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The site selected should be well the buttocks, and the needle should be directed anteriorly-that is, if the patient is lying skin plane. Scheduling immunizations after factor replacement therapy, if feasible, may be considered. The distance separating the injections is arbitrary but should be at least 1 inch, if possible, so that local reactions are unlikely to overlap. A brief period of bleeding at the injection site is common and usually can be controlled by applying gentle pressure. Parents also should be advised not to threaten children with injections or use them as a punishment for inappropriate behavior. Older children may be more comfortable sitting on the examination table edge and hugging their parent chest to chest while an immunization is administered. Topical application of ethyl chloride, sprayed onto a cotton ball that is then placed over the injection site for 15 seconds prior to administering the injection, also has been shown to decrease injection pain in school-aged children. Scheduling Immunizations A vaccine is intended to be administered to a person capable of an appropriate optimal immunologic response for a person must be balanced against the need to achieve timely protection against disease. For example, pertussis-containing vaccines conferring protection in young infants-who experience the highest morbidity and mortality from pertussis-mandates that immunization occur early, despite a lessened serum antibody response. For this reason, in some developing countries, oral poliovirus vaccine is given at birth, in accordance with recommendations of the World Health Organization. An additional factor in selecting an immunization schedule is the need to achieve a uniform and regular response. For some vaccines, periodic booster doses (eg, with tetanus and diphtheria toxoids and acellular perVaccines are safe and effective when administered simultaneously. This information is particularly important for scheduling immunizations for children with lapsed or missed immunizations and for people preparing for international travel (see Simultaneous Administration of Multiple Vaccines, p 35). The schedule is reviewed regularly, and the updated schedule is issued annually in February. Interim recommendations occasionally may be made when issues such as a shortage of a product or a safety concern arise, or a new Table 1. Guidelines for Spacing of Live and Inactivated Antigens Antigen Combination 2 or more inactivateda Inactivated plus live 2 or more liveb a b Recommended Minimum Interval Between Doses None; can be administered simultaneously or at any interval between doses None; can be administered simultaneously or at any interval between doses 28-day minimum interval if not administered simultaneously See text for exceptions. Special attention should be given to footnotes on the schedule, which summarize major recommendations for routine childhood immunizations. In many instances, the guidance will be applicable to children in other countries, but individual pediatricians and recommending committees in each country are responsible for determining the appropriateness of the recommendations for their settings. Studies have demonstrated that the recommended age and interval between doses of the same antigen(s) ( However, if a measles-containing vaccine is administered before 12 months of age, the dose is not counted toward the 2-dose measles vaccine series. The child should be reimmunized at 12 through 15 months of age with a measles-containing vaccine. A third dose of a measles-containing vaccine is indicated at 4 through 6 years of age but can be administered as early as 4 weeks after the second dose (see Measles, p 535). Although immunizations should not be scheduled at an interval or age less than those recommended in recheck of otitis media). If the parent or child is not known to the clinician or follow-up cannot be ensured (eg, habitually misses appointments), administration of the vaccine at that visit rather than rescheduling the child for a later visit is preferable. Doses administered 5 days or more before the minimum interval or age should not be counted as valid doses and should be repeated as age appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum interval. This 4-day recommendation does not apply to rabies vaccine because of the immunization schedule (http:/ /redbook. Although data documenting the effects of interchangeability are limited, most experts have considered vaccines interchangeable when administered according to their recommended indications. Because simultaneous administration of routinely recommended vaccines is not known to alter the effectiveness or safety of any of the recommended childhood vaccines, simultaneous administration of all vaccines that are appropriate for the age and immunization status of the recipient is recommended. Simultaneous administration of multiple vaccines can increase immunization at separate anatomic sites. All available types or brand-name products do not need to be stocked by each health care professional, and it is recognized that the decision of health care professionals to implement use of new combination vaccines involve complex economic and logistical considerations. Factors that should be considered by the provider, in consultation with the parent, include the potential for improved vaccine coverage, the number of injections needed, vaccine safety, vaccine availability, interchangeability, storage and cost issues, and whether the patient is likely to return for follow-up. When patients have received the recommended immunizations for some of the components in a combination vaccine, administering the extra antigen(s) in the combination vaccine is permissible if they are not contraindicated ( Serologic testing is an alternative to vaccination for certain antigens (eg, measles, rubella, hepatitis A, and tetanus). In particular, of immune response to rubella vaccine also has been demonstrated, but the effect on response to mumps or varicella vaccines is not known. Physicians should not assume that children are protected fully against measles during these intervals. In addition, the standards also recommend use of tracking systems to provide reminder/recall notices to nonminor patients, parents or legal guardians, and physicians when immunizations are due or overdue. Additional information about immunization information systems can be found online ( Adverse events following vaccination may be true causally associated vaccine adverse events or reactions, such as local pain and tenderness at the injection site. Highly effective vaccines have dramatically reduced the threat of infectious diseases, and because of this success some people now worry more about potential vaccine adverse effects than the illnesses vaccines prevent. Recommendations are made to maximize protection and minimize risk by providing speto vaccination. The Brighton Collaboration provides guidelines for collecting, analyzing, and presenting vaccine safety data, which facilitates sharing and comparison of vaccine data among professionals working in the area of vacof progress, can be found online (https:/ /brightoncollaboration. This review determined that the childhood immunization schedule is safe and that following the complete childhood immunization schedule is strongly associated with reducing vaccine-preventable diseases. In addition to adverse events, vaccine product problems and vaccine administration errors may be reported. Responsible Physician Facility Name/Address City State Zip City State Zip City State Zip Telephone no. Describe adverse events(s) (symptoms, signs, time course) and treatment, if any Check all appropriate: Patient died (date mm dd yy Life threatening illness Required emergency room/doctor visit Required hospitalization ( days) Resulted in prolongation of hospitalization Resulted in permanent disability None of the above 9. Vaccine purchased with: Private funds Military funds Other/unknown Public funds 17. Adverse event following prior vaccination (check all applicable, specify) Onset Type Dose no. Reports for reactions to other vaccines are voluntary except when required as a condition of immunization grant awards. In addition, linkages have been established between health plans and state immunization information systems to enhance data on vaccine exposure. The only contraindication applicable to all vaccines is a history of anaphylaxis to a previous dose or to a vaccine component, unless the patient has undergone desensitization. Vaccinations may be deferred when a precaution is present until the health condition resulting in the precaution improves or resolves. Most precautions are the result of temporary conditions (eg, moderate or severe illness), and a vaccine can be administered when the illness abates. Failure to understand true contraindications and precautions can result in administration of a vaccine when it should be withheld (see Immunization in Immunocompromised Children, p 74). A current screening form for children and adults, available in several languages, can be obtained from each state immunization program or the Immunization Action Coalition ( The only contraindication applicable to all vaccines is a history of a severe allergic reaction (ie, anaphylaxis) after a previous dose of that vaccine or a component of that vaccine. The presence of a moderate or severe acute illness with or without a fever is a precaution to administration of all vaccines. The decision to administer or delay vaccination because of a current or recent acute illness depends on the severity of symptoms and etiology of the condition. Delaying avoids causing diagnostic confusion between manifestations of the underlying illness and possible adverse effects of vaccination or superimposing adverse effects of the vaccine on the underlying illness.

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In a subsequent metaanalysis using data from the same studies, Siskind and colleagues found that 40. In an additional network meta-analysis of 32 antipsychotic medications, Huhn and colleagues (Huhn et al. Studies that focused on individuals with a first-episode of psychosis or treatment resistance were not included as were studies in which individuals had concomitant medical illnesses or a predominance of negative or depressive symptoms. Findings from studies using administrative databases also suggest benefits of treatment with clozapine. Similar benefits of clozapine were found in analysis of prospective registry data from Finland obtained for all persons with schizophrenia who received inpatient care from 1972 to 2014 (Taipale et al. Of the 62,250 individuals in the prevalent cohort, 59% were readmitted during follow-up time of up to 20 years (median follow-up duration 14. A meta-analysis that examined effects of clozapine on hospital use also found benefits for clozapine (Land et al. When the study subjects were limited to those who were adhering to treatment, the higher mortality during treatment with other antipsychotic medications did not reach statistical significance. These findings are also consistent with results of a meta-analysis that showed significantly lower rates of long-term crude mortality in patients who received continuous treatment 131 with clozapine as compared to patients treated with other antipsychotic medications (mortality rate ratio 0. In an Australian national survey of 1,049 people with a diagnosis of schizophrenia or schizoaffective disorder who reported taking any antipsychotic medication (Siskind et al. Grading of the Overall Supporting Body of Research Evidence for Efficacy of Clozapine in Treatmentresistant Schizophrenia. Most studies have some limitations based on their descriptions of randomization, blinding procedures, and study dropouts. Most individuals who receive treatment with clozapine have had at least one trial of another antipsychotic medication and most would meet usual clinical criteria for treatment-resistant schizophrenia, even when this is not well specified in the study description. Studies measure psychotic symptoms, response to treatment, all cause treatment discontinuation, psychiatric hospitalization, all-cause hospitalization, depression, and mortality. Some of these outcomes are directly related to the review questions and some are indirectly related. Although most meta-analyses and observational studies show benefits for clozapine, not all meta-analyses show superiority of clozapine to other antipsychotic medications in individuals with treatment resistant schizophrenia. Some confidence intervals are narrow without overlapping the threshold for clinically significant benefits, whereas other confidence intervals are wide or overlapping. Increases in dose and corresponding increases in blood levels of clozapine appear to be related to improved clinical efficacy in non-toxic ranges of dosing. Although publication bias for clozapine-specific studies was not tested, publication bias is relatively common in studies of psychopharmacology due to non-publication of negative studies. The magnitude of effect is moderate overall but varies with the specific side effect. As compared to other antipsychotic medications, clozapine is associated with a greater risk of weight gain, sialorrhea, sedation, metabolic effects, seizures, constipation, anticholinergic side effects, tachycardia, and dizziness but a lower risk of all cause treatment discontinuation, extrapyramidal side effects, or need for anticholinergic medication. Studies measure observed and reported side effects of clozapine, as well as treatment discontinuation (all cause and due to adverse effects). Study findings are consistent in the relative magnitude and direction of effects for specific side effects and for treatment discontinuation. However, clinical observations suggest that many side effects do increase in occurrence or severity with the dose of clozapine. Not all studies assess side effects in a systematic fashion and patients may be less likely to report some side effects if they are not directly assessed. Nevertheless, publication bias is relatively common in studies of psychopharmacology due to non-publication of negative studies. Interpretation of the findings was also complicated by the use of several different coil placements. Although there was not a significant difference in suicide deaths (five for clozapine and three for olanzapine), Kaplan-Meier lifetable estimates indicated a significant reduction in the two-year event rate in the clozapine group (p=0. The suicide attempt rate with clozapine treatment was also reduced as compared to the six months prior to clozapine initiation (2. As compared to other antipsychotic medications, larger effects of clozapine on suicide attempts and suicide are found in observational registry studies with longer periods of follow-up and larger sample sizes. Nevertheless, rates of suicide are increased among individuals with schizophrenia making the observational study findings of relevance to routine clinical practice. Nevertheless, observational study findings are indirect due to the lack of selection of patients at high risk of suicide. The reduction in suicide deaths in larger samples with longer follow-up periods is consistent with the reduction in suicide attempts. Additional monitoring and an increased frequency of clinical contacts with clozapine may enhance the effects of the medication relative to other antipsychotic medications, at least in observational studies. The small number of relevant studies makes assessment of publication bias impossible. Grading of the Overall Supporting Body of Research Evidence for Harms of Clozapine in Individuals With Substantial Risk Factors for Suicide Attempts or Suicide See Appendix C, Statement 7, Grading of the Overall Supporting Body of Research Evidence for Harms of Clozapine. A systematic review on pharmacological management of persistent hostility and aggression in persons with schizophrenia spectrum disorders found 92 articles with sufficient methodological information to evaluate although none were at low risk of bias (Victoroff et al. Two of these studies (N=48 and N=151) compared clozapine to chlorpromazine (Claghorn et al. These findings support the opinions of many experts in viewing clozapine as beneficial in those at substantial risk of aggressive behaviors. For a discussion of the evidence related to the side effects of clozapine, see Appendix C, Statement 7. Available studies report statistical superiority but there are no good estimates of the magnitude effect either within or among studies. Most studies are focused on inpatients, including forensic psychiatry populations, who exhibit physically assaultive behavior. The doses of medication used are within normal to high dose ranges for usual clinical practice. Confidence intervals are not reported in all studies or in the available metaanalysis. Nevertheless, a lack of precision is likely due to the small samples in most studies. In observational outpatient studies, additional monitoring and an increased frequency of clinical contacts with clozapine may enhance medication effects relative to other antipsychotic medications. The high risk of bias in many of these studies suggests that confounding factors may be present but unrecognized. The relatively small number of studies and the heterogeneity of study designs make it difficult to assess publication bias. However, publication bias seems possible due to the tendency for negative clinical trial results to go unpublished. Although the findings are consistent, the applicability to typical clinical practice is limited. Other sources of possible bias were unable to be assessed but are likely to be present. There are a number of possible explanations for these apparent disparities related to the design of the studies and differences in study populations (Correll et al. Individuals who are agreeable to participating in a randomized clinical trial are more likely to be adherent to treatment than a broader population of individuals with a particular diagnosis. In addition, no differences in extrapyramidal side effects were seen in a 28* this guideline statement should be implemented in the context of a person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments for schizophrenia. The other comparisons showed no differences for these outcomes and there were also no differences noted for non-response rate, relapse rate, dropouts for adverse events, extrapyramidal symptoms, or weight gain.


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Shannon submitted "A Proposal for the Dartmouth Summer Research Project on Artificial Intelligence. Naturally, the proposal and the resulting conference-the 1956 Dartmouth Summer Research Project on Artificial Intelligence-were the culmination of decades of thought by many others (Buchanan, 2005; Kline, 2011; Turing, 1950; Weiner, 1948). Although the conference produced neither formal collaborations nor tangible outputs, it clearly galvanized the field (Moor, 2006). Thought leaders in this era saw the future clearly, although optimism was substantially premature. Licklider wrote the hope is that, in not too many years, human brains and computing machines will be coupled together very tightly, and that the resulting partnership will think as no human brain has ever thought and process data in a way not approached by the informationhandling machines we know today. The latter was initially known as the connectionist school, but we now know the technique as artificial neural networks. The major thrust of the paper is that "in order for a program to be capable of learning something it must first be capable of being told it," and hence the formalization of declarative logic programming. By the 1970s, however, excitement gave way to disappointment because early successes that worked in well-structured narrow problems, failed to either generalize to broader problem solving or deliver operationally useful systems. The field of machine learning applies the scientific method to representing, understanding, and utilizing datasets, and, as a result, practitioners are known as data scientists. Popular machine learning techniques include random forests, boosting, support vector machines, and artificial neural networks. The resulting systems are called deep learning systems and showed significant performance improvements over prior generations of algorithms for some use cases. It is noteworthy that Hinton was awarded the 2018 Turing Prize alongside Yoshua Bengio and Yann LeCun for their work on deep learning (Metz, 2019). As discussed above and more in Chapter 4, the word overhyped, however, should be mentioned again. In concept, a self-driving car is a motor vehicle that can navigate and drive its occupants without their interaction. For this discussion, it is more important to note that the component technologies have been evolving publicly for some years. In research contexts, ad hoc networks enable motor vehicles to communicate directly with each other about emergent situations and driving conditions (Zongjian et al. That is, the machine extracts objects such as humans, cyclists, road signs, other vehicles, lanes, and other relevant factors from the video data and has been programmed to identify and interpret the images in a way that is understandable to a human. However, for all the laudable goals, including improving driving safety, errors remain and sometimes those errors are fatal. As reported in the press, the woman killed in spring 2018 as she walked her bicycle across the street was sensed by the onboard devices, but the software incorrectly classified her as an object for which braking was unnecessary. It was also reported that the "backup" driver of this autonomous vehicle was distracted, watching video on a cell phone (Laris, 2018). Reaching back to the 1960 quote, above, from Licklider, it is important to note that the title of his article was "Man-Computer Symbiosis. For clinicians to effectively manage this symbiosis, they must (1) understand their own weaknesses. This is offered through a chat bot, which not only exercises natural language interpretation and generation but also logical reasoning to perform the scheduling. The field of quantitative analytics was born in response to the computerization of the major trading exchanges. One of the early "automated" trading strategies, portfolio insurance, is widely believed to have either caused or exacerbated the 1987 stock market crash (Bookstaber, 2007). The failure of Long-Term Capital Management offers another cautionary example (Lowenstein, 2011). This fund pursued highly leveraged arbitrage trades, where the pricing and leverage were algorithmically determined. Unexpected events caused the fund to fail spectacularly, requiring an almost $5 billion bailout from various financial institutions. Large distribution channels such as Netflix and Amazon leverage machine learning algorithms for content recommendation to drive sales and engagement (Yu, 2019). These systems initially relied on algorithms such as collaborative filters to identify customers similar to others in terms of what media they consumed and enjoyed. More recently, deep learning techniques have been found superior for this task (Plummer, 2017). An interesting development has been that early techniques relied on metadata (descriptive features of media) in order to generate recommendations. For instance, computer vision is used now to index film to identify faces, brands, and locations, which are coupled with human tags to create rich metadata (Yu, 2019). The general complaint that all the music on the radio "sounds the same" may be based in part on the need to conform to the styles "approved" by the algorithms. Google initially released software called Deep Dream, which was able to create art in the style of famous artists, such as Vincent van Gogh (Mordvintsev et al. This technique is now used in many cell phone apps, such as Prisma Photo Editor3, as "filters" to enhance personal photography. The deepfake technique can be used to create videos of people saying and doing things that they never did, by swapping their faces, bodies, and other features onto videos of people who did say or do what is portrayed in the video. The potential effect of such technology, when coupled with the virality of social networks, for the dissemination of false content is terrifying. Predictive policing has captured the public imagination, potentially due to popular representations in science fiction films such as Minority Report (Perry et al. State-of-the-art predictive policing technology identifies areas and times of increased risk of crime rather than identifying the victim or perpetrator (Kim et al. However, implementations of these technologies can propagate racial, gender, and other kinds of profiling when based on historically biased datasets (see Chapter 1) (Caliskan et al. Under research are efforts to identify theft, diversion, and abuse from all manner of dispensing devices. Note that many of these applications are also controversial for privacy concerns and surveillance capacity and scope, in addition to their potential to propagate racial, gender, and sexual orientation biases (see Chapter 1). Large gaps remain in the goal of aligning population and cultural expectations and preferences with the regulation and legislation of privacy, which is a subject covered in more detail in Chapter 7. One might provocatively claim that there is a planet in our solar system (probably) populated exclusively by robots, and that one of those robots is artificially intelligent. While the concept of an "intelligent machine" has interested philosophers at least as far back as Descartes, the most popular conception was first proposed by Alan Turing (1950). For instance, to play chess, the computer must somehow hold the current state of the board, the rules of the game, and the desired outcome in its memory. A key observation is that these representations are often layered; stated differently, an effective representation comprises a hierarchy of abstractions. Consider chess again, the base representation is the field and players, the next layer may be particular formations of pieces, the next evolving set plays, and so on. NevilleNeil writes, We have had nearly 50 years of human/computer competition in the game of chess but does that mean any of those computers are intelligent? The first is that chess is not a test of intelligence; it is the test of a particular skill-of playing chess. The second reason is that thinking chess was a test of intelligence was based on a false cultural premise that brilliant chess players were brilliant minds, more gifted than those around them. Yes, many intelligent people excel at chess, but chess, or any other single skill, does not denote intelligence. A camera-based computer vision system has raw data of pixels: a block of numbers representing color. From there, the computer vision system will build a hierarchy of abstractions, such as edges, solids, shapes, objects, pedestrian, automobile, or road sign. The key advance of deep learning systems is that they are able to perform this hierarchical abstraction automatically, whereas previous systems relied on the composition of multiple independent parts. These capture reality, represent and reason over it, and then affect reality, respectively. The operations in question are linear algebra operations such as matrix multiplication. IoThis the movement to collect sensor data from all manner of physical devices and make them available on the Internet.

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To take a few more examples, specific drug paraphernalia may be uniquely salient to individuals with a cocaine addiction but not to individuals with anxiety or pain. In schizophrenia, misattribution of salience to external and internal stimuli is a core feature of the disorder and may explain the genesis of psychotic symptoms such as delusions and hallucinations (Palaniyappan & Liddle, 2012). Saliency detection mechanisms in the brain are at the core of this process and can be conceptualized into two general mechanisms. Seed-based intrinsic functional connectivity analysis of its major nodes also reliably reproduces the core cortical nodes of the network, and subcortical nodes in the ventral striatum and ventral tegmental area can also be detected albeit at a weaker level (Figure 2). These tracts are distinct from the fronto-occipital and superior longitudinal fasciculi, which connect the dorsolateral frontoparietal central executive network (Figure 4). This limbic pathway is critical for processing novel information and enabling interaction between cognition, emotion, and action (Mori, Oishi, & Faria, 2009; Schmahmann et al. Crucially, in addition to its response to external stimuli, the insula is also sensitive to internal signals associated with autonomic processes such as heartbeat, skin conductance, and respiration (Critchley, Eccles, & Garfinkel, 2013; Singer et al. Three systems of insular functional connectivity identified with cluster analysis. Networks associated with the three insula subdivisions are largely segregated in the resting state. Although networks associated with the three insula subdivisions are largely segregated during active tasks, they show prominent overlap in the posterior insula, basal ganglia, and thalamus. Decoding the role of the insula in human cognition: functional parcellation and large-scale reverse inference. The first row shows sagittal slices viewed from the right, and the second row shows coronal slices viewed anteriorly. Dynamic reconfiguration of structural and functional connectivity across core neurocognitive brain networks with development. Functionally linked resting-state networks reflect the underlying structural connectivity architecture of the human brain. The von Economo neurons in frontoinsular and anterior cingulate cortex in great apes and humans. Z-scores correspond to likelihood of specific task-based terms in the Neurosynth database. Meta-analyses of studies showing general brain regions involved in autonomic processing. These cues include biasing signals from the amygdala associated with negatively valenced stimuli and the nucleus accumbens and ventral tegmental area signals associated with reward (Lindquist, Wager, Kober, Bliss-Moreau, & Barrett, 2012). Importantly, brain responses within these regions increase and decrease proportionately and often antagonistically, in relation to specific cognitive demands and subjective task difficulty. Critically, these switching mechanisms help focus attention on task-relevant stimuli and goals, and as a result, they take on added significance or saliency (Menon & Uddin, 2010; Figure 11). Although the study of brain network development is still in its infancy, new studies are beginning to shed light on the typical and atypical developmental trajectories of this network. A critical role for the right fronto-insular cortex in switching between central-executive and default-mode networks. In addition, isolated lesions to the insula have been associated with dysfunction in autonomic function; gustatory, olfactory, auditory, somatosensory, and multimodal perception; body Brain Mapping: An Encyclopedic Reference, (2015), vol. The anatomy of first-episode and chronic schizophrenia: An anatomical likelihood estimation meta-analysis. Aberrant salience network (bilateral insula and anterior cingulate cortex) connectivity during information processing in schizophrenia. Developmental maturation of dynamic causal control signals in higher-order cognition: A neurocognitive network model. I discuss a few examples here from recent advances in network modeling of the dementias, schizophrenia, and mood disorders. Notably, conceptualization of psychosis as aberrant signaling of salient events (Kapur, 2003) has led researchers to propose that abnormalities in the attribution of salience to external and internal stimuli are a core feature of schizophrenia and may explain the genesis of psychotic symptoms such as delusions and hallucinations (Palaniyappan & Liddle, 2012). These findings are important because anxiety disorders are a common comorbid feature of many psychiatric disorders, including depression, phobia, and posttraumatic stress disorder (Antony & Stein, 2009). These signaling mechanisms together with poor integrity of network nodes and their anatomical connectivity. Diminished outflow from the cingulate cortex results in psychomotor poverty and impoverished goal-directed action. The consequence of abnormalities at any of these levels is deficient, context-dependent engagement and disengagement of cognitive systems important for attending to salient external stimuli or internal mental events. Weak salience mapping can arise from at least three input factors: (i) aberrant stimulus mapping, such as weak or enhanced cue signaling and novelty detection; (ii) aberrant limbic reward and motivational signals; and (iii) aberrant self-referential mental processes representing internal value and autobiographical memory. It plays a crucial role in identifying the most biologically and cognitive relevant endogenous and external stimuli in order to adaptively guide behavior (Beissner, Meissner, Bar, & Napadow, 2013; Lovero, Simmons, Aron, & Paulus, 2009; Menon & Uddin, 2010; Seeley et al. Control signals to other large-scale networks that facilitate access to working memory resources 5. Switching between the lateral frontoparietal central executive network and the medial frontoparietal default-mode network to keep attention focused on task-relevant goals. Tanya Evans, Daniel Abrams, and Aarthi Padmanabhan for their valuable feedback, Neha Vellanki for proofreading, and Sandhya Prathap and Tricia Ngoon for their assistance with the figures. Circuitry and functional aspects of the insular lobe in primates including humans. The autonomic brain: An activation likelihood estimation meta-analysis for central processing of autonomic function. Salience network integrity predicts default mode network function after traumatic brain injury. Meta-analysis of neuroimaging studies of the Wisconsin card-sorting task and component processes. Decoding the role of the insula in human cognition: Functional parcellation and large-scale reverse inference. Auditory novelty oddball allows reliable distinction of top-down and bottom-up processes of attention. Relationship between cingulo-insular functional connectivity and autistic traits in neurotypical adults. Neural integration of top-down spatial and feature-based information in visual search. Neural correlates of the automatic and goal-driven biases in orienting spatial attention. Cortical projections to the superior colliculus in the macaque monkey: A retrograde study using horseradish peroxidase. The synchronization within and interaction between the default and dorsal attention networks in early infancy. Functional connectivity in the resting brain: A network analysis of the default mode hypothesis. Default-mode activity during a passive sensory task: Uncoupled from deactivation but impacting activation. Cognitive control and the salience network: An investigation of error processing and effective connectivity. Neural systems approaches to understanding major depressive disorder: An intrinsic functional organization perspective.

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A total of 8 randomized controlled trials using metoclopramide and 1 trial combining erythromycin with metoclopramide were reviewed by meta-analysis. The use of prokinetic agents was not found to make a difference in terms of mortality or infection. Metoclopramide also has associated adverse complications, including tardive dyskinesia, more 87 frequently in the elderly. Furthermore, the incidence of watery diarrhea was statistically higher in patients receiving combination therapy. Research regarding the efficacy of this technique has provided conflicting results. Studies suggest that "the elevated residual volumes by themselves have little clinical meaning and that only when combined with vomiting, sepsis, sedation, or the need for vasopressor agents does the correlation with worsening patient outcome emerge. Higher residuals in premature infants are thought to be related to position (with left lateral and supine positions being associated with higher volumes), as well as the degree of prematurity and normal dysmotility of prematurity. In April 2006, the Joint Commission issued a Sentinel Event Alert on tubing misconnections. Review currently used systems to assess practices that include the potential for misconnection, including nonstandard, rigged work-arounds (Luer adapters, etc). Train nonclinical staff and visitors not to reconnect lines but to seek clinical assistance instead. Only clinicians or users knowledgeable about the use of any device should make a reconnection. When making a reconnection, routinely trace lines back to their origins and then ensure that they are secure. When arriving at a new setting or as part of a hand-off process, recheck connections and trace all tubes. This master standard set the stage for redesigned connectors to be used in respiratory, enteral, noninvasive blood pressure monitoring, neuraxial, urology, and intravascular systems. Boullata et al this new connector is available on enteral administration sets, enteral syringes, and enteral feeding tubes. To transition from the new connector to the current feeding tube, a transition set is available to provide connectivity so that patients receive their nutrition formula, hydration, and medications. The alert also included a table of related Joint Commission requirements for institutions and agencies regarding the use of tubing. Errors can occur from patient assessment to prescribing, order review, and documentation, although most recognized errors focus on product selection and administration. Healthcare organizations can create a culture of safety by reassuring workers that they will not be punished for reporting safety events and framing these events as an opportunity for education. Organizations also need to identify ancillary staff who could possibly be responsible for the connection, disconnection, or reconnection of devices attached to patients and develop policies and procedures that outline responsibilities for these staff members relating to the connection or disconnection of medical tubing. Nutrition in clinical practice-the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Effect of postpyloric feeding on gastroesophageal regurgitation and pulmonary microaspiration: results of a randomized controlled trial. Can percutaneous endoscopic jejunostomy prevent gastroesophageal reflux in patients with preexisting esophagitis? A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness. Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial. Duodenal versus gastric feeding in medical intensive care unit patients: a prospective, randomized, clinical study. The incidence of ventilator-associated pneumonia and success in nutrient delivery with gastric versus small intestinal feeding: a randomized clinical trial. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding with early gastric feeding in critically ill patients. Duodenal versus gastric feeding in ventilated blunt trauma patients: a randomized controlled trial. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. Gastric versus duodenal feeding in patients with neurological disease: a pilot study. Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. A randomized controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients. North American summit on aspiration in the critically ill patient: consensus statement. Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomized trial. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. Intermittent enteral feeding: the influence on respiratory and digestive tract colonization in mechanically ventilated intensive-care-unit patients. Comparison of continuous vs intermittent nasogastric enteral feeding in trauma patients: perceptions and practice. Erythromycin reduces delayed gastric emptying in critically ill trauma patients: a randomized, controlled trial. Erythromycin improves gastric emptying in critically ill patients intolerant of nasogastric feeding. Enteral naloxone reduces gastric tube reflux and frequency of pneumonia in critical care patients during opioid analgesia. Metoclopramide for preventing pneumonia in critically ill patients receiving enteral tube feeding: a randomized controlled trial. Erythromycin vs metoclopramide for facilitating gastric emptying and tolerance to intragastric nutrition in critically ill patients. Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients. Poor validity of residual volume as a marker for risk of aspiration in critically ill patients. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. Gastric residuals and their relationship to necrotizing enterocolitis in very low birth weight infants. The value of routine evaluation of gastric residuals in very low birth weight infants. Gastric residual evaluation in preterm neonates: a useful monitoring tool or a hindrance? Evaluation of potential factors predicting attainment of full gavage feedings in preterm infants. Outcomes of gastric residuals whilst feeding preterm infants in various body positions. Small Bore Connectors for Liquids and Gases in Healthcare Applications-Part 1: General Requirements. A multi-disciplinary approach to medication safety and the implication for nursing education and practice. Home enteral tube feeding in patients with inherited metabolic disorders: safety issues.

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Projection of population, by age, 1980-2065 70 60 50 80+ 65+ 15-64 0-14 Percentage 40 30 20 10 0 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060 Local authorities and characterization and classification of geographical units by the socio-economic level of the population Local authorities in Israel administer the local affairs of a locality or group of localities. They are divided according to their municipal status into municipalities (cities), local councils, and regional councils (a regional council includes several forms of localities, such as moshavim, kibbutzim, and rural localities). The concept of socio-economic level of the population of a geographical unit reflects a combination of basic characteristics of a specific geographical unit investigated (for example, the population of a local authority). The socio-economic index for local authorities characterizes each local authority by the socio-economic level of the population consisting of its residents relative to the socio-economic level of the populations in all other local authorities. Based on the socio-economic index, all local authorities were grouped into 10 clusters, whereby cluster 1 represents localities of lowest socioeconomic level and cluster 10 represents localities of highest socioeconomic level. Percentage of persons age 15 and over covered by social protection systems 2010 Total Men Women 37. The government sector includes government ministries, the National Insurance Institute, national institutions, local authorities and public non-profit institutions whose expenditures were mostly financed by the government. The 2016 survey reveals an improvement in food security in the population compared to the 2011/2012 survey. People requiring interventions against neglected tropical diseases, 2006-2017 400 3. Persons aged 30 who would die before age 70 from chronic diseases, 2005-2016 14,000. Annual consumption of pure alcohol (in liters) per person (persons aged 15+), 2005-2016 3. Persons killed in road accidents by sex and population group, 2001-2017 14 12 Total population Males Females Jews Arabs 3. Smokers aged 21 and over, by sex, 2002-2017(1) 50 40 Females Males Total population 3. The survey of adult skills defines problem-solving in technology-rich environments as "using digital technology, communication tools and networks to acquire and evaluate information, communicate with others and perform practical tasks. Reading Grades 2/3 of primary education Parity index (girls/ boys) Parity index (students of rural school/ students of urban school) Parity index (low socioeconomic status/ high socioeconomic status) 1. Accreditation reflects the recognition of significant environmental education in a school and outlines a possible course of action for schools that want to start environmental activities based on existing frameworks. Green and Greener Kindergarten, 2007-2016 Green Kindergarten Greener Kindergarten (Continuing Green Kindergarten) certification 400 Number 300 200 100 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 4. The integrated plan for implementing sustainability education in the school system, 2010-2016 150 Number of schools 120 90 60 30 0 2010 2011 2012 2013 2014 2015 2016 4. Access to the following is 85% (data refer to public education only) at all levels of education: (b) the Internet for pedagogical purposes; (c) computers for pedagogical purposes. Data for women subject to violence by current or former intimate partner cannot be displayed due to high sampling errors. The data present the proportion of women in the Knesset from the first Knesset (1949) to the current twentieth Knesset (from 2015). The majority of the population not connected to wastewater treatment is the Bedouin population that lives in localities with no municipal status. The percentage of renewable energy out of the primary energy supply and out of electricity production is very low in Israel (less than 3 percent), despite the significant increase in 2008-2016. Primary energy supply Energy ratio Energy ratio and primary energy supply(1), 2005-2016 t. Activities of households as employers; undifferentiated goods- and services-producing activities of households for own use Total A B B+C D E F G H I J K L M N O P Q R S T 2,207 1,834 1,926 2,464 2,265 2,882 2,157 783 1,103 4,727 1,266 2,560 1,483 369 1,154 1,908 2,007 135 2017 1,655 2,038 U. Activities of households as employers; undifferentiated goods- and services-producing activities of households for own use 2016 Total 1,772 A B B+C D E F G H I J K L M N O P Q R S T 2,305 2,381 1,858 2,712 2,376 3,069 2,390 877 1,195 4,964 1,336 2,867 1,556 396 1,215 1,970 2,111 159 2,151 U. Persons aged 20 and over who felt discrimination(1) by sex, age and population group, 2017 100. Nonetheless, the level of participation varies from cases where citizens may express their opposition to a project to cases where a much wider public participation process exists. Cultural heritage includes museums, archives, antiquities preservation and archeological sites preservation. Public space includes the following land uses: public services, culture and leisure, infrastructure and transportation, public parks and other public open areas. Israel has yet to ratify the Ban Amendment but already complies with its provisions further limiting the export of hazardous waste. Banks are a leading sector in this field with a mandatory requirement to publish a sustainability report. The most common corporate responsibility reporting mechanism is produced by and known as "Maala". The network includes local Israeli companies as well as international companies operating in Israel. It should be noted that Maala only publishes the final ratings of the reporting companies and not the detailed reports of the companies. In addition, individual instruction kits and checklists are prepared for each local authority. Regular local government audits carried out on behalf of national government will include audits of the implementation of the environmental guidelines. Its various subcommittees will focus on strategy, health and emergency, natural resources and agriculture and environment, energy and infrastructure and technologies, research and development, local authorities and communication and education. The chart displays chlorophyll concentrations, which indicate algal bloom as a result of nutrient pollution, at three selected sites. Samples were taken from 9 locations at different depths and marine litter hotspots. This monitoring program includes sampling of both floating marine litter and litter accumulated on the sea bottom, for both micro and macro plastics. The number of macro plastic particles ranged from 233 to 7443 particles, with no clear geographic trend. Primary beach litter monitoring, however, shows a possible decreasing trend in the presence of plastic bags which could be attributed to the recently passed Plastic Bag Law. These stations have been sampled during the height of winter (March) and summer (August) nearly every year since 2003. It assimilates a broad framework of current approaches and concepts of sustainable forest management according to the latest developments in forestry, ecology, social and economic sciences. These master plans, combined with a national scale survey, serve as a foundation for long-term strategic forest management plans. Persons aged 20 and over who were injured by violence (use of physical force), 2002-2017 2. Proportion of population aged 20 and over that feel safe walking alone at dark around the area they live, 2015-2017 2015 2016 2017 100 Percentage 80 60 40 20 0 Total Males Females Sex 16. Percentage of persons aged 20 and over victims of violence with physical assault who reported to the police 16. The Unit constitutes a center of professional knowledge in the field of freedom of information in Israel and gathers relevant information, conducts public awareness campaigns and trains civil servants and other public employees. Proportion of budgetary central government expenditure funded by taxes, 2002-2017 100. These indicators require further development so that they can be computed and published. End hunger, achieve food security and improved nutrition and promote sustainable agriculture Goal 3. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all Goal 5. Ensure availability and sustainable management of water and sanitation for all Goal 7. Ensure access to affordable, reliable, sustainable and modern energy for all Goal 8. Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation Goal 10.

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What do you think creating more wellness will give you in your life a year from now? What physical sensations arise when you think about a you that has created more wellness in her life? Also, witness how you imagine you will treat yourself from this empowered place of having created a greater sense of wellness in your life? Will you be more willing to be present with the uncomfortable parts of life or will your need to buffer with over working, over drinking, over eating, and binge watching tv? Will you be living less from a place of survival and more from a place of flourishing? But it will expand our ability to be present with this part of life and to tap into a place that allows us to think clearer when these times come. Imagine yourself being willing to experience this suckiest of sucky situations again. Byron Katie teaches that the ability to say this "creates open-mindedness, creativity, and flexibility. Any resistance you may have is softened, and that allows you to open up to the situation in your life rather than keep hopelessly applying willpower to eradicate it or push it away. One that can say and mean, "I am willing to look forward to experiencing this suckiest of suck again" because that "actively opens you to life as it unfolds. When you realize that suffering and discomfort are the call to inquiry and to the freedom that follows, you may actually begin to look forward to uncomfortable feelings. You may even experience them as friends coming to show you what you have not yet investigated thoroughly enough. Not in reaching the arrival of the *after* version of you, but in crossing the field that lies between here and there. This is a model that Tim Ferris of the Four Hour Work Week adopted from the teachings of Seneca. To learn a new way of doing things, but I promise you that this one question will change your life!! Tim Ferris writes ~ the world is tough enough these days and for highly driven type A people. To keep going hard is like whipping a horse that keeps going faster until it dies on the track. Think back to the presentation you heard on Friday: Preventing Burnout + Promoting Balance: Mindfulness for Attorneys. If it was not a problem to create the time and space for wellness in my life, how might I go about creating it? I want you to consider that our analytically honed mind taken to an extreme becomes dysfunctional and no longer a strength. Instead, I want you to use the skill of issue spotting, and spot the issue of when you see integrating mindfulness as problematic, challenging, difficult. When you spot that issue, instead of focusing your mind on a problem and a solution, I want you to pivot. We are going to begin to lift ourselves out of the realm of effect and up to the level of cause. We must hone the skill of looking for elegant solutions and ease and not just complexity. What Result (See Appendix 1, Self Coaching Model) do you want to create in your life on purpose so that you may enjoy the process of who you would need to become to create it? How could you have the best time creating the Result [see R line in *after* picture] you decided on in Question Numbered 5? What would your future self, who has already achieved that R, say to you today, as you plan for the next year? What are three specific obstacles to achieving that goal that you can anticipate today? I can turn this obstacle into a roadmap by brainstorming other viewpoints about time. I do the things that are in my unique ability and delegate to others the things that are in their unique ability. I learned that if I engage in any kind of social media or binge watching or drinking more than one drink a night, I have time, [Hint: How you think today has created the current R in your life. How does the *after* version of you who has fully integrated the one thing she has identified today for 365 days think differently from the you of today? Go back and do the other two obstacles you think of today, and return to this exercise as new obstacles present themselves. Learn + Understand the Self-Coaching Model; Commit to Coach Yourself on a Daily Basis; and Live on Purpose from the Clarity of Your Future Self. Learn and Understand the Self-Coaching Model (the "Model"): the Model is made up of the following parts: Circumstances: What are the facts, and only the facts, of this situation? This is where our power to realize that we are not our thoughts our emotions or our actions. We are the thinker of the thoughts, the feeler of the emotions, the doer of the deeds, the decider. Shorthand for the Model: C: T: F: A: R: the model can be worked multiple ways, for multiple purposes, and from multiple angles. If you want to set a goal, including the wellness goal we are going to set today, you can start with the goal you want to achieve by putting the goal in the Result line and work the Model backwards, plugging in the Thoughts and Feelings that you will need to think and feel on a daily basis to fuel the Action necessary to achieve that Result (goal). You want to begin to embody that future version of ourselves by experiencing those thoughts and feelings now instead of deferring those feelings for a year: C: T: F: A: R: (2019 Wellness Goal) Note 1: you are not your Thoughts. A huge part of becoming a lawyer living well is to understand this and to expand the space between the situation in which you find yourself (stimulus) and your Thoughts (response), so that you may become aware of unintentional, default thinking and the results that creates in your life and intentional, on purpose thinking and the results that creates in your life. Note 2: According to the World Health Organization, "Depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease. Committing to your wellness is not only a worthwhile endeavor, but also an endeavor directly related to your quality of life. You must commit to coach yourself toward your goal on a daily basis, if you really want to achieve your goal. Your brain will tell you that you are too busy or overwhelmed or stressed to practice your wellness goal. Instead of exercising after work you make a cocktail, pour a glass of wine, order out, fall back on comfort food, binge watch television, work more. The Model gives you the awareness and relief you need to keep moving forward toward your goal, as well as the insight into why you are falling back on the familiar patterns of the previous version of yourself. Take one Thought (one sentence from your brain dump list) and put it into the T line of the model. Then, work through the model to understand the connection between your Thoughts, your Feelings, your Actions, and your Results. Each day after you complete the Intentional thought model, imagine for 17 seconds or more the you who has hit her wellness goal one year from now. One exercise relates to mindfulness, loving kindness, compassion, having an open heart, and when you strengthen that muscle the world becomes a vibrant place we recognize the incredible aspect of humanity surrounds you in every person. Committing to coach yourself on a daily basis in relationship to your goal is actively choosing to exercise the muscles that you will need to make it over the finish line. Personal side agreement with myself that you may want to borrow: I commit to doing this every day, but I allow myself to skip one day, but never two days in a row. Giving myself permission ahead of time to skip a day allows for the contingencies in my life. It also reminds me of my commitment to myself and the importance to rearrange the next day with an eye toward prioritizing that commitment to myself about other commitments. My favorite teacher on this concept of living into your future self is the contemporary poet and philosopher, David Whyte. Had you not gone out the door, had you not made the phone call, had you not made that promise, you would have a very different life now. Whyte reminds us that we can go back - that person was the ancestor of our present future happiness. The great question for this weekend is, how could you be the ancestor of your own future happiness? What promise, even, could you break, that would make you the ancestor of your future happiness, that you could come back to yourself, this weekend, and thank yourself for having stepped out on that path into a future which has made both a better world for yourself and the world in which you have given your gifts?

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Students who lived on campus exhibited greater gains in critical thinking than those who commuted (Chickering 1974; Pascarella et al. Pace (1990) found that students who lived on campus benefited more in terms of intellectual development, even though their participation in relevant activities is not much higher than those who live off campus. This suggests that it may not be the activities themselves that promote or foster development, but the contact with peers and others associated with such activities. General cognitive growth during college is fostered not just by course work and academic involvement, but also by social and intellectual interaction with peers and faculty (p. With regard to work, no significant differences were found in critical thinking gains for students who worked on campus, worked off campus, or did not work during the first year of college (Pascarella et al. Institutional mission and culture shape campus environments and influence student outcomes to varying degrees. For example, students attending small, private liberal arts colleges more frequently reported gains in cognitive complexity, ostensibly fueled by their engagement in educationally purposeful academic activities and with peers, and by the institutional ethos (Kuh 1993, 1995). That is, such findings may suggest that student cognitive growth may be influenced by a variety of experiences and conditions on a campus, particularly when out-of-class climates and experiences complement and encourage students to integrate what they learn in class with their lives outside the classroom (Kuh 1995). These activities may be especially important for African American students (MacKay and Kuh 1994) and older, part-time students who seem to benefit more in terms of cognitive development from the amount of time they invest in studying and related activities (Arnold et al. Volkwein, King, and Terenzini (1986) reported results consistent with the above for transfer students to a large state university during their first year at the new institution on a dependent measure of intellectual skill development; however, the net effect of out-of-class experiences was much smaller (though still statistically significant) than the amount of their involvement in the classroom. At the same time, there is some evidence that engaging in cocurricular activities contributes to knowledge acquisition (Kuh 1993, 1995) with men and women benefiting to a comparable degree (Kuh 1995). Essentially, what matters most is what one does with his/her time, sex and ethnicity notwithstanding. Pascarella and Terenzini (2005) concluded that students make significant gains in subject matter knowledge, verbal and quantitative skills, and oral and written communication during the undergraduate years. Students also tend to demonstrate their greatest learning gains in those subjects consistent with their major (Pascarella and Terenzini). For example, natural science and engineering majors report greater gains in scientific and quantitative reasoning than humanities and social science majors (Cheng 2000; Hu and Kuh 2002; Pace 1990). Full-time students report making greater gains in mathematics, science, and technology than part-time students; African American students perceived greater gains in these subjects than Asian students (Horn and Ethington 2002). Students from all minority groups are taking a more rigorous curriculum than in the past, although African American, Latino, and American Indian students continue to trail their Asian and White counterparts in advanced math and science course taking (U. The number of hours students spend studying and their level of effort and engagement in empirically verified effective educational practices have a strong, significant effect on their overall academic development (Astin 1993b; Pascarella and Terenzini 2005). As with cognitive complexity, institutional type appears to have somewhat of an impact on the knowledge and academic skills students acquire while in college. Students attending small, private liberal arts colleges more frequently reported gains in knowledge and academic skills, which they attributed more often to classroom, lab, and studio activities than to out-of-class experiences (Kuh 1993). Attending an academically selective institution seems to have only a trivial effect on knowledge acquisition (Pascarella and Terenzini 2005). First- and second-generation students do not seem to differ in the gains they make during college after controlling for differences in background characteristics and levels of engagement during college (Terenzini et al. However, there may be an interaction between first-generation status and college experiences in that the effects of engagement on learning differ for first- and second-generation students. Pike and Kuh (2005b) found that first-generation students reported making less progress in their learning and intellectual development, though this was due more to their aspirations and living off campus than to background characteristics. Working (on campus, off campus, or not at all) was not related to gains in reading comprehension or mathematics during the first year of college (Pascarella et al. The relationship between certain engagement practices and learning outcomes appears to be stronger for 2-year college students than students attending 4-year colleges. For example, Baer, Cook, and Baldi (2006) reported that the relationships between literacy (especially prose and document literacy) and preponderance of analytical coursework for students at 2-year colleges was associated with dramatic differences as engagement increases. This pattern is the same, although not nearly as pronounced, for students at 4-year schools. Taken together, these findings suggest that students at 2-year schools marked by challenging classroom activities and a success-oriented campus climate have higher literacy scores. The two outcome categories within this domain, altruism and estheticism, represent interest in the welfare of others and in people from different backgrounds, and appreciation for the arts (Kuh 1993). By the time they graduate, students are more likely to support gender equality and are more likely to be tolerant of the political, social, and religious views of others (Pascarella and Terenzini 2005). Among the factors associated with these changes are living on campus, participating in cultural awareness workshops, undertaking social leadership activities, and perceiving that their institution places an emphasis on diversity and multiculturalism. In addition, faculty views, the peer environment, and other factors consistently and positively influence changes in a range of sociopolitical and civic attitudes and behaviors (Astin and Kent 1983; Kuh 1995; Kuh and Lund 1994; Pascarella, Ethington, and Smart 1988; Vogelgesang 2001). For example, Astin, Sax, and Avalos (1999) found that the frequency with which a student volunteers during college predicts similar behavior after college. Peer interactions in particular tend to have significant net effects on changes on these dimensions (Astin 1993b). Student interactions with other students who are different ethnically or culturally have a strong, positive effect on cultural awareness (Astin). Gumport (2001) concluded that women were substantially more engaged in civic pursuits compared with men, who were more likely to stay abreast of current events. Vogelgesang (2001) found that a diverse student body was a significant predictor only for White students in developing a commitment to promoting racial understanding, and the effect is negative. Certain activities have positive impact across races, including enrolling in ethnic studies courses, attending racial awareness workshops, engaging in cross-racial interactions, and participating in community service. Hurtado and Ponjuan (2005) found that actual experiences in the college environment are more important than student background in predicting perceptions of a hostile climate for diversity. Not surprisingly, full-time community college students reported greater gains in knowledge of the world than did part-time students (Horn and Ethington 2002). Pascarella and Terenzini report that community college students show greater gains than similar students at 4-year institutions in their openness to both intellectual and racial/ethnic diversity. Students attending small, private liberal arts colleges more frequently reported changes in altruism and estheticism (Kuh 1993). As Gumport (2001) and Kuh (1993) observed, some institutions appear to leave a distinctive imprint, as their graduates exhibit substantially stronger dispositions toward certain values. Given that this domain is more of a value-oriented outcome it makes sense that institutional types, missions, environments and cultures would have a significant impact on what students learn from college regarding these outcomes (Kuh). Interpersonal and Intrapersonal Competence this domain consists of five attributes considered indispensable to living a meaningful, selfregulating, fulfilling life. They are self-awareness, autonomy, confidence, social competence, and sense of purpose. Educationally purposeful out-of-class experiences such as peer interactions, work experiences, and meaningful leadership activities are linked with positive social self-esteem, self confidence, and other aspects of personal development (Kuh 1993, 1995; Pascarella and Terenzini 2005), with women gaining more in self-esteem than men. Similarly, experience in a paraprofessional role is related to gains in selfconfidence, self-awareness, skills in interpersonal communication, and group dynamics. Pascarella and Terenzini concluded that attending a structurally diverse institution tended to enhance social self-concept. Service-learning courses help students clarify and define their identities and strengthen their self-esteem, internal locus of control, and interpersonal skills. Taking diversity courses, tutoring, helping to teach a course, working with a faculty member on a research project, and being involved in course group 83 July 2006 projects, as well as the quality of instruction, all are positively linked to varying degrees with academic self-concept, self-esteem, and self-directed behavior. Student-faculty interaction beyond the classroom is positively correlated with personal growth in the areas of leadership, social activism, and intellectual self-esteem (Astin 1993b), and academic as well as social self-concept (Astin and Kent 1983; Pascarella et al. Pace (1984) found that the largest differences in self-reported gains in personal and social development were between on-campus and off-campus students (Chickering 1974). Living-learning centers in particular appeared to have a positive influence on aesthetic appreciation (Blimling 1993); coeducational living environments are associated with declines in self-consciousness and anxiety in social settings (Reid 1974). Most of these gains are attributed to interactions with faculty and peers (Pascarella and Terenzini 1991). For example, students who live or spend time with someone from a different racial and ethnic background gain in appreciation for the aesthetic qualities of life (Astin 1993b). In addition, exposure to people with diverse perspectives and interaction with people who have more advanced stages of moral reasoning. Students of color tend to report making greater gains in personal and social development from attending college than White students (Horn and Ethington 2002; Kuh 1995; Placier, Moss, and Blockus 1992). However, African Americans at historically Black institutions appear to benefit more in terms of desired outcomes of college from academic engagement.

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We require greater availability of autoinjectors of adrenaline, which is presently limited by the cost. Greater availability of up-to-date diagnostic procedures for allergy to food additives is needed. Improvement in diagnostic facilities for allergic patients (mainly for food and drug allergies). Tendencies in epidemiology of allergic diseases in Russian Federation during last 10 years (in Russian). In rural areas the availability of allergy/clinical immunology service is lower than in urban areas. Data source: Ministry of Public Health of Russian Federation, and Russian Association of Allergology and Clinical Immunology For patients: we need to improve the availability of diagnostics and treatment. For service: we need to address the deficit of trained allergologists and allergy departments. Adult asthma prevalence, morbidity and mortality and their relationships with environmental and medical care factors in Singapore. A population-based questionnaire survey on the prevalence of peanut, tree nut, and shellfish allergy in 2 Asian populations. Immediate food hypersensitivity among adults attending a clinical immunology/allergy centre in Singapore. Association of ambient air-pollution levels with acute asthma exacerbation among children in Singapore. Utilization of healthcare resources for asthma in Singapore: demographic features and trends. The main problem is the small critical mass of specialists, not only in allergy and immunology but also in other subspecialties, especially pediatrics. Estimated figure of those trained for at least a year in an institution with a recognized allergy and immunology program: 15. There are no allergy subspecialty fellowships, and most allergists have done their subspecialty training in overseas institutions. Many physicians with little allergy specialist training practice allergy, eg, dermatologists, otolaryngologists. The conditions are very common, and general practitioners manage them at primary level and refer the problem cases. Allergy practice in institutions is carried out by specialists and academics, although the bulk of care is conducted at the primary care level. The greatest challenge is the small critical mass of specialists due to the small population. The Allergy Society of South Africa also conducts congresses and workshops for General Practitioners. Data source: Allergy Society of South Africa Our major challenges are tuberculosis and human immunodeficiency virus, and a lot of government resources are spent on these diseases. We also have an urgent need for epidemiological studies to assess the economic impact of allergic disease. Association between sensitization to outdoor spider mites and clinical manifestations of asthma and rhinitis in the general population of adults. Neither General Practitioners nor Pediatricians receive specific training about the diagnosis and treatment of allergic diseases during their education. If General Practitioners have a special interest they usually attend an allergy department for one month during postgraduate training. Allergy services are well provided in important cities in Spain, but do not exist in rural areas, and patients may have to travel a long distance or have difficulty in accessing allergy services. Some regions have allergy services only in Private Hospitals but not in Public Hospitals. Data Source: Spanish Society of Allergology and Clinical Immunology; the National Commission of Allergy Regional differences in allergy/clinical immunology service provision between urban and rural areas Copyright 2013 World Allergy Organization W A W A O We i t o o koo n A nl e rlg e r g yp2 0 1 1 - 2 0 1 2 O Whit h B e B ok o l A ly: U date 3 223 Enhancements required for improved patient care Education in allergy: a) to promote teaching of the specialty of Allergy in Medical Schools; b) to enhance rotation in allergy services of physicians from other specialties such as primary care, dermatology, respiratory medicine, etc. Proceedings of 4th Scientific Sessions, Allergy and Immunology Society of Sri Lanka. A descriptive pilot study of allergic rhinitis Proceedings of 4th Scientific sessions, Allergy and Immunology Society of Sri Lanka. Proceedings of 4th Scientific sessions, Allergy and Immunology Society of Sri Lanka. Atopy, allergic diseases and soil-transmitted nematode infections in children in Sri Lanka. Most services are provided in Colombo, the capital city of Sri Lanka, but as the country is small, patients are referred to hospitals in the city. There are limitations in personnel, training, and laboratory investigations which need enhancement to improve patient care. In addition, adrenaline auto-injectors are not available for most patients with anaphylaxis, and this inadequacy needs to be addressed. Percentage of population with one or more 30% of adult population allergic diseases 25% of childhood population 25% of the total population Data source: Published population studies. If asthma is included, the prevalence for adults is about 30% until ages 40-50 years; above that age there is a lower prevalence. There is a clear geographical variation between southern and northern Sweden with much higher density of services in southern Sweden. Determination of multiple allergen- specific IgE by microfluidic immunoassay cartridge in clinical settings. Pediatr Allergy Immunol (in press) Sulphur dioxide Particulate matter Reference: Air pollution, weather, and associated risk factors related to asthma prevalence and attack rate Environmental Research, Volume 104, Issue 3, July 2007, Pages 402-409 Wen-Chao Ho, William R. The national health insurance system does not provide sufficient incentive for the prevention of allergy and asthma in the general population, despite the fact that these allergic diseases are the most prominent chronic diseases in Taiwan. Prevalence of asthma, allergic rhinitis and eczema among university students in Bangkok. Survey of the prevalence of asthma, allergic rhinitis and eczema in schoolchildren from Khon Kaen, Northeast Thailand. Boonsawat W, Charoenphan P, Kiatboonsri S, Wongtim S, Viriyachaiyo V, Pothirat C, Thanomsieng N. Vichyanond P, Sunthornchart S, Singhirannusorn V, Ruangrat S, Kaewsomboon S, Visitsunthorn N. There is still unequal access for patients to see specialists in allergy/immunology in Thailand. Most of the studies have concentrated on the prevalence of asthma in both children and adults from different regions of the country. These studies show that, depending upon the geographical region, the asthma prevalence in childhood varies between 2-15% in childhood and 2-5% in adults; and the prevalence of rhinitis ranges between 4. Major allergen triggers that are implicated in the development or exacerbation of allergic disease House dust mite Grass pollens Cat Molds Data not available Major (indoor/outdoor) environmental pollutants that are implicated in the development or exacerbation of allergic disease the annual socio-economic costs of allergic diseases There are no data on the overall costs of allergic disease. New legislation resulted in allergy and immunology being combined into a single subspecialty. Estimated figure: 182 this figure is increasing because many universities are training fellows, and every year there are graduates from training programs. General practitioners do receive training in allergy diagnosis and treatment but the level of knowledge is not at the desired level. This training is received during medical school at the level of undergraduate training. Allergy and immunology services are better established in urban areas where universities are located. We need to improve the education of general practitioners about allergic diseases. The South East is much better provided for compared to more outlying parts of the country, such as the North, Scotland and Wales. Data Source: House of Lords Implementation Committee We need to improve undergraduate training in allergy and primary care training in allergy, and to ensure that more physicians are trained in allergy. The creation of specialist centers with good communications between these centers and primary care (the hub and spoke model) would greatly enhance patient care. Epidemiological studies are needed to assess the socio-economic burden of allergic diseases. A separate medical specialty since 1982 Estimated figure: 35 (this figure is decreasing) General Practitioners receive curricular course on allergic diseases during their postgraduate specialty training.

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We need to increase the number of allergists/clinical immunologists in order to provide better coverage throughout the provinces. We have made history by starting the first allergy and clinical immunology trainingprogram in Panama in 2010. We have have a plan to gradually grow the specialty and society for the better management of allergies in our country. However, in recent years through several courses we are trying to change this situation. A clear difference exists between the quality of allergy services in rural and urban areas. We have a high incidence of allergic disease, especially Allergic Rhinitis in children. However, there is a large deficit in the training of doctors in immunlogy and allergy. Clinical profile of pediatric patients with respiratory allergies who underwent skin test for aeroallergens at the allergy clinic (A 5-year retrospective study) (unpublished) **Binas V et al. Sensitization to common aeroallergens in children with allergic respiratory diseases at a tertiary hospital. In 1972, these allergists formed the Philippine Society of Allergology and Immunology, thus formalizing the existence of the distinct subspecialty in the country. Allergy and Immunology is part of the medical curriculum, both in Internal Medicine and Pediatrics in all medical schools. Medical students are taught how to recognize, diagnose and treat allergic/immunologic diseases, nd receive sufficient training to prepare them to become primary health care providers. Most allergy/immunology subspecialists (estimated 80%) practice in the National Capital Region (the region surrounding Manila, the capital of the country). Data Source: Philippine Society of Allergy, Asthma and Immunology membership list We need more physicians trained in allergy. This would be facilitated by arranging for new allergists to spend time studying in centers abroad, and by easier, affordable access for clinicians to information and education about allergy. Epidemiological studies are required to assess prevalence of allergic diseases on a regular basis. Research grants are needed to support the implementation of management guidelines for allergic diseases. There are no significant differences in allergy/immunology service between urban and rural areas although there are less allergy units in rural areas. American Lung Association, Epidemiology and Statistics Unit, Research and Program Services. Asthma rates in children under the age of five have increased more than 160% from 1980-1994. Allergic Rhinitis is estimated to affect approximately 60 million people in the United States, and its prevalence is increasing. The prevalence of food allergy among children under the age of 18 increased 18% percent from 1997 to 2007. Adults: National Health Interview Survey, 2008 and Summary Health Statistics for U. Allergic rhinitis affects between 10% and 30% of all adults and as many as 40% of children. In 2007, approximately 3 million children under the age of 18 were reported to have a food or digestive allergy in the previous 12 months. For example oak (Quercus) and maple (Acer) in the south and east, mountain cedar (Juniperus ashei) in Texas and Oklahoma, other Cupressaceae in other parts of the country, olive (Olea) in some parts of California, hazelnut (Corylus) in Oregon. The socio-economic impact of atopic dermatitis in the United States: a systematic review. It accounts for an annual loss of more than 14 million school days per year (approximately 8 days for each student with asthma) and more hospitalizations than any other childhood disease. It is estimated that children with asthma spend an nearly 8 million days per year restricted to bed. Economic burden in direct costs of concomitant chronic obstructive pulmonary disease and asthma in a Medicare Advantage population. Age-related association of fine particles and ozone with severe acute asthma in New York City. Environmental Contributions to Allergic Disease, Current Allergy Reports 1: 506-514. An integrated model of environmental factors in adult asthma lung function and disease severity: a cross-sectional study. Training is available to successful graduates of accredited residency programs of either pediatrics or internal medicine. The length of fellowship is two years (with optional a third year for research) (academic) leading to a certification examination by a conjoint board of pediatrics and internal medicine. Rural patients have increased difficulty obtaining health care in general, and limited data suggesting they receive inferior care for asthma. There is limited data that there may be a higher burden of asthma hospitalizations, though further study in this area needs to be done. Rural Americans also travel greater distances to obtain care, and greater distance to care is a risk for poor health outcomes and increased morbidity and mortality. Patient care would be enhanced by the implementation of electronic medical records utilizing the special knowledge of Allergists. Most undergraduate programs include basic skills for diagnosing/treating asthma, but have several limitations regarding allergic rhinitis, drug allergy, food allergy, etc. There are no Allergy/Clinical Immunology services in the rural areas in Venezuela. Government services are scarce, and there are no drug distribution programs; this means that most patients have to buy their medication without reimbursement, making it difficult for the physician to prescribe the correct therapy, and causing problems with patient compliance. Except for a few isolated research efforts, the state provides very limited and confusing epidemiologic information. No official information is available regarding morbidity for almost any disease (including asthma and allergies) in the last 10 years. For any National-based allergy and asthma control program we must begin by gathering reliable epidemiological data, providing a strong academic background to our medical students, and designing diagnosis and treatment protocols that are suitable for General Practitioners, and that include a medication supply for patients. There are no specialist allergy or clinical immunology services outside the capital city, Harare. The primary challenge facing patients is access to accurate, accessible and good quality clinical diagnosis of their conditions. Factors impacting on this situation include poor patient awareness of the existence of allergic diseases, limited government emphasis on the growing allergy epidemic, and limited funding for allergy service delivery, with limited preparedness of health workers to adequately diagnose and appropriately treat allergic conditions. Patients with asthma face challenges of delayed diagnosis and so tend to present with more severe disease. The subsequent challenge is a mismatch between disease severity and treatment regimens. Severe asthma and anaphylaxis patients are faced with the general challenges of shortages in the numbers of allergy and emergency physicians, limited access to intensive care units and limited access to emergency medication. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. Antibiotics are prescribed at more than 100 million adult ambulatory care visits annually, and 41% of these prescriptions are for respiratory conditions (1). In the United States, at least 2 million antibiotic-resistant illnesses and 23 000 deaths occur each year, at a cost to the U. Increased community use of antibiotics is highly correlated with emerging antibiotic-resistant infections. In places with greater prescribing of broad-spectrum antibiotics, specifically extended-spectrum cephalosporins and macrolides, rates of multidrug-resistant pneumococcal disease are higher (3). Antibiotics are also responsible for the largest number of medication-related adverse events, implicated in 1 of every 5 visits to emergency departments A for adverse drug reactions (4). Although data on adverse events after inappropriate antibiotic use are not available, an estimated 5% to 25% of patients who use antibiotics have adverse events, and about 1 in 1000 has a serious adverse event (2).