The reaction to the antigen on the skin can be measured and the result used to assess the likelihood of infection with tuberculosis. Medications: Any substances that are intended to diagnose, cure, treat, or prevent disease or affect the structure or function of the body of humans or other animals. For an inanimate surface to be considered sanitary, the surface must be clean and the number of germs must be reduced to such a level that disease transmission by that surface is unlikely. This procedure is less rigorous than disinfection and is applicable to a wide variety of routine housekeeping procedures involving, for example, bedding, bathrooms, kitchen countertops, floors, and walls. Screening: Mass examination of a population group to detect the existence of a particular disease. Secretions: Wet materials such as saliva that are produced by cells or glands and have a specific purpose in the body. Standard precautions: Apply to contact with non-intact skin, mucous membranes, blood, all body fluids, and excretions except sweat, whether they contain visible blood or not. Streptococcus: A common bacterium that can cause sore throat, upper respiratory illnesses, pneumonia, skin rashes, skin infections, arthritis, heart disease (rheumatic fever), and kidney disease (glomerulonephritis). Toddler: A child between the age of ambulation and toilet learning/training (usually between 13 and 35 months). Universal precautions: Apply to blood and other body fluids containing blood, semen, and vaginal secretions, but not to feces, nasal secretions, sputum, sweat, tears, urine, saliva, and vomitus, unless they contain visible blood or are likely to contain blood. Red Cabb ag e Lab: Acids and Bas es Introduc tion: Liquids all around us have either acidic or basic (alkaline) properties. However, both strong acids and strong bases can be very dangerous and burn your skin, so it is important to be very careful when using such chemicals. In order to measure how acidic or basic a liquid is, one must use the pH scale as illustrated below: the strength of the pH scale is determined by the concentration of hydrogen ions (H+) where a h i gh co n ce n t r a t i o n of H+ ions indicate a lo w pH and a h i gh co n ce n t r a t i o n of H+ ions indicate a h i gh pH. The pH scale ranges from 1 to 14 where 1 to 6 is classified as acidic, 7 neutral (neither a base or an acid) and 8 to 14 is classified as basic. In this lab, you will use the juice from red cabbage as a pH indicator to test common household liquids and determine their pH levels. You will mix cabbage juice with different household liquids and see a color change produced by a pigment called flavin (an anthocyanin) in red cabbage. Through this color change, you will be able to successfully identify the approximate pH of common household liquids using the table below: Color: Approx. P r e di c t w h e t h e r ea c h of t h e su bsta n ce s i s a ci di c, n e u t r a l o r basi c. Once it is blended, filter out the leaves inside the mixture with the strainer and pour the mixture into a large container. Pour 100 ml of each individual liquid into its respective cup (except for baking soda). Do this one at a time and record the color change below: Liquid: Hand Sanitizer Lemon Soda Apple Juice White Vinegar Baking Soda Shampoo Conditioner Color Change/ pH Actual pH Now look up t h e a ct u a l p H of ea ch of t h e su bsta n ce s a nd se e ho w a cc u r a t e t h e ca bba ge j u i ce i ndi ca t o r w a s! How did your reasoning for your predictions change after seeing the approximate pH level? Categorize your results below: Strong Acids Weak Acids Neutral Weak Bases Strong Bases Now add 10 ta bl e spoo ns m o r e of baki n g soda in t o a n e w c u p.

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Glucose is found inside cells, where it is changed into energy as needed, as well as in the bloodstream, where it is carried around to all of our organs. Our bodies have a wonderful and complicated system for making sure that blood glucose levels are normal day in and day out. If our glucose levels were to fall too low, we would lose the ability to think and function normally. If they were to go too high, it could cause damage to the body that happens over the course of many years. Patients are diagnosed as having diabetes if their blood glucose is 126 mg/ dL when fasting, their blood glucose is 200 mg/dL and they have symptoms of diabetes, and/or their A1C result is 6. An oral glucose tolerance test is rarely used to diagnose people with diabetes, and if the blood glucose level is 200 mg/dL 2 h after drinking a sugary sweet drink, the diagnosis of diabetes may be made. In most cases, except in those who are very sick, any test should be repeated to confirm the diagnosis. In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing. The Basics of Type 1 Diabetes 3 Normal blood glucose level is usually around 100 mg/dL. People with diabetes check their blood glucose levels by poking their fingertips or using continuous glucose monitoring (see p. In addition to checking the blood glucose level directly, there is a way to track blood glucose levels over time known as the A1C. It does not replace daily blood glucose monitoring, but in combination with daily readings, an A1C can determine how well the current diabetes treatment plan is working (Table 1. A person who is elderly and troubled by hypoglycemia may have a goal of an A1C <8%. Your bloodstream carries the glucose to cells throughout your body and uses it for energy. To help glucose get into your cells, b-cells in your pancreas make insulin, which attaches to each cell and opens the door for glucose to enter. Location of pancreas with expanded view of pancreatic islet and Insulin is made in the b-cells, which are part of the Islets of Langerhans in the pancreas. Normally, glucagon protects us by promoting production of glucose from the liver, helping to prevent a decline of glucose in the blood that otherwise would occur during fasting. But in diabetes, glucagon may fight or resist the action of insulin at inappropriate times, when glucose utilization is required. C-peptide is important because it can be used to measure how much insulin a person is making, especially if someone is on insulin shots. The immune system has a very tough job-evaluate every cell, protein, and molecule in the body and decide whether it should stay or go. Immune system cells constantly patrol the body for trouble: bacteria, viruses, fungi, and even cancer cells. Sometimes, however, the immune system can get it wrong and see danger where there is none. When that happens, an autoimmune disease, such as rheumatoid arthritis, celiac disease, or type 1 diabetes, may be the unfortunate outcome. In type 1 diabetes, the immune system mistakenly kills the only insulinproducing cells in the body. In type 1 diabetes, the immune system mistakenly believes that certain parts of the pancreas-the b-cells-need to be killed. The main job of the b-cells is to sense rising glucose levels in the blood and respond by releasing insulin. The young child who is urinating frequently, drinking large quantities, losing weight, and becoming increasingly tired and ill is the classic picture of a child with new-onset type 1 diabetes. A child who is potty-trained and dry at night who starts having accidents and wetting the bed again could have diabetes. These children are immediately started on insulin therapy, which they must remain on for the rest of their lives. They may go through a phase, early in treatment, during which insulin requirements seem to fall, commonly called the "honeymoon phase," but over time, all require appropriate doses of insulin to keep their blood glucose levels in the normal range. And no one ever explained what having type 1 diabetes was: I was told I needed to test my blood sugar and inject insulin before I knew what either of those meant. The doctor tried to explain to me how things would work now that I was a type 1 diabetic officially. When adults are diagnosed with diabetes, they are often told that they have type 2 diabetes at first. This is often due to a lack of an understanding in the medical community that type 1 diabetes can start at any age. It seems more likely that a young adult, someone in their late teens or early 20s, may be diagnosed appropriately with type 1 diabetes, but anyone can be misdiagnosed. Their doctor finds an elevated blood glucose level at a routine visit and starts them on a diet, exercise, and an oral medication. Generally, this requires antibody tests and possibly the measurement of a C-peptide level. Ten Months of Hell "I was 50, having presurgery tests, and the surgeon said my blood sugar was way too high. He did the surgery anyway, and then referred me to my primary care physician, who tested my blood sugar again. Finally, I found another endocrinologist recommended by someone, and he also treated me for type 2, with no success. Then I switched to another endocrinologist, who had type 1, and he also treated me for type 2. So much of my time and energy was devoted to keeping my blood sugar under control. Anybody who knows me knows that was a horrible sacrifice, because chocolate is one of my favorite foods. Anyway, that endocrinologist started me on insulin, and my life became much easier. People who have had type 1 diabetes for a long time have learned to live with it in one way or another. Some people who have had diabetes for 40 years started out testing their urine for glucose and giving themselves only one or two shots of animal insulin per day. Today, newer insulins and technology can make a world of difference in terms of managing blood glucose levels, but for people used to surviving without these tools, change can be intimidating. For many, they have had the disease for so long that they "guesstimate" how many carbs they are eating and adjust their insulin dose by instinct more than numbers. However, it is a good idea to meet with a diabetes educator and/or a registered dietitian every year or two just to stay 8 the Type 1 Diabetes Self-Care Manual updated on what is happening in the world of diabetes and to gain new and helpful information. Sometimes the primary care team is a good place to start when seeking further referral to a new diabetes doctor. Through the Years "I was 15 when I noticed the excessive thirst of the onset, and it took a few days for me to mention it to my parents. I recall being stunned by the news, but I also recall thinking of it as being an obligation for which I would be responsible. I was fortunate that my father was a physician and a diabetic, and my mother a nurse, so there was a lot of support and understanding. I still relied on my parents for diabetic supplies (insulin and urine test strips) and for glass syringes and needles (which I kept in a small Mason jar filled with alcohol). There were not many hypoglycemic reactions that I recall, probably because my glucose level was much higher than I would tolerate now. This was partially because of my youth, but also there was no method to test for blood sugar levels in the mid-1960s. Control was still tenuous (looking back), but I continued to live my life in spite of it. First, I realized that I had to be serious about control when I first noticed retinopathy and had a series of successful laser photocoagulation treatments over six years.

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Second Edition 2013 Rules of Unified English Braille 16: Line Mode, Guide Dots 220 Refer to: Guidelines for Technical Material, Part 13, for rules on constructing arrows. Examples: [a line with a right-pointing arrow at the right end:] "33333333333333o [a double line with a downward-pointing arrow at the mid-point:] "377777\%777777 16. In general, choose a symbol based on the physical shape of the line or feature (such as a junction) rather than the meaning of the symbol in other contexts. Examples: [a line with a small rectangle near the right end:] "33333333333&xxxy33 [a line with different levels and with slanted and right-angle changes of level:] "333icce38-033 16. Group one or more of the symbols together when necessary providing that each group is surrounded by spaces. Examples: [a single solid left-leaning diagonal line:] < < < < Second Edition 2013 Rules of Unified English Braille 16: Line Mode, Guide Dots 222 [a dotted vertical line:] ^ ^ ^ ^ [a left-leaning diagonal line meeting a double right-leaning diagonal line in a v-shape:] < <,>,> <,> 16. Even when the left end of a horizontal line forms a corner or crossing with a vertical or diagonal line, open the horizontal line with the horizontal line mode indicator. When a vertical line or one of the variant vertical lines crosses a diagonal line or is too close to a diagonal line, use either of the diagonal line segments or variant diagonal line segments. Examples: [two vertical lines crossed by a left-leaning diagonal line:] Note: this diagram is almost too complex to use line mode. Use no less than two guide dots and leave at least one blank cell before and after the sequence. Second Edition 2013 Rules of Unified English Braille 16: Line Mode, Guide Dots 228 Examples: [excerpt from a table of contents:] Slovenia. The list Added "s" and apostrophe "s" When an "s" or apostrophe "s" is added to any word on the list, use the shortform with the following three exceptions: abouts almosts hims ab s almo/s hims about ab aboutface aboutfacing eastabout knockabout rightabout runabout thereabout westabout aboutfaced aboutturn gadabout layabout roundabout southabout turnabout whereabout aboutfacer aboutturned hereabout northabout roustabout stirabout walkabout above abv aboveboard hereinabove aboveground abovementioned according ac unaccording Second Edition 2013 accordingly unaccordingly Rules of Unified English Braille Appendix 1: Shortforms List 230 across acr readacross after af afterbattle afterburn afterburning aftercoffee afterdeck aftergame afterhatch afterlife afterlunch aftermatch aftermeeting aftermost afterparty aftersale aftershave aftershower aftertax aftertheatre aftertreatment afterworld morningafter whereafter afterbirth afterburned aftercare afterdamp afterdinner afterglow afterhatches afterlight afterlunches aftermatches aftermidday afterpain afterpiece afterschool aftershock aftersupper aftertaxes afterthought afterword hereafter thereafter whereinafter afterbreakfast afterburner afterclap afterdark afterflow afterguard afterhour afterlives aftermarket aftermath aftermidnight afterparties afterplay aftersensation aftershow aftertaste aftertea aftertime afterwork hereinafter thereinafter afternoon afn goodafternoon midafternoon afternoontea afterward afw Second Edition 2013 Rules of Unified English Braille Appendix 1: Shortforms List 231 again ag hereagain thereinagain hereinagain whereagain thereagain whereinagain against ag/ hereagainst thereagainst whereagainst almost already also alm alr al al? Examples: ahimsa ahimsa decl>a;n mu/a*e lacrosse mu/] braillist drafter brailli/ draft] m>ab mu/ang necess>ily %ld] declaration lacrosse marabout mustang mustache muster rafter 3. When the shortform for "after", "blind" or "friend" is part of a longer word and is followed by a vowel or a "y", do not add the longer word to the Shortforms List. Examples: aftereffect blinded aft]e6ect 2fri5d$ afterimage blinding aft]image bl9d$ bl9d+ befriended be and con shortforms 5. When any of the shortforms that begin with "be" or "con" are within a longer word, do not add the longer word to the Shortforms List unless the letters the shortform represents begin the longer word. Examples: hereinbefore misconceived "h9be=e inbetween 9betwe5 misconceiv$ Second Edition 2013 Rules of Unified English Braille Appendix 2: Word List 241 Appendix 2: Word List this Appendix provides an alphabetic list of the example words used to show contraction use in Section 10: Contractions. Second Edition 2013 Rules of Unified English Braille Appendix 2: Word List 267 10. Line 1: Line 2: Line 3: Line 4: Line 5: Line 6: Line 7: a b c d e f g h i j k l m n o p q r s t u v x y z & = (! Unicode column: the Unicode values given are not intended to be strictly definitive but are a useful reference. To insert a symbol in many Windows applications including Word, type the Unicode number then Alt-x. Usage and reference column: When not otherwise indicated, symbols are assumed to take a grade 1 meaning. Some symbols are not specified in either of these documents but have been included here for completeness. Second Edition 2013 Rules of Unified English Braille Appendix 3: Symbols List 276 Usage and reference (3. Unicode Name myself much must 006e lowercase letter n not necessary neither 006f lowercase letter o right pointing arrow (east), arrow terminator lowercase letter p people paid perceive perceiving perhaps 0071 lowercase letter q quite quick 0072 myf m* m/ n n nec nei o o p p pd p]cv p]cvg p]h q q qk r r r Usage and reference grade 2 (10. Unicode Name receive receiving rejoice rejoicing 0073 rcv rcvg rjc rjcg s s s Usage and reference grade 2 (10. Unicode Name 7 7 7 77 77 777 8 8 8 9 9 9 2033 Usage and reference were grade 2, standing alone (10. Unicode Name 0306 breve above following letter parallelogram third transcriberdefined print symbol first transcriberdefined typeform word indicator first transcriberdefined typeform symbol indicator first transcriberdefined typeform passage indicator first transcriberdefined typeform terminator closing angle bracket greater-than script terminator @+ @#d @#? Second Edition 2013 Rules of Unified English Braille Appendix 3: Symbols List Braille Print. Unicode Name double small circle for electrons double line bond grade 1 symbol indicator ence ong ful tion ness ment ity grade 1 terminator grade 1 word indicator grade 1 passage indicator capital letter A capital letter B capital letter C capital letter D capital letter E capital letter F capital letter G capital letter H. Z Unicode Name 0049 004a 004b 004c 004d 004e 004f 0050 0051 0052 capital letter I capital letter J capital letter K capital letter L capital letter M capital letter N capital letter O capital letter P capital letter Q capital letter R,i,j,k,l,m,n,o,p,q,r,r,s,t,u,v,x,x,y,y,z,&,* Usage and reference (4. Unicode Name variant leftleaning diagonal line segment bar under previous item straight barb, lower half (directionless) capital letter W regular barb, lower half, counter nondirectional double quotation mark seconds inches opening single quotation mark closing single quotation mark capital yogh capital thorn capital eth capital wynn (wen) variant rightleaning diagonal line segment capitals terminator opening music indicator dash,<,:,,w,w,7,7,7,8,0,#y,#! Unicode Name single line bond 0338 solidus (forward slash) overlay on following capital letter horizontal stroke overlay on following capital letter breve above following capital letter macron above following capital letter capital eng cedilla below following capital letter grave accent above following capital letter circumflex above following capital letter simple rightpointing arrow under previous item circle (ring) above following capital letter tilde above following capital letter dieresis/umlaut above following capital letter,@* Usage and reference [16] (4. Unicode Name 0323 dot under previous item ligature indicator where only the following letter is capitalised acute accent above following capital letter caron (hacek, wedge) above following capital letter first transcriberdefined modifier on following capital letter second transcriberdefined modifier on following capital letter third transcriberdefined modifier on following capital letter second variant vertical line segment capital reserved non-Roman letter capital reserved non-Roman letter capital reserved non-Roman letter capital reserved non-Roman letter capital reserved non-Roman letter,^4,^6 Usage and reference [12] (4. Paulson Papers on Investment Case Study Series A Chinese Pharmaceutical Startup Acquires an American Firm to "Go Global" June 2016 Paulson Papers on Investment Preface Case Study Series F or decades, bilateral investment has flowed predominantly from the United States to China. Unlike bond holdings, which can be bought or sold through a quick paper transaction, direct investments involve people, plants, and other assets. The Paulson Papers on Investment aim to look at the underlying economics- and politics-of these cross-border investments between the United States and China. Many observers debate the economic, political, and national security implications of such investments. Investment opportunities are much discussed by Americans and Chinese in the abstract but these discussions are not always anchored in the underlying economics or a realistic investment case. The goal of the Paulson Papers on Investment is to dive deep into various sectors, such as agribusiness or manufacturing-to identify tangible opportunities, examine constraints and obstacles, and ultimately fashion sensible investment models. But even as we look ahead, we also aim to look backward, drawing lessons from past successes and failures. And that is the purpose of the case studies, as distinct from the other papers in this series. Other Chinese investments have failed: revenue sank, companies shed jobs, and, in some cases, businesses closed. Damien Ma, Fellow and Associate Director of the Paulson Institute think tank, directs the case study project. For this case study of WuXi AppTec, we are grateful to James Harter, a talented University of Chicago graduate and student fellow at the Paulson Institute, for his excellent research and continued dedication. A Chinese Pharmaceutical Startup Acquires an American Firm to "Go Global" Paulson Papers on Investment Case studies are reconstructed on the basis of the public record, personal interviews with participants, and journalistic accounts. But they may have gaps and other inadequacies where the record is incomplete, facts are murky, or players chose not to share their views. Cover Photo: WuXi AppTec A Chinese Pharmaceutical Startup Acquires an American Firm to "Go Global" Paulson Papers on Investment Timeline 1982 Case Study Series From a basement in Minneapolis, Bonnie Baskin, a PhD in microbiology, launches ViroMed Inc. The financial crisis has significant effects on the global biotech industry: over the next three years, fully one quarter of all publicly listed biotech companies either cease to operate or are acquired. July September December 2010 A Chinese Pharmaceutical Startup Acquires an American Firm to "Go Global" Paulson Papers on Investment Key Players United States Case Study Series John J. Both candidates were said to be incensed over the intended merger of drug giants Pfizer and Allergan-a merger that valued Allergan at over $160 billion. What particularly irked the two candidates was the post-merger plan to relocate the new company to Dublin, Ireland, the home of Allergan. The merger would have meant enormous tax savings, considering that the company paid $3. It has repeatedly cut its research budget in favor of acquisitions and other profit-driven maneuvers. The merger, he argued, "allows us to continue to sustain an investment of approximately $9 billion mainly spent in the United States," adding, "we have 40,000 combined employees in the United States. By 2013, Pfizer had cut the R&D budget of the combined company to Case Study Series just $6. The answer lies in what it says about underlying changes in the global pharmaceutical industry. Mega deals like Pfizer-Allergan invariably attract the spotlight and invite political controversy. Merck shed about 24,000 jobs from 2009 to 2013 following its acquisition of SheringPlough. Unlike the outsourcing and automation of low-skilled jobs in manufacturing, for instance, the jobs disappearing from the pharmaceutical sector are well paid and require advanced degrees. These are precisely the types of high-skilled jobs that have been assumed to be "safe" for American workers from the twin forces of globalization and automation that have radically altered some industries and regions of the United States.


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Cyclosporiasis Cyclospora cayetanensis can be transmitted through water or food. Additional nonspecific symptoms include chills, headache, anorexia, cough, weakness, sore throat, dizziness, and muscle pain. Diagnosis Positive cultures of blood, stool, or other specimens are required for diagnosis. Diagnosis Confirmation of diagnosis is based on cultures of stool, blood, or other specimens on special media and/or with selective techniques. Fluid and electrolyte replacement Avoid antimotility agents, which may prolong symptoms and are associated with toxic megacolon Antibiotic treatment benefits fewer than half of pts but is indicated in cases with high fever, bloody and/or severe diarrhea, disease persistence for 1 week, or worsening symptoms. These bacteria are transmitted from person to person via the fecal-oral route and occasionally via intermediate vectors such as food, water, flies, and fomites. Shigella causes extensive ulceration of the epithelial surface of the colonic mucosa. Clinical Manifestations with lower abdominal pain, mild diarrhea, malaise, weight loss, and diffuse lower abdominal or back pain. Amebomas- inflammatory mass lesions- may develop in chronic amebic intestinal disease. Spores can persist on environmental hospital surfaces for months and on the hands of hospital personnel who do not practice adequate hand hygiene. Clinical Manifestations Diarrhea is the usual manifestation, with up to 20 bowel movements per day. The cell culture cytotoxin test is specific but less sensitive and also takes 48 h. Oral administration of vancomycin is effective but expensive and may increase the incidence of vancomycin-resistant enterococci. Other approaches have been described, but for persisent disease, the combination of vancomycin (125 mg qid) with rifampin (300 mg bid) for 10 days is one preferred option. Fluoroquinolones are useful, but resistance is increasing, particularly in Southeast Asia, parts of the western continental United States, and Hawaii. Uncommon complications include epididymitis, prostatitis, penile edema, abscess or fistulae, seminal vesiculitis, and balanitis in uncircumcised men. Third-trimester disease can cause prolonged rupture of membranes, premature delivery, chorioamnionitis, funisitis, neonatal sepsis, and perinatal distress and death. Ophthalmia neonatorum, the most common form of gonorrhea in neonates, is preventable by prophylactic 1% silver nitrate drops, but treatment requires systemic antibiotics. Infertility due to fallopian tube scarring has been strongly linked to antecedent C. Painful adenopathy above and below inguinal ligament presents with the "sign of the groove. Tests surpass culture in sensitivity and allow use of urine specimens rather than urethral or cervical swabs. In moist intertriginous areas, papules can enlarge and erode to produce broad, highly infectious lesions called condylomata lata. Source: these recommendations are based on those issued by the Centers for Disease Control and Prevention in 2002. Clinical Manifestations First episodes of genital herpes can be associated with fever, headache, malaise, and myalgias. More than 80% of women with primary genital herpes have cervical or urethral involvement. Lesions slowly enlarge, causing genital swelling (especially of the labia), with occasional progression to pseudoelephantiasis. Diagnosis Typical intracellular Donovan bodies are seen within large mononuclear cells in smears from lesions or biopsy specimens. Bullae are also seen in necrotizing fasciitis, gas gangrene, and Vibrio vulnificus infection in pts with cirrhosis who have ingested contaminated raw seafood or been exposed to Gulf of Mexico or Atlantic seaboard waters. Erysipelas: Lymphangitis of the dermis, with abrupt onset of fiery red swelling of the face or extremities, well-defined indurated margins, intense pain, and rapid progression. The frequency of erythromycin resistance in group A Streptococcus is currently 5% in the United States but has reached 70 to 100% in some other countries. Most, but not all, erythromycin-resistant group A streptococci are susceptible to clindamycin. Myonecrosis is usually related to trauma; however, spontaneous gangrene- usually due to C. In 90% of pts, one joint is involved- most often the knee, which is followed in frequency by the hip, shoulder, wrist, and elbow. Gonococcal Arthritis Women are more likely than men to develop disseminated gonococcal disease, particularly during menses and during pregnancy (see Chap. True gonococcal arthritis usually affects a single joint: hip, knee, ankle, or wrist. Miscellaneous Etiologies Other causes of septic arthritis include Lyme disease, tuberculosis and other mycobacterial infections, fungal infections (coccidioidomycosis, histoplasmosis), and viral infections (rubella, mumps, hepatitis B, parvovirus). Fluid should be examined for crystals to rule out gout or pseudogout, and an attempt should be made to identify the extraarticular source of hematogenous seeding. Empirical antibiotics can include oxacillin (2 g q4h) if gram-positive cocci are seen in synovial fluid; vancomycin (1 g q12h) if methicillin-resistant S. If fluoroquinolone resistance is not prevalent, a fluoroquinolone can be given for the entire course. Osteomyelitis: infection of bone caused by pyogenic bacteria and mycobacteria that gain access to bone by the hematogenous route (20% of cases, primarily in children), via direct spread from a contiguous focus of infection, or by a penetrating wound Sequestra: ischemic necrosis of bone resulting in the separation of large devascularized bone fragments; caused when pus spreads into vascular channels Involucrum: elevated periosteum deposits of new bone around a sequestrum 2. Characteristic finding in osteomyelitis: increased uptake in all three phases of scan. Specificity moderate if plain films are normal, but poor in presence of neuropathic arthropathy, fractures, tumor, infarction. Cephalosporins may be used for the treatment of patients allergic to penicillin whose reaction did not consist of anaphylaxis or urticaria (immediate-type hypersensitivity). Hepatic candidiasis results from seeding of the liver during neutropenia in pts with hematologic malignancy but presents when neutropenia resolves. Amphotericin B is usually prescribed initially, but fluconazole may be useful for outpatient treatment. Localized: bacterial pneumonia, Legionella, mycobacteria Nodular: suggests fungal etiology. Candida has a predilection for the kidneys, reaching this site via either hematogenous seeding or retrograde spread from the bladder. Adding antibiotics is not appropriate unless there is a clinical or microbiologic reason to do so. Do not narrow the spectrum unnecessarily (continue to treat for both gram-positive and gram-negative aerobes).