Mentax

Louanne Hudgins, M.D.

• Division of Medical Genetics/Dept. Pediatrics
• Stanford University
• Stanford, California

This publication may be downloaded and copied without charge for all reasonable antifungal ophthalmic solution discount mentax 15 gm visa, non-commercial educational purposes fungus parasite buy discount mentax 15 gm on line, provided no alterations in the text are made antifungal yeast infection over the counter order mentax 15 gm overnight delivery. I have had a great deal of help and feedback from many people in writing this book fungal rash on face cheap mentax 15gm line. Among the many scholars and friends I am indebted to are Marina Burt fungus stop zane hellas discount mentax 15 gm online, Earl Stevick anti fungal detox safe 15 gm mentax, Heidi Dulay, Robin Scarcella, Rosario Gingras, Nathalie Bailey, Carolyn Madden, Georgette Ioup, Linda Galloway, Herbert Seliger, Noel Houck, Judith Robertson, Steven Sternfeld, Batyia Elbaum, Adrian Palmer, John Oller, John Lamendella, Evelyn Hatch, John Schumann, Eugene Briere, Diane Larsen-Freeman, Larry Hyman, Tina Bennet, Ann Fathman, Janet Kayfetz, Ann Peters, Kenji Hakuta, Elinor Ochs, Elaine Andersen, Peter Shaw, and Larry Selinker. I also would like to express my thanks to those scholars whose work has stimulated my own thinking in the early stages of the research reported on here: John Upshur, Leonard Newmark, and S. Pit Corder all recognized the reality of language "acquisition" in the adult long before I did. Formal and Informal Linguistic Environments in Language Acquisition and 40 Language Learning 4. The Theoretical and Practical Relevance of Simple Codes in Second Language 119 Acquisition Bibliography 138 iii Introduction this book is concerned with what has been called the "Monitor Theory" of adult second language acquisition. Monitor Theory hypothesizes that adults have two independent systems for developing ability in second languages, subconscious language acquisition and conscious language learning, and that these systems are interrelated in a definite way: subconscious acquisition appears to be far more important. The introduction is devoted to a brief statement of the theory and its implications for different aspects of second language acquisitions theory and practice. We define acquisition and learning, and present the Monitor Model for adult second language performance. Following this, brief summaries of research results in various areas of second language acquisition serve as both an overview of Monitor Theory research over the last few years and as introduction to the essays that follow. Acquisition and Learning and the Monitor Model for Performance Language acquisition is very similar to the process children use in acquiring first and second languages. It requires meaningful interaction in the target language- natural communication-in which speakers are concerned not with the form of their utterances but with the messages they are conveying and understanding. Error correction and explicit teaching of rules are not relevant to language acquisition (Brown and Hanlon, 1970; Brown, Cazden, and Bellugi, 1973), but caretakers and native speakers can modify their utterances addressed to acquirers to help them understand, and these modifications are thought to help the acquisition process (Snow and Ferguson, 1977). It has been hypothesized that there is a fairly stable order of acquisition of structures in language acquisition, that is, one can see clear 1 similarities across acquirers as to which structures tend to be acquired early and which tend to be acquired late (Brown, 1973; Dulay and Burt, 1975). Acquirers need not have a conscious awareness of the "rules" they possess, and may self- correct only on the basis of a "feel" for grammaticality. Conscious language learning, on the other hand, is thought to be helped a great deal by error correction and the presentation of explicit rules (Krashen and Seliger, 1975). Error correction it is maintained, helps the learner come to the correct mental representation of the linguistic generalization. Whether such feedback has this effect to a significant degree remains an open question (Fanselow, 1977; Long, 1977). No invariant order of learning is claimed, although syllabi implicitly claim that learners proceed from simple to complex, a sequence that may not be identical to the acquisition sequence. The fundamental claim of Monitor Theory is that conscious learning is available to the performer only as a Monitor. In general, utterances are initiated by the acquired system-our fluency in production is based on what we have "picked up" through active communication. Our "formal" knowledge of the second language, our conscious learning, may be used to alter the output of the acquired system, sometimes before and sometimes after the utterance is produced. We make these changes to improve accuracy, and the use of the Monitor often has this effect. Figure 1 illustrates the interaction of acquisition and learning in adult second language production. Corder (1967), citing an unpublished paper by Lambert, also discusses the acquisition-learning distinction and the possibility that acquisition is available to the adult second language performer. The Monitor Theory differs somewhat from these points of view, in that it makes some very specific hypotheses about the inter-relation between acquisition and learning in the adult. In the papers that follow, I argue that this hypothesis sheds light on nearly every issue currently under discussion in second language theory and practice. Conditions of Monitor Use There are several important constraints on the use of the Monitor. The first condition is that in order to successfully monitor, the performer must have time. In normal conversation, both is speaking and in listening, performers do not generally have time to think about and apply conscious grammatical rules, and, as we shall see later, we see little or no effect on the Monitor in these situations. Heidi Dulay and Marina Burt have pointed out to me that a performer may have time but may still not monitor, as he or she may be completely involved with the message. There is, thus, a second condition: the performer must be "focused on form", or correctness. An important third condition for successful Monitor use is that the performer needs to know the rule, he or she needs to have a correct mental representation of the rule to apply it correctly. Syntacticians freely admit that they have only analyzed "fragments" of natural languages, applied linguists concede that they have mastered only part of the theoretical literature in grammar, language teachers usually do not have time to fully study the descriptive work of all applied linguists, and even the best language students do not usually master all the rules presented to them. It is therefore very difficult to apply conscious learning to performance successfully. Situations in which all three conditions are satisfied are rare (the most obvious being a grammar test! In the last few years, the acquisition-learning distinction has been shown to be useful in explaining a variety of phenomena in the field of second language acquisition. While many of these phenomena may have alternative explanations, the claim is that the Monitor Theory provides for all of them in a general, non ad hoc way that satisfies the intuitions as well as the data. The papers in this volume review this research, and include discussion of how the second language classroom may be utilized for both acquisition and learning. Individual Variation Chapter 1, based on a paper written in 1976 and published in Ritchie (1978), describes how the learning-acquisition distinction captures one sort of individual variation in second language performance. Based on case histories, this section proposes that there are basically three types of performer: Monitor "overusers" are performers who feel they must "know the rule" for everything and do not entirely trust their feel for grammaticality in the second language. At the other extreme is the underuser, who appears to be entirely dependent on what he can "pick up" of the second language. Underusers seem to be immune to error correction, and do not perform well on "grammar" test. They may acquire a great deal of the target language, however, and often use quite complex constructions. The optimal user is the performer who uses learning as a real supplement to acquisition, monitoring when it is appropriate and 4 when it does not get in the way of communication. Very good optimal users may, in fact, achieve the illusion of native speaker competence in written performance. They "keep grammar in its place", using it to fill gaps in acquired competence when such monitoring does not get in the way of communication. Attitude and Aptitude Chapter 2 illustrates how the acquisition-learning hypothesis provides a parsimonious explanation for what had appeared (to me) to be a mysterious finding: both language aptitude, as measured by standard language aptitude tests, and language attitude (affective variable) are related to adult second language achievement, but are not related to each other. The first is that aptitude may be directly related to conscious learning (especially certain components as detailed in Chapter 2). As we shall see in Chapter 2, scores on aptitude tests show a clear relationship to performance on "monitored" test situation and when conscious learning has been stressed in the classroom. The second hypothesis is that such factors relate directly to acquisition and only indirectly to conscious learning. Briefly, the "right" attitudinal factors produce two effects: they encourage useful input for language acquisition and they allow the acquirer to be "open" to this input so it can be utilized for acquisition. The pedagogical implications of these hypotheses will not surprise many experienced teachers: if the direct relationship between acquisition and attitudinal factors does exist, and if our major goal in language teaching is the development of communicative abilities, we must conclude that attitudinal factors and motivational factors are more important the aptitude. This is because conscious learning makes only a small contribution to communicative ability. Affective changes that occur around puberty, some related to Formal Operations, affect language acquisition. The chapter concludes with a re-definition of the "good language learner", now defined as someone who is first and foremost an acquirer, and who may also be an "optimal Monitor user". It shows how the acquisition-learning distinction helps to solve a puzzle in the second language acquisition research literature: several studies apparently show that formal learning environments are best for attaining second language proficiency, while other studies appear to show that informal environments are superior. In this section, it is argued that informal environments, when they promote real language use (communication) are conducive to acquisition, while the formal environment has the potential for encouraging both acquisition and learning. This chapter, then, begins the discussion of the potential of the second language classroom for language acquisition, a discussion that is continued in later sections (Chapters 8 and 9). The Domain of the Conscious Grammar: the Morpheme Studies Chapter 4 reviews research pertaining to acquisition or difficulty order of certain structures, that is, which structures adult second language acquirers tend to acquire early and which they tend to acquire late. They provide more information than merely showing us the actual order of acquisition. They also show us when performers are using conscious grammar and when they are not. We have hypothesized that when conditions for "Monitor-free" performance are met, when performers are focused on communication and not form, adult errors in English as a second language (for grammatical morphemes in obligatory occasions1) are quite similar to errors made by children acquiring English as a second 6 language (some similarities to first language acquisition have been noted as well). When second language speakers "monitor", when they focus on form, this "natural order" is disturbed. The appearance of child-like errors in Monitor-free conditions is hypothesized to be a manifestation of the acquired system operating in isolation, or with little influence of the Monitor. Current research in the "morpheme studies" supports the hypothesis that second language performers utilize the conscious grammar extensively only when they have to do extreme "discrete-point" grammar tests, test that test knowledge of rules and vocabulary in isolation. Also included in Chapter 4 is a response to some criticisms of the morpheme studies. The Role of the First Language Chapter 5 deals with so-called first language "interference". It attempts to provide some empirical data for a position first held by Newmark (1966): "interference" is not the first language "getting in the way" of second language skills. Rather, it is the result of the performer "falling back" on old knowledge when he or she has not yet Fig. In terms of the Monitor performance model, interference is the result of the use of the first language as an utterance initiator: first language competence may replace acquired second language competence in the performance model, as in Fig. From the data we have so far, this hypothesis correctly predicts that those aspects of syntax that tend to be acquired are also those that show first-language-influenced errors in second language performance. It is, not surprisingly, found most often in foreign language, as opposed to second language situations, where opportunities for real communication are fewer, and is only rarely seen in "natural" child second language acquisition. Children are usually allowed to go through a "silent period", during which they build up acquired competence through active listening. Several scholars have suggested that providing such a silent period for all performers in second language acquisition would be beneficial (see for example, Postovsky, 1977) Note that it is possible for performers to use the first language and the Monitor to perform without any acquired competence in the second language. This bizarre mode is severely limited, yet its use may give the adult a temporary head-start over children, who presumably rely on acquisition alone for the most part. It discusses current research in two areas of neurolinguistics and the relationship of this research to the acquisition-learning hypothesis. More recent reports place the completion of the development of cerebral dominance much earlier (some claiming age 5, others claiming that laterality is present at birth). The implications of this research are that the "critical period" and cerebral dominance may not be related at all. Other explanations of child-adult differences are discussed, namely the hypothesis presented in Chapter 2, that Formal Operations causes an increase in our ability to learn but damages our ability to acquire. Psychological and neurological evidence is presented in support of the hypothesis that there is an early stage in second language acquisition (not learning) that involves the right side of the brain. Since it may be the case that early first language acquisition also involves some right hemisphere participation, confirmation of such a hypothesis would strengthen the parallel between first and second language acquisition. Routines and Patterns Chapter 7 originally appeared in Language Learning and was coauthored with Robin Scarcella. A performer can use routines and patterns without learned or acquired knowledge of its internal parts. This chapter presents evidence to support the hypothesis that routines and patterns are fundamentally different from both acquired and learned language, and they do not "turn into" acquired or learned language directly. This evidence is drawn from neurolinguistic research, and studies in child first, child second, and adult language acquisition. Theory to Practice Chapter 8 deals directly with application to the second language classroom. It focuses, first of all, on the important question of how we acquire, concluding that comprehensible input is the crucial and necessary ingredient. This hypothesis, the "Input Hypothesis", is discussed in more detail in Chapter 9. I then discuss what sorts of activities provide comprehensible input, input language in which the focus is on the message and not the form. This chapter is optimistic with respect to the role and value of the classroom in encouraging second language acquisition, suggesting that 9 the classroom should be viewed as a place where the student can get the input he or she needs for acquisition. The classroom may be superior to the outside world for beginning and low intermediate students, in that the real world is often quite unwilling to provide such students with comprehensible input, as Wagner-Gough and Hatch have pointed out. This section also discusses the possible role of conscious learning, pointing out that "easy" rules can be taught for optimal Monitor use, but that "hard" rules may only serve a "language appreciation" function for most students. The Relevance of Simple Codes the final chapter, Chapter 9, is the most recently written, and appeared in Scarcella and Krashen (1980). The conclusion is that such input is not only highly useful, but it is possibly essential. Simple codes may provide for the second language acquirer what "caretaker speech" provides for the first language acquirer, comprehensible input with a low "affective filter". Simple codes, input that the acquirer understands, are not deliberately grammatically sequenced or controlled. Rather, the speaker is only concerned with whether the listener understands the message.

Syndromes

• Take steps to prevent shock. Lay the person flat, elevate the feet about 12 inches, and cover the person with a coat or blanket. However, do NOT place the person in this shock position if a head, neck, back, or leg injury is suspected or if it makes the person uncomfortable.
• Wound infections
• Weight loss
• Reactions to anesthesia medicines
• Inadequate or unbalanced diet
• Your skin appears to be very stretchy
• A heel cup, felt pads in the heel area, or shoe insert.
• Do not touch anything that may contain cat feces
• Choking episodes
• Long-term gastritis

Although sometimes a normal finding fungus under ring best buy mentax, for example fungus gnats fruit flies generic mentax 15 gm on-line, in the presence of generalized hyperrefiexia (anxiety fungus resistant materials order mentax with paypal, hyperthyroidism) antifungal nail tablets order mentax paypal, it may be indicative of a corticospinal tract lesion above C5 or C6 fungus gnats bradysia species cheap mentax 15 gm, particularly if present unilaterally antifungal with steroid buy line mentax. Reaction to accommodation is preserved (partial iri- doplegia), hence this is one of the causes of light-near pupillary dissociation. The rest tremor may resemble parkinsonian tremor and is exacerbated by sustained postures and voluntary movements. If a causative lesion is defined, there is typically a delay before tremor appearance (4 weeks to 2 years). It is based on the fact that when a recumbent patient attempts to lift one leg, downward pressure is felt under the heel of the other leg, hip extension being a normal synergistic or synkinetic movement. The first two mentioned signs are usually the most evident and bring the patient to medical attention; the latter two are usually less evident or absent. The sympathetic innervation of the eye consists of a long, three neurone, pathway, extending from the diencephalon down to the cervicothoracic spinal cord, then back up to the eye via the superior cervical ganglion and the inter- nal carotid artery, and the ophthalmic division of the trigeminal (V) nerve. Arm symptoms and signs in a smoker mandate a chest radiograph for Pancoast tumour. Observation of anisocoria in the dark will help here, since increased anisoco- ria indicates a sympathetic defect (normal pupil dilates) whereas less anisocoria suggests a parasympathetic lesion. Ageusia may also be present if the chorda tympani branch of the facial nerve is involved. Reduction or absence of the stapedius refiex may be tested using the stetho- scope loudness imbalance test: with a stethoscope placed in the patients ears, a vibrating tuning fork is placed on the bell. Normally the perception of sound is symmetrical, but sound lateralizes to the side of facial paresis if the attenuating effect of the stapedius refiex is lost. Cross References Anaesthesia; Hyperalgesia Hyperalgesia Hyperalgesia is the exaggerated perception of pain from a stimulus which is normally painful (cf. This may result from sensitization of nocicep- tors (paradoxically this may sometimes be induced by morphine) or abnormal ephaptic cross-excitation between primary afferent fibres. Cross References Allodynia; Dysaesthesia; Hyperpathia Hyperekplexia Hyperekplexia (literally, to jump excessively) is an involuntary movement disor- der in which there is a pathologically exaggerated startle response, usually to sudden unexpected auditory stimuli, but sometimes also to tactile (especially trigeminal) and visual stimuli. The startle response is a sudden shock-like move- ment which consists of eye blink, grimace, abduction of the arms, and fiexion of the neck, trunk, elbows, hips, and knees. Ideally for hyperekplexia to be diagnosed there should be a physiological demonstration of exaggerated startle response, but this criterion is seldom adequately fulfilled. Familial cases have been associated with mutations in the fi1 subunit of the inhibitory glycine receptor gene. Cross References Incontinence; Myoclonus Hypergraphia Hypergraphia is a form of increased writing activity. It has been suggested that it should refer specifically to all transient increased writing activity with a non-iterative appearance at the syntactic or lexicographemic level (cf. Hypergraphia may be seen as part of the interictal psychosis which some- times develops in patients with complex partial seizures from a temporal lobe (especially non-dominant hemisphere) focus, or with other non-dominant tem- poral lobe lesions (vascular, neoplastic, demyelinative, neurodegenerative), or psychiatric disorders (schizophrenia). Increased writing activity in neurological conditions: a review and clinical study. Cross References Automatic writing behaviour; Hyperreligiosity; Hyposexuality Hyperhidrosis Hyperhidrosis is excessive (unphysiological) sweating. Localized hyperhidrosis caused by food (gustatory sweating) may result from aberrant connections between nerve fibres supplying sweat glands and salivary glands. Other causes of hyperhidro- sis include mercury poisoning, phaeochromocytoma, and tetanus. Transient hyperhidrosis contralateral to a large cerebral infarct in the absence of auto- nomic dysfunction has also been described. Symptoms may be helped (but not abolished) by low dose anticholinergic drugs, clonidine, or propantheline. Cross References Ballism, Ballismus; Chorea, Choreoathetosis; Dysarthria Hyperlexia Hyperlexia has been used to refer to the ability to read easily and fiuently. Patients with hypermetamorphosis may explore compulsively and touch everything in their environment. This is one element of the environmental dependency syndrome and may be associated with other forms of utilization behaviour, imitation behaviour (echolalia, echopraxia), and frontal release signs such as the grasp refiex. Clinical features of hyperpathia may include summation (pain perception -185 H Hyperphagia increases with repeated stimulation) and aftersensations (pain continues after stimulation has ceased). The term thus overlaps to some extent with hyperal- gesia (although the initial stimulus need not be painful itself) and dysaesthesia. There is an accompanying diminution of sensibility due to raising of the sensory threshold (cf. Hyperpathia is a feature of thalamic lesions, and hence tends to involve the whole of one side of the body following a unilateral lesion such as a cerebral haemorrhage or thrombosis. Cross References Allodynia; Dysaesthesia; Hyperalgesia Hyperphagia Hyperphagia is increased or excessive eating. Binge eating, particularly of sweet things, is one of the neurobehavioural disturbances seen in certain of the frontotemporal dementias. Cross References Cover tests; Heterophoria; Hypophoria Hyperpilaphesie the name given to the augmentation of tactile faculties in response to other sensory deprivation, for example, touch sensation in the blind. This may be physiological in an anxious patient (refiexes often denoted ++), or pathological in the context of corticospinal pathway pathology (upper motor neurone syn- drome, often denoted +++). It is sometimes difficult to distinguish normally brisk refiexes from pathologically brisk refiexes. Hyperrefiexia (including a jaw jerk) in isolation cannot be used to diagnose an upper motor neurone syndrome, and asymmetry of refiexes is a soft sign. On the other hand, upgoing plantar responses are a hard sign of upper motor neurone pathology; other accom- panying signs (weakness, sustained clonus, and absent abdominal refiexes) also indicate abnormality. This may be due to impaired descending inhibitory inputs to the monosynaptic refiex arc. Rarely pathological hyperrefiexia may occur in the absence of spasticity, suggesting different neuroanatomical substrates underlying these phenomena. Hyper-refiexia without spasticity after unilateral infarct of the medullary pyramid. It has also been observed in some patients with frontotemporal dementia; the finding is cross-cultural, having been described in Christians, Muslims, and Sikhs. In the context of refractory epilepsy, it has been associated with reduced volume of the right hippocampus, but not right amygdala. Religiosity is associated with hip- pocampal but not amygdala volumes in patients with refractory epilepsy. Cross References Hypergraphia; Hyposexuality Hypersexuality Hypersexuality is a pathological increase in sexual drive and activity. Sexual disinhibition may be a feature of frontal lobe syndromes, particularly of the orbitofrontal cortex. Clinical signs may include a bounding hyperdynamic circulation and sometimes papilloedema, as well as features of any underlying neuromuscular disease. Sleep studies confirm nocturnal hypoventilation with dips in arterial oxygen saturation. It usually implies spasticity of corticospinal (pyramidal) pathway origin, rather than (leadpipe) rigidity of extrapyramidal origin. Cross Reference Anaesthesia Hypoalgesia Hypoalgesia is a decreased sensitivity to , or diminution of, pain perception in response to a normally painful stimulus. It may be demonstrated by asking a patient to make repeated, large amplitude, opposition movements of thumb and forefinger, or tapping movements of the foot on the fioor. Cross References Akinesia; Bradykinesia; Dysmetria; Fatigue; Hypokinesia; Parkinsonism; Saccades Hypomimia Hypomimia, or amimia, is a deficit or absence of expression by gesture or mimicry. Cross References Dysarthria; Dysphonia; Parkinsonism Hypophoria Hypophoria is a variety of heterophoria in which there is a latent downward deviation of the visual axis of one eye. This may be physiological, as with the diminution of the ankle jerks with normal ageing; or pathological, most usually as a feature of peripheral lesions such as radiculopathy or neuropathy. The latter may be axonal or demyelinating, in the latter the blunting of the refiex may be out of proportion to associated weakness or sensory loss. Although frequently characterized as a feature of the lower motor neurone syndrome, the pathology underlying hyporefiexia may occur anywhere along the monosynaptic refiex arc, including the sensory affer- ent fibre and dorsal root ganglion as well as the motor efferent fibre, and/or the spinal cord synapse. Hyporefiexia may also accompany central lesions, particularly with involve- ment of the mesencephalic and upper pontine reticular formation.

Group A streptococcal infection among children in child care has been reported antifungal emulsion paint purchase mentax amex, including an association with varicella outbreaks antifungal during pregnancy buy 15gm mentax free shipping. A child with proven group A strepto- coccal infection should be excluded from classroom contact until 24 hours after initiation of antimicrobial therapy fungus gnats bacillus thuringiensis purchase generic mentax. Although outbreaks of streptococcal pharyngitis in these set- tings have occurred antifungal resistance purchase generic mentax line, the risk of secondary transmission after a single case of mild or even severe invasive group A streptococcal infection remains low antifungal gargle discount 15gm mentax with visa. Chemoprophylaxis for con- tacts after group A streptococcal infection in child care facilities generally is not recom- mended (see Group A Streptococcal Infections quinoa fungus discount mentax online american express, p 668). Infants and young children with tuberculosis disease are not as contagious as adults, because children are less likely to have cavitary pulmonary lesions and are unable to expel large numbers of organisms into the air forcefully. If approved by health care offcials, children with tuberculosis disease may attend group child care if the follow- ing criteria are met: (1) chemotherapy has begun; (2) ongoing adherence to therapy is documented; (3) clinical symptoms have resolved; (4) children are considered noninfec- tious to others; and (5) children are able to participate in activities. The need for periodic subsequent tuberculin screening for people without clinically important reactions should be determined on the basis of their risk of acquiring a new infection and local or state health department recommendations. Adults with symptoms compatible with tuberculosis should be evaluated for the disease as soon as possible. Child care providers with suspected or confrmed tuberculosis disease should be excluded from the child care facility and should not be allowed to care for chil- dren until their evaluation is negative or chemotherapy has rendered them noninfectious (see Tuberculosis, p 736). Isolation or exclusion of immunocompetent people with parvovirus B19 infection in child care settings is unwarranted, because little or no virus is present in respiratory tract secretions at the time of occurrence of the rash of erythema infectio- sum. In addition, because fewer than 1% of pregnant teachers during erythema infec- tiosum outbreaks would be expected to experience an adverse fetal outcome, exclusion of pregnant women from employment in child care or teaching is not recommended (see Parvovirus B19, p 539). This is based on the equivalent risk of acquisition of parvo virus B19 from a community source not affliated with the child care facility. The epidemiology of varicella has changed dramatically since licensure of the varicella vaccine in 1995. In the prevaccine era, attendance in child care was a described risk factor for children acquiring varicella at earlier ages. Children with varicella who have been excluded from child care may return after all lesions have dried and crusted, which usually occurs on the sixth day after onset of rash. Immunized children with breakthrough varicella with only maculopapular lesions can return to child care or school if no new lesions have appeared within a 24-hour period. All staff members and parents should be notifed when a case of varicella occurs; they should be informed about the greater likelihood of serious infec- tion in susceptible adults and adolescents and in susceptible immunocompromised people in addition to the potential for fetal sequelae if infection occurs during the pregnancy of a susceptible woman. Adults without evidence of immunity should be offered 2 doses of varicella vac- cine unless contraindicated. Susceptible child care staff members who are pregnant and exposed to children with varicella should be referred promptly to a qualifed physician or other health care professional for counseling and management. During a varicella outbreak, people who have received 1 dose of varicella vaccine should, resources permitting, receive a sec- ond dose of vaccine, provided the appropriate interval has elapsed since the frst dose (3 months for children 12 months through 12 years of age and at least 4 weeks for people 13 years of age and older). In immunocompetent people, herpes zoster lesions that can be cov- ered pose a minimal risk, because transmission usually occurs as a result of direct contact with fuid from lesions (see Varicella-Zoster Infections, p 774). The highest rates (eg, 70%) of viral shedding in oral secretions and urine occur in children between 1 and 3 years of age, and excretion commonly continues (sometimes intermittently) for years. Therefore, use of standard precautions and hand hygiene are the optimal methods of prevention of transmission of infection. Although risk of contact with blood containing one of these viruses is low in the child care setting, appro- priate infection-control practices will prevent transmission of bloodborne pathogens if exposure occurs. All child care providers should receive regular training on how to prevent transmission of bloodborne infections and how to respond should an exposure occur ( Indirect transmission through environmental contamination with blood or saliva is possible. This occurrence has not been documented in a child care setting in the United States. Because saliva contains much less virus than does blood, the potential infectivity of saliva is low. Infectivity of saliva has been demonstrated only when inoculated through the skin of gibbons and chimpanzees. The responsible public health authority or child care health consultant should be consulted when appropriate. Serologic testing generally is not warranted for the biting child or the recipient of the bite, but each situation should be evaluated individually. Toothbrushes and pacifers should be labeled individually and should not be shared among children. Information about a child who has immunodefciency, regardless of cause, should be available to care providers who need to know how to help protect the child against other infections. For example, immunodefcient children exposed to measles or varicella should receive postexposure immunoprophylaxis as soon as possible (see Measles, p 489, and Varicella-Zoster Infections, p 774). Written documentation of immunizations appropriate for age should be provided by parents or guardians of all children in out-of-home child care. Unless contraindica- tions exist or children have received medical, religious, or philosophic exemptions, immunization records should demonstrate complete immunization for age as shown in the recommended childhood and adolescent immunization schedules (see Fig 1. Immunization mandates by state for children in child care can be found online ( Children who have not received recommended age-appropriate immunizations before enrollment should be immunized as soon as possible, and the series should be completed according to Fig 1. In the interim, permitting unimmunized or inadequately immunized children to attend child care should depend on medical and legal counsel regarding how to handle the risk and whether to inform parents of enrolled infants and children about potential exposure to this risk. These children place other children at risk of contracting a vaccine-preventable disease. If a vaccine-preventable disease to which children may be susceptible occurs in the child care program, all underimmunized chil- dren should be excluded for the duration of possible exposure or until they have com- pleted their immunizations. All adults who work in a child care facility should have received all immunizations routinely recommended for adults ( Child care providers should be immunized against infuenza annually and should be immunized appropriately against measles as shown in the adult immunization schedule. Child care providers are expected to render frst aid, which may expose them to blood. All child care providers should receive written information about hepatitis B disease and its complications as well as means of prevention with immunization. All child care providers should receive written information about varicella, particularly disease mani- festations in adults, complications, and means of prevention. All adults who work in child care facilities should receive a one-time dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine regardless of how recently they received their last dose of Td for booster immunization against tetanus, diphtheria, and pertussis. For other recommendations for Tdap vaccine use in adults, including unimmunized or partially immunized adults, see Pertussis (p 553) and the adult immunization schedule. Soiled dispos- able diapers, training pants, and soiled disposable wiping cloths should be discarded in a secure, hands-free, plastic-lined container with a lid. Diapers should contain all urine and stool and minimize fecal contamination of children, child care providers, environ- mental surfaces, and objects in the child care environment. Disposable diapers with absorbent gelling material or carboxymethylcellulose or single-unit reusable systems with an inner cotton lining attached to an outer waterproof covering that are changed as a unit should be used. Clothes should be worn over diapers while the child is in the child care facility. This clothing, including shoes, should be removed and placed where it will not have contact with diaper contents during the diaper change. The use of potty chairs should be dis- couraged, but if used, potty chairs should be emptied into a toilet, cleaned in a utility sink, and disinfected after each use. Staff members should disinfect potty chairs, toilets, and diaper-changing areas with a freshly prepared solution of a 1:64 dilution of house- hold bleach (one quarter cup of bleach diluted in 1 gallon of water) applied for at least 2 minutes and allowed to dry. These sinks should be washed and disinfected at least daily and should not be used for food preparation. Food and drinking utensils should not be washed in sinks in diaper- changing areas. Handwashing sinks should not be used for rinsing soiled clothing or for cleaning potty chairs. Children should have access to height-appropriate sinks, soap dispensers, and disposable paper towels. Children should not have independent access to alcohol-based hand sanitizing gels or use them without adult supervision, because they are fammable and toxic if ingested because of their high alcohol content. Alcohol-based sanitizing gels should be limited to areas where there are no sinks. In general, routine housekeeping procedures using a freshly prepared solution of com- mercially available cleaner (eg, detergents, disinfectant detergents, or chemical ger- micides) compatible with most surfaces are satisfactory for cleaning spills of vomitus, urine, and feces. For spills of blood or blood-containing body fuids and of wound and tissue exudates, the material should be removed using gloves to avoid contamination of hands, and the area then should be disinfected using a freshly prepared solution of a 1:10 dilution of household bleach applied for at least 2 minutes and wiped with a dis- posable cloth after the minimum contact time. Crib mattresses should have a nonporous easy-to-wipe surface and should be cleaned and sanitized when soiled or wet. Sleeping cots should be stored so that contact with the sleeping surface of another mat does not occur. Bedding (sheets and blankets) should be assigned to each child and cleaned and sanitized when soiled or wet. All frequently touched toys in rooms that house infants and tod- dlers should be cleaned and sanitized daily. Toys in rooms for older continent children 1 Centers for Disease Control and Prevention. Soft, nonwashable toys should not be used in infant and toddler areas of child care programs. Tables and countertops 1 used for food preparation, food service, and eating should be cleaned and sanitized between uses and between preparation of raw and cooked food. People with signs or symptoms of illness, including vomiting, diarrhea, jaundice, or infectious skin lesions that cannot be covered or with potential foodborne pathogen infections should not be responsible for food handling. Because of their frequent exposure to feces and children with enteric diseases, staff members whose primary function is the preparation of food should not change diapers. Except in home-based care, staff members who work with diapered children should not prepare food for, or serve food to , older groups of children. Staff members involved in changing diapers should not be involved in food preparation or serving on the same day. If doing both is necessary, staff members should prepare food before doing diaper changing, do both tasks for as few children as possible, and handle food only for infants and toddlers in their own group and only after thoroughly washing their hands. Caregivers who prepare food for infants should be aware of the impor- tance of careful hand hygiene. Dogs and cats should be in good health, immunized appro- priately for age, and kept away from child play areas and handled only with staff super- vision. Reptiles, rodents, amphibians, and baby poultry and their habitats should not be handled by children (see Diseases Transmitted by Animals [Zoonoses]: Household Pets, Including Nontraditional Pets, and Exposure to Animals in Public Settings, p 215). Children in group child care settings should receive all recommended immunizations, including annual infuenza vaccine. The health consultant should conduct program observations to correct hazards and risky practices. Compendium of measures to prevent disease associated with ani- mals in public settings, 2011: National Association of State Public Health Veterinarians, Inc. Monitoring of the program results and developing protocols to deal with incidents when human milk inadvertently is fed to an infant other than the designated infant also are necessary (see Human Milk Banks, p 131). Health care facilities have developed policies that could be adapted to the child care setting to address such incidents. Meticulous labeling, storage, and verifcation of recipient identity before providing human milk should be practiced by child care providers. School Health Clustering of children together in a school setting provides opportunities for transmission of infectious diseases. Determining the likelihood that infection in one or more children will pose a risk for schoolmates depends on an understanding of several factors: (1) the mechanism by which the organism causing infection is spread; (2) the ease with which the organism is spread (contagion); and (3) the likelihood that classmates are immune because of immunization or previous infection. Decisions to intervene to prevent spread of infection within a school should be made through collaboration among school offcials, local public health offcials, and health care professionals, considering the availability and effectiveness of specifc methods of prevention and risk of serious complications from infection. Although specifc laws vary by state, most states require proof of protection against poliomyelitis, tetanus, pertus- sis, diphtheria, measles, mumps, rubella, and varicella. In 2007, the Centers for Disease Control and Prevention recommended that all states require that children entering elementary school have received 2 doses of varicella vaccine or have other evidence of immunity to varicella. Physicians involved with school health should be aware of current public health guidelines to prevent and control infectious diseases. In all circumstances requiring inter- vention to prevent spread of infection within the school setting, the privacy of children who are infected should be protected. Diseases Preventable by Routine Childhood Immunization Children and adolescents immunized according to the recommended childhood and adolescent immunization schedule (see Fig 1. Measles and varicella vaccines have been demonstrated to provide protection in some susceptible people if administered within 72 hours after exposure.

Reconstruction after tumor resection and radiation may result in exposure and complex wounds fungus gnats purchase discount mentax line. Because of the effects of radiation on local tissue fungus diet generic mentax 15gm overnight delivery, free tissue transfer74 is required for reconstruction fungus fingers discount 15 gm mentax otc. The benefits of a vascular- ized graft include accelerated healing and primary bone healing antifungal plant spray buy discount mentax 15gm on line. Repair and coverage for sternal wound infections can use many adjacent flaps to provide good stable soft tissue coverage dimorphic fungi definition buy 15gm mentax overnight delivery. A pectoralis flap has been used in infants for closure of sternal wound infections fungus gnats hawaii cheap 15gm mentax overnight delivery. Rectus muscle can also be used in a vertically based fashion, but the course of the internal mammary artery to the superficial epigas- tric may be disrupted, so the contralateral side should be used. Component separation (which involves separating and advancing certain layers of abdominal muscles, and lengthening their reach to achieve primary midline closure) and tissue expanders are being used to aid in closure of abdominal wall defects when classic methods are unsuccessful. Rohrich and col- leagues83 proposed an algorithm for management of abdominal wall reconstruction, which outlined the size of the defect and an appropriate regional flap or free tissue transfer. Other groups have reported complete reconstruction of the abdominal wall in adults using the lateral circumflex system and a conjoined tensor fascia lata and anterolateral thigh flap. Noaman85 performed a retrospective study in adult patients with an average defect of 8 cm of bone in the extremity. They had a 93% success rate, and, as in the spine, the benefits of vascularized bone grafting included osteogenesis at the fracture site. In the pediatric population requiring lower extremity reconstruction, 75% of patients were Overview of Wound Healing and Management 203 Fig. Although it may never be possible to eliminate the risk of a wound, the medical armamentarium continues to expand with methods to manage it. The expanded knowledge of cell signaling within a wound may someday allow clinicians to guide healing in a normal cascade even in abnormal conditions. The liberation of histamine like substance in injured akin; the underlying cause of factitious urticarial and wheal produced by burning, and observations upon the nervous controls of certain skin reactions. Macrophages and fibrosis: how resident and infiltrating mono- nuclear phagocytes orchestrate all phases of tissue injury and repair. Improved scar quality following primary and secondary healing of cutaneous wounds. Adjuncts to preparing wounds for closure: hyperbaric oxygen, growth factors, skin substitutes, negative pressure wound therapy (vacuum-assisted closure). Effects of early excision and aggressive enteral feeding on hypermetabolism, catabolism, and sepsis after severe burn. The most current algorithms for the treatment and prevention of hyper- trophic scars and keloids. Clinical approach to wounds: debride- ment and wound bed preparation including the use of dressings and wound- healing adjuvants. Pulsed dye laser therapy and z-plasty for facial burn scars: the alternative to excision. Treating the chronic wound: a practical approach to the care of nonhealing wounds and wound care dressings. Wound management in an era of increasing bac- terial antibiotic resistance: a role for topical silver treatment. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic founda- tion. Microdeformation of three-dimensional cultured fibroblasts induces gene expression and morphological changes. Foam pore size is a critical interface parameter of suction-based wound healing devices. Vacuum drainage in the management of complicated abdominal wound dehiscence in children. A randomized, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. Nasal reconstruction with local flaps: a simple algo- rithm for management of small defects. Morbidity of pediatric dog bites: a case series at a level one pediatric trauma center. Retrospective analysis of facial dog bite injuries at a Level I trauma center in the Denver metro area. Aerobic bacterial flora of oral and nasal fluids of canines with reference to bacteria associated with bites. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Improved results from a standard- ized approach in treating patients with necrotizing fasciitis. Soft-tissue defects and exposed hard- ware: a review of indications for soft-tissue reconstruction and hardware preser- vation. Use of the vascularized free fibula graft with an arteriovenous loop for fusion of cervical and thoracic spinal defects in previ- ously irradiated pediatric patients. The use of vascularized fibular grafts for the reconstruction of spinal and sacral defects. Sternal wound infections in pediatric congenital cardiac surgery: a survey of incidence and preventative practice. Management of deep sternal infection in infants and children with advanced pectoralis major muscle flaps. Transdiaphragmatic omental harvest: a simple, effi- cient method for sternal wound coverage. Reconstruction of complex abdominal wall defects with free flaps: indications and clinical outcome. Management of upper limb bone defects using free vascularized osteoseptocutaneous fibular bone graft. Pediatric lower extremity sarcoma reconstruction: a review of limb salvage procedures and outcomes. The use of massive bone allograft with intramedul- lary free fibular flap for limb salvage in a pediatric and adolescent population. Biological reconstruction after resection of bone tumors of the proximal tibia using allograft shell and intramedullary free vascularized fibular graft: long-term results. Treatm entEvidence Sum m ary fi Urine culture isN O T indicated in m ostasym ptom aticpatients,asthere isno benefit and potentialharm. H ow ever,iffirstcystitisepisode,susceptibility likely 19 betterthan itappearsin the antibiogram,w here patientsw ith m ore com plicated & hem olytic)are rare w ith shortterm therapy (fi14 days). There w asno difference in clinicalcure;how ever,1 study dem onstrated 41 com pared to placebo in a m eta-analysis(N =4,n=275),butdata islim ited. Studiesare lim ited by the num berofpatientsincluded w ith renalfunction 42 43 23 (N N H =14). Post-coital fi Considerin patientsw hen cystitisroutinely presentsw ithin Prophylaxis 24-48 hoursofintercourse. N orfloxacin ** fi fi 200m g po x1 fi Reinfection:Differentorganism (generally)presentsafter2 w eeksoftherapy. Itis Beers2015 recom m endsavoiding long-term use ofnitrofurantoin in those fi65 yearsdue to adverse effects 11 Low Quality Evidence, Strong Recom m endation B st. Considersw abbing the fi Age:<2 yearsold & >65 yearsold fi Recentinvasive procedurese. M ay add antibioticsif fi Antibiotic use in the past6 m onths fi Traum a associated fi risk. Delayed rashescaused by penicillin,ifafterfirstfew doses/days& no fi Beta-lactam s:group ofantibioticsw ith a distinctive beta-lactam ring;includespenicillins,cephalosporins,and carbapenem s. Allergym ayoccurto itchiness/hives,are nottypically indicative ofa true IgE-m ediated eitherthe beta-lactam ring (in w hich case apatientisallergicto allbeta-lactam s)orto the unique side chain (in w hich case the allergyisonlyto specificagents). Afterencountering a specificantigen,IgE antibodiescan triggeran im m une response. When possible,referpatientsw ith uncertain penicillin allergy for fi "True"IgE-m ediated allergy:potentiallylife-threatening reaction;also know n asa type-1 im m ediate hypersensitivityreaction. Skin testing isespecially helpfulw hen the allergy history fi Graded challenge:som e variation in approaches,butoften a sm alldose ofa potentialallergen. When the risk oftrue penicillin allergy islow,a graded challenge th fi Desensitization:sim ilarto the graded challenge,butata slow erpace. A sam ple protocolforan oral using a cephalosporin w ith a dissim ilarside-chain isappropriate. Table 1:Factorsthatdecrease the likelihood ofa true allergy 10,000 In a given group of10,000 patients: 5 Skin testisnegative:thisprovidesa 97-99% certainty thatthe patientisnotallergic. Tim ing:ifreaction occurred afterdaysto w eeksoftaking antibiotic,itisunlikely to be IgE-m ediated. M anagem entofPenicillin Allergy Aftera reaction to penicillin,can a beta-lactam be prescribed in the futurefi The answ errequiresaccurate differentiation betw een three typesofbeta-lactam adverse reactions. Penicillin Adverse Event SeriousPenicillin Adverse Event True IgE-M ediated Penicillin Allergy. Stevens-Johnson syndrom e,interstitial Atm inim um,presentsasan itchy rash orhives. M ore severe sym ptom sinclude itchy,occursin fi10% ofpatientstaking penicillin,usually nephritis,hem olyticanem ia,serum sickness*. These reactionscan be life-threatening and 12 9-11 after2-5 daysoftherapy,and m ay lastseveralw eeks. These reactionsusually occur>72hrsafterbeta- usually occur<1hraftertaking a beta-lactam dose. Ifthe skin testresultis IgE-m ediated,and so a cephalosporin ordifferent an alternative agent. Stevens-Johnson syndrom e,interstitialnephritis,hem olyticanem ia,serum sickness)are contraindicationsto anybeta-lactam; reactionslisted. G enerally,these occur fi Ifallergy islikely IgE-m ediated,skin test(ifpossible)using a cephalosporin w ith a differentside chain than the cephalosporin thatpreviously reacted. Ifno after7-10 daysoftherapyand relate to 12-15 reaction,give a graded challenge;ifreaction,orifskin testing notavailable,use an alternative agent(ordesensitization). Sym ptom s 2017 include urticarialvasculitis,renal -Skin testsin Saskatchew an are available via referral(currently <6 m onth w aiting list). Evidence suggeststhatcarbapenem shave a ~1% cross-reactivity w ith penicillins,and are appropriate in 16 desensitization are contraindicated. Com m on A dverse Events O verallN N H = 8-12 Yeastinfection N N H = 23 fi In a m eta-analysis(10 trials,2450 patients)com paring antibioticsto placebo foracute rhinosinusitis,com m on adverse events(such asnausea,vom iting, 2,5 diarrhea,orabdom inalpain)occurred in 27% ofpatientson antibioticsversus15% on placebo (N N H = 8-12). The antibioticsused in thism eta-analysis 3,4,5 included penicillins,m acrolides,and tetracyclines. A llergic Reactions N N H from 20 (rash,hives)to 10,000 (anaphylaxis) 7,8 Allergic reactionscan occurw ith any antibiotic;penicillin in particularisw ellstudied. About5-10% ofpatientsw illself-reporta penicillin allergy; how everthe 9 vastm ajority ofthese reactionsare delayed reactions,occurring daysto w eeksafterinitiating therapy,and do nottypically indicate a true allergy. Serious A dverse Events N N H from 300 to 30,000 Rare butseriousadverse eventsare associated w ith allantibiotics. Large,long-term random ized controlled trialsare uncom m on,and so itisdifficultto puta precise estim ate on how prevalentthese eventsare. Although thisisthoughtto be unlikely,there isa sm allbutrealrisk & a backup birth controlm ethod isalw aysrecom m ended. Every course ofantibiotic islikely to resultin som e em erging resistance w hich could affectthe next choice ofantibiotic regim en forthatindividual,especially ifw ithin 3 m onthsofthe previousantibiotic. Forexam ple,strainsofStreptococcuspneum oniae resistantto levofloxacin w ere docum ented in the sam e year 21 22 levofloxacin w asintroduced to the m arket. Rare,butw orrisom e,reportsofbacteria resistantto every available antim icrobialcan be found in the literature. Q uotes from the team fi:H arm sspeak louderw hen there islittle orno benefitto offsetthem! In concentration-dependentkilling,an antim icrobialism ore effective ata higherdose. Classificationsare notabsolute -forexam ple,agentsm ay be bacteriostaticin m ostsituationsbutbactericidalathigh concentrations,orbacteriostaticagainstsom e organism sand bactericidalagainstothers. Anaerobiccoverage can be im portantin situationssuch asaspiration pneum onia,intra-abdom inalinfections,and diabeticfootulcers. Antim icrobialsw ith good activity include m etronidazole,clindam ycin,am ox-clav,and m oxifloxacin. Asa result,they cannotbe view ed undera gram stain and are naturally resistantto allbeta-lactam s. Antim icrobialsw ith good activity include m acrolides,fluoroquinolones,and tetracyclines. Com m on beta-lactam ase producersinclude H aem ophilus influenzae,Neisseria gonorrhoeae,M oraxella catarrhalis,Escherichia coli,Proteus,Klebsiella,and Bacteroidesfragilis. H ow ever,today Staph aureusisreliably resistantto penicillin,am oxicillin,and am picillin through beta-lactam ase production.

Order mentax discount. How to manage fungal infection in private areas of men? - Dr. Nischal K.

References

• Strosberg J, El-Haddad G, Wolin E, et al. Phase 3 trial of 177Lu-dotatate for midgut neuroendocrine tumors. N Engl J Med 2017;376(2):125-135.
• Signorello LB, Mulvihill JJ, Green DM, et al. Congenital anomalies in the children of cancer survivors: a report from the childhood cancer survivor study. J Clin Oncol 2012;30(3):239-245.
• Harris LS, Cohn K, Galin MA: Alkali injury from fireworks. Ann Ophthalmol 3:849, 1971.
• Bhatt DL, Kapadia SR, Bajzer CT, et al. Dual antiplatelet therapy with clopidogrel and aspirin after carotid artery stenting. J Invasive Cardiol 2001;13(12):767-71.
• Hocevar B, Gray M: Intestinal diversion (colostomy or ileostomy) in patients with severe bowel dysfunction following spinal cord injury. J Wound Ostomy Continence Nurs 35:159, 2008.