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By: Bruce Alan Perler, M.B.A., M.D.

  • Vice Chair for Clinical Operations and Financial Affairs
  • Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0002711/bruce-perler

The retina has been reattached medicine 5000 increase quality 5mg aricept, and the foveal shape has almost been restored to treatment for uti cheap 5 mg aricept visa normal symptoms vitamin b deficiency cheap 5mg aricept free shipping. Image interpretation points As in this case symptoms uterine cancer generic aricept 5 mg visa, patients often see a doctor when the retinal reveal few changes in the detached retina. The detachment with the lack of folds in the detached retina on fundus photo often appears to stop here temporarily. A retinal detachment including the macula and folds of detached retina are visible. There are seen in the detached retina intraretinal separation in the Henle’s fiber layer of the outer plexiform layer and undulating outer nuclear layer (outer nuclear layer and photoreceptor inner and outer segments, which are findings characteristic to rhegmatogenous retinal detachment. The extent of the residual retinal detachment in the inferior posterior pole is smaller, and thus the detachment is resolving. Cystoid spaces can sometimes be seen this subsided by the fifth postoperative month. Despite the successful retinal detachment surgery, best-corrected visual acuity better than 0. Retinoschisis is significant in the retinal nerve fiber layer and in the Henle’s fiber layer of the outer plexiform layer and appears to be connected to the pit through hyporeflective vacuole or slit spaces in the optic disc rim and in the deep portion of the optic disc rim. The outline of the pit is clearly visible as a result of this tissue, and we can see that the lamina cribrosa is defective. Image interpretation points An optic disc pit is thought to be a congenital anomaly where a accompanied by retinoschisis in the inner and/or outer retinal round or elliptical pit forms in the temporal part of the optic layers. The lamina cribrosa is defective in the pit area, which is either from cerebrospinal fluid, retinal blood vessels, or the vitreous filled with abundant collagen. However, according to recent observational studies using side of the optic disc in this case. This retina and the optic disc rim connect and communicate with the is known as optic disc pit maculopathy. Such a breach, in the practice or home-care setting, can lead to medical, social, and nancial impacts on patients, clients, and staff, as well as damage the reputation of the hospital. Creating visible evidence that these protocols are consistently implemented within the hospital will invariably strengthen the loyalties of clients to the hospital as well as deepen the pride the staff have in their roles, both of which are the basis of successful veterinary practice. These guidelines and recommendations should not be inary Medicine, Ohio State University, Columbus, Ohio, and Department of construed as dictating an exclusive protocol, course of treatment, or Health Management, Atlantic Veterinary College, the University of Prince procedure. Variations in practice may be warranted based on the needs Edward Island, Charlottetown, Prince Edward Island, Canada (J. Further research is needed to document some College of Public Health, University of Iowa, Iowa City, Iowa (C. Because each case is different, veterinar Oradell Animal Hospital, Paramus, New Jersey (H. Stull was the chair of the Infection Control, Prevention, and Bio security Guidelines Task Force. To that end, the guidelines complications, or the consequences of an unattering online re present a progression of interventions from most to least critical. As such, these guidelines comple while minimizing the risk of exposing other patients, staff, ment the growing emphasis in human medicine on infection and clients. Taken together, these factors measure the added benets of infection control practices in vet created a strong motivation to assemble a task force of experts to erinary practices. These Their recommendations reect the latest scientic data, clinical guidelines provide a conceptual roadmap and specic, practical expertise, and best practices for infection control. Examples include · Help veterinary practice teams understand the importance of organismssuchasrabies,Microsporum, Leptospira spp. Fomites can include a wide variety of objects such · Provide practical information that can be adapted as client ed as exam tables, cages, kennels, medical equipment, environmental ucation materials. Disease examples include canine parvovirus Conversely, the purpose of the guidelines is not to focus on and feline calicivirus infections. However, most pathogens pertinent to companion ani and Biosecurity mal veterinary medicine do not survive in the environment for Routes of Transmission extended periods or do not travel great distances due to size and Infection control and prevention depends on disrupting the trans as a result require close proximity or contact for disease trans mission of pathogens from their source (the infected animal or mission. Examples of common aerosolized pathogens include human) to new hosts (animal or human) or locations. Environmental contamination is most contact, fomites, aerosol (airborne), oral (ingestion), and vector commonly due to exudates, feces, urine, or saliva. Some microorganisms can be transmitted by more than one diseases acquired via oral transmission include feline panleukopenia route. Direct Contact Transmission Direct contact transmission occurs through direct body contact Vector-Borne Transmission with the tissues or uids of an infected individual. Vector-borne transmission can be an important route of transmission in climates where these pests exist year round and may be brought into the practice by an infested pa tient. Examples of vector-borne diseases include heartworm disease, Bartonella infection, Lyme disease (borreliosis), and plague. Zoonotic Transmission It is important to remember many animal diseases are zoonotic and therefore pose a risk for the healthcare team as well as clients. Examples of zoonotic control methods used in determining effective infection control proce pathogens include Microsporum, Leptospira, Campylobacter,and dures to disrupt pathogen spread. Although less effective, lower tiers the hierarchy of controls concept, often used to address measures. While critical for effective infection control and should be used when elimination controls are the most effective at reducing hazards, they indicated. However, the process of instituting a pro clude gram need not be an “all or none” approach. Tools have been developed to assist with this specic training, in infection control. Regardless of the tool used, it is most critical to success are an interest in the topic, motivation important that all key areas of a program are examined to make improvements, and support. Existing resources are available in the human and the continuum of effective risk mitigation is included and veterinary elds that provide an engaged practice. Training should occur during orientation and at least serve as the main resource for guidance of many compo annually. To be effective, protocols to reduce patient, staff, and client infection-related hazards. Existing protocols developed as electronic resources to review should be provided and comple general guidance or for a specic practice are an excellent tion documented. Identify a staff member to collect client education materials materials that assist clients in understanding infectious and specic for use in your practice. Efforts should be made to zoonotic disease risks and the basic steps they can take to identify, catalog, and make readily available appropriate protect themselves, household members, and their animals. Place signage at the room entry that it should not be used until cleaning and disinfection is completed. Scrubbing surfaces is often necessary to remove feces or bodily uids, biolms, and stubborn organic debris, especially in animal housing areas. For all rinsing and product application procedures, care must be exercised to avoid overspray. Higher pressures can help remove stubborn organic debris but may also force debris and organisms into crevices or porous materials, from which they can later emerge. Additionally, high-pressure washing causes aerosolization and overspray, which may spread organisms widely, even into previously uncontaminated areas. If excess water remains, subsequently applied disinfectants may be diluted to the point of inefcacy. Rinse thoroughly with clean water; this is especially important for disinfectants that leave a residue or for surfaces vulnerable to damage from the disinfectant. Always follow the disinfectant label (Figure 2) for appropriate use, concentration, and contact time (see Figures 3, 4; Table 11 for choosing a disinfectant). Ensure appropriate contact time, rinse with clean water, and allow the treated area to dry, as stated above. Perform hand hygiene *If gloves are removed rst, hands must only touch uncontaminated surfaces of the gown, typically behind the neck (ties) and at the back of the shoulders. The gown is then peeled down off the body and arms, balling or rolling in the contaminated surfaces (front and sleeves). The preferred method for dofng a disposable gown and gloves is, therefore, to break the ties at the neck by pulling on the upper front portion of the gown with the hands still gloved, balling or rolling in the contaminated surfaces, and pulling the gloves off inside-out as the hands are withdrawn from the gown’s sleeves. Several sources provide client-appropriate materials on these weakness, and provides a warning to allow for an early re topics, such as Worms and Germs blog’s pet resources sponse to a concern, reducing patient and staff illness, ex (wormsandgermsblog.

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Tetrodotoxin treatment tinea versicolor order genuine aricept on-line, saxitoxin and their signifcance in the study of excitation phenomena medicine cabinets with lights discount 5mg aricept mastercard. The infectious agents that transmit prion diseases are resistant to medications 1 gram 10mg aricept fast delivery inactivation by heat and chemicals and thus require special biosafety precautions treatment xanax overdose purchase cheap aricept line. Prion diseases are transmissible by inoculation or ingestion of infected tissues or homogenates, and infectivity is present at high levels in brain or other central nervous system tissues, and at slightly lower levels in lymphoid tissues including spleen, lymph nodes, gut, bone marrow, and blood. Neither PrP specifc nucleic acids nor virus-like particles have been detected in purifed, infectious preparations. Occupational Infections No occupational infections have been recorded from working with prions. Natural Modes of Infection the recognized diseases caused by prions are listed under Table 7 (human diseases) and Table 8 (animal diseases). The only clear risk factor for disease transmission is the consumption of infected tissues such as human brain in the case of kuru, and meat including nervous tissue in the case of bovine spongiform encephalopathy and related diseases such as feline spongiform encephalopathy. After cross-species infection there is often a gradual adaptation of specifcity for the new host; however, infectivity for the original host may also be propagated for several passages over a time-span of years. The process of cross-species adaptation can also vary among individuals in the same species and the rate of adaptation and the fnal species specifcity is diffcult to predict with accuracy. Such considerations help to form the basis for the biosafety classifcation of different prions. However, when a prion from one species is inoculated into another the resultant infected animal should be treated according to the guidelines applying to the source of the inoculum. Although the exact mechanism of spread of scrapie among sheep and goats developing natural scrapie is unknown, there is considerable evidence that one of the primary sources is oral inoculation with placental membranes from infected ewes. There has been no evidence for transmission of scrapie to humans, even though the disease was recognized in sheep for over 200 years. However, the human prion diseases in this setting 284 Biosafety in Microbiological and Biomedical Laboratories are not communicable or contagious. Prions from many cases of inherited prion disease have been transmitted to apes, monkeys, and mice, especially those carrying human PrP transgenes. Special Issues Inactivation of Prions Prions are characterized by resistance to conventional inactivation procedures including irradiation, boiling, dry heat, and chemicals (formalin, betapropiolactone, alcohols). While prion infectivity in purifed samples is diminished by prolonged digestion with proteases, results from boiling in sodium dodecyl sulfate and urea are variable. Likewise, denaturing organic solvents such as phenol or chaotropic reagents such as guanidine isothiocyanate have also resulted in greatly reduced but not complete inactivation. The use of conventional autoclaves as the sole treatment has not resulted in complete inactivation of prions. Some investigators recommend that formalin-fxed tissues from suspected cases of prion disease be immersed for 30 min in 96% formic acid or phenol before histopathologic processing (Table 9), but such treatment may severely distort the microscopic neuropathology. The safest and most unambiguous method for ensuring that there is no risk of residual infectivity on contaminated instruments and other materials is to discard and destroy them by incineration. Contaminated disposable instruments or materials should be incinerated at 1000° C or greater. The highest concentrations of prions are in the central nervous system and its coverings. Based on animal studies, it is likely that prions are also found in spleen, thymus, lymph nodes, and intestine. The main precaution to be taken by laboratorians working with prion-infected or contaminated material is to avoid accidental puncture of the skin. When performing necropsies on large animals where there is an opportunity that the worker may be accidentally splashed or have contact with high-risk materials. Disposable plasticware, which can be discarded as a dry regulated medical waste, is highly recommended. Although there is no evidence to suggest that aerosol transmission occurs in the natural disease, it is prudent to avoid the generation of aerosols or droplets during the manipulation of tissues or fuids and during the necropsy of experimental animals. It is further strongly recommended that impervious gloves be worn for activities that provide the opportunity for skin contact with infectious tissues and fuids. Animal carcasses and other tissue waste can be disposed by incineration with a minimum secondary temperature of 1000°C (1832°F). Medical waste incinerators should comply with applicable state and federal regulations. Gloves, embedding molds, and all handling materials are disposed s regulated medical waste. Tissue cassettes are processed manually to prevent contamination of tissue processors. In preparing sections, gloves are worn, section waste is collected and disposed in a regu lated medical waste receptacle. Handling and processing of tissues from patients with suspected prion disease the special characteristics of work with prions require particular attention to the facilities, equipment, policies, and procedures involved. Rinse instruments with water, transfer to open pan and autoclave at 121C (gravity displacement) or 134C (porous load) for 1 hour. These strong corrosive solutions require careful disposal in accordance with local regulations. The use of containers with a rim and lid designed for condensation to collect and drip back into the pan is recommended. Immersion in sodium hypochlorite bleach can cause severe damage to some instruments. Transmissible spongiform encephalopathies in non-domestic animals: origin, transmission and risk factors. Rendering practices and inactivation of transmissible spongiform encephalopathy agents. Geneva (Switzerland): the Organization; [updated 2006 Sept 21; cited 2006 Sept 21]. New studies on the heat resistance of hamster-adapted scrapie agent: threshold survival after ashing at 600 degrees C suggests an inorganic template of replication. Inactivation of transmissible spongiform encephalopathy (prion) agents by Environ LpH. Brief descriptions of the facility and engineering concepts for the conduct of microbiological research are also provided. Rather, an overview is provided to clarify the expectations, functions and performance of these critical primary barriers. Proper maintenance of cabinets used for work at all biosafety levels cannot be over emphasized. This process is referred to as certifcation of the cabinet and should be performed annually. The needs to work with tissue cultures, maintain sterility of cell lines, and minimize cross-contamination have contributed to concerns regarding product integrity. For example, high-speed blenders designed to reduce aerosol generation, needle-locking syringes, micro burners and safety centrifuge cups or sealed rotors are among the engineered devices that protect laboratory workers from biological hazards. An important piece of safety equipment is the biological safety cabinet in which manipulations of infectious microorganisms are performed. Background Early prototype clean air cubicles were designed to protect the materials being manipulated from environmental or worker-generated contamination rather than to protect the worker from the risks associated with the manipulation of potentially hazardous materials. Therefore, these cubicles could not be used for handling infectious agents because the worker was in a contaminated air stream. To protect the worker during manipulations of infectious agents, a small workstation was needed that could be installed in existing laboratories with minimum modifcation to the room. The earliest designs for primary containment devices were essentially non-ventilated “boxes” built of wood and later of stainless steel, within which simple operations such as weighing materials could be accomplished. They were characterized by mass airfow into the cabinets albeit with widely varying air volumes across openings. However, since the air was unfltered, the cabinet was contaminated with environmental microorganisms and other undesirable particulate matter. Control of airborne particulate materials became possible with the development of flters, which effciently removed microscopic contaminants from the air. The flter medium is pleated to increase the overall surface area inside the flter frames and the pleats are often divided by corrugated aluminum separators (Figure 1).

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The development and validation of a structured diagnostic psychiatric inter Schneider medicine 257 order cheapest aricept and aricept, R symptoms vertigo buy discount aricept line. Improving publicly funded Journal of Substance Abuse Treatment substance abuse treatment: the value of 13(2):93–98 medications list a-z aricept 5mg with visa, 1996 medicine examples order aricept 10 mg without prescription. Substance sexual and physical abuse and sub dependent inpatients who accept smok stance use problems: A review. American Journal of Drug and Assessment of alcohol withdrawal: the Alcohol Abuse 24(4):589–601, 1998. Conjoint ment for drug abuse: A meta-analysis versus one-person family therapy: and review of the controlled, com Further evidence for the effectiveness parative studies. Clinical Child and Cultural Patterns: A Cross-Cultural Family Psychology Review 3(2):117–134, Perspective, Second Edition. Acamprosate and relapse prevention in Report to Congress on the Prevention and the treatment of alcohol dependence: A Treatment of Co-Occurring Substance placebo-controlled study. Journal of Studies on Services, Substance Abuse and Mental Alcohol 63:534–541, 2002. Government Office of Technology Journal of Contemporary Human Services Assessment. A partner’s Abuse and Mental Health Services drug-using status impacts women’s drug Administration, U. Patterns of drug use among Cuban Abuse and Mental Health Services American, African-American, and white Administration, 1999. Mental Health: Culture, Race, Archives of General Psychiatry 49:876– and Ethnicity—A Supplement to Mental 880, 1992. Group therapy for patients cocaine-dependent mothers: Evidence with bipolar disorder and substance of efficacy. Journal of Substance Abuse Behavioral Therapy Supplement: 7 Treatment 16:265–275, 1999. Relapse Mental Health Services Administration, Prevention Workbook for African 2002. A Child and Adolescent Psychiatry 37:252– comprehensive and comparative review 261, 1998. Journal of Addictive validity and predictive utility of the stages Diseases 16(2):41–56, 1997. Should Health Care for the Homeless Council, patients’ religiosity influence clinicians’ 2002. Substance use dis of Clinical Psychiatry 59(6):289–293, orders: Sex differences and psychiatric 1998. This appendix describes procedures for implementing this service and other methods for detecting clients’ substance use. Clients generally need more frequent monitoring during the initial stages of treatment when they are try ing to achieve abstinence but still may be using substances. Routine specimen collection after admission should take place in conjunction with regular clinic visits. Under ideal conditions, the consensus panel believes that collec tion should occur not less than once a week or more frequently than every 3 days in the first weeks of treatment. It is important that the scheduled frequency of urine collection match the usual detection window for the primary drug. Too long an interval between urine tests can lead to unreliable results because most of the target drug and its metabolites will have been excreted. On the other hand, if the interval between tests is too short, a single incidence of drug use may 237 be detected twice in separate urine samples. Information about how to beat the drug test Multiple positive urine test results produced ing system is widely available. Web sites by a single ingestion (carryover positives) can advertise inexpensive products that can be be discouraging for the client and mislead added to urine specimens to absorb toxins as ing for the clinician (Preston et al. Concentrated, “clean” specimens can they require less intensive monitoring of be purchased for mixing with warm water at abstinence. A variety of low-cost, self-testing reduce the frequency of scheduled tests and kits also are available to preview likely randomize the collection times. If employers, randomly selected sample representatives of the criminal justice sys tem, or children’s protection agencies feel that such reporting is necessary, they can be Collection Procedures advised to conduct their own testing or to and Policies accept other clinical evidence of client prog Urine sample collection procedures need to ress in treatment. Some programs insist that submitted so that the substance use can be a staff member of the same sex accompany a addressed therapeutically. It may be help client into the bathroom to observe urine col ful to remind clients that the clinic conducts lection. A sink cross-reactivity and false positive results that is separate from the toilet area also dis on screening tests, clients need to keep courages attempts to dilute samples (Bureau counselors informed about any prescribed of Justice Assistance 1999). Tests of creatinine Appropriate attention needs to be given to or specific gravity can determine whether a handling and storing collected specimens. Collected specimens need to be kept cool—or refrigerated—until transmitted • Chemical properties. Clients • Metabolism rates and excretion routes and staff members who touch the urine • Amount, administration route, frequency, collection bottles need to be reminded to and chronicity of the dose consumed wash their hands thoroughly. Rubber gloves • Sensitivity and specificity of the assay should be worn by technicians who perform • Individual variations in clients’ physical onsite analyses. Batteries and Testing However, the higher the dose taken and the more frequently the substance has been used Techniques over an extended time, the more likely that Programs need to test for a standard bat it will be detected. Although substances are tery of drugs, which may include such drug excreted at various rates, they accumulate in groups as amphetamines, barbiturates, the body with continued use. Realistically, should add substances to the routine battery, it may be difficult to detect illicit substances temporarily or permanently, if patterns of in most clients who stop all use for several substance use change in the target popula days before a drug screen. It is helpful to file of a client’s substance use over more stay up to date about local drug use pat than a few days requires both urine test terns identified by the nearest Community results and a good retrospective history. For example, oxycodone Selecting an Appropriate (OxyContin) has become a serious drug of Testing Technique abuse in particular locales. Fads come and A program should consider a variety of fac go for abuse of a wide variety of substances tors in selecting a method and source for. Turnaround time in receiving results Detection Limits for the is another important determinant. Whereas Substances Being Tested onsite methods can provide results in a mat the length of time during which different ter of minutes, more accurate and expensive licit and illicit substances or their metabo commercial laboratory analyses may take Urine Collection and Testing Procedures and Alternative Methods for Monitoring Drug Use 239 Exhibit B-1 Urine Toxicology Detection Periods for Different Substances Substance Typical Urine Detection Period Amphetamine or methamphetamine 2–4 days Barbiturates Short-acting—Secobarbital 1–2 days Long-acting—Pentobarbital 2–4 days Phenobarbital 10–20 days Benzodiazepines Therapeutic dose 3–7 days Chronic dosing Up to 30 days Cocaine 1–3 days Cannabinoids Casual use 1–3 days Daily use 5–10 days Chronic use Up to 30 days Ethanol (alcohol) 12–24 hours Opioids. Reliability is a major for clinical purposes do not require the same consideration. These provide more eligibility for sports competitions, or proba definitive information about the quantita tion or parole violations. Some cities and tive concentrations (nanograms/milliliter) States have assumed responsibility for select of specific drugs or their metabolites in ing a single vendor for providers under their urine specimens and are more accurate jurisdiction to use and choosing a standard than drug screens (have higher specific battery of drugs to be tested. They are much more wish to create a buying collective to negotiate expensive (up to $100 per assay), techni the best discounts from a local drug-testing cally complex, labor intensive, and time laboratory. If the results of a drug test will be used as Two categories of urine tests are available: a basis for actions taken against an indi vidual. These detect only the pre positive findings should be followed by a sumptive presence or absence of a class of confirmatory test of equal or greater sen drugs in the urine specimen, return results sitivity and better specificity (Bureau of rapidly, are relatively inexpensive ($1 to Justice Assistance 1999). Although results $5 per assay), can be set to detect low con from these quantitative tests can be more centrations of drugs (have high sensitivity), useful than a simple positive or negative and are relatively simple to perform. But for monitoring intermediate changes in these screening tests—the ones most fre drug consumption patterns, the concentra quently used by substance abuse treatment tion in urine might be the same for a small programs—do not distinguish specific drug amount of a drug administered recently as metabolites (only groups), provide only for a large amount of the drug consumed qualitative results (yes or no), and may several days ago. This potential for cross-reactivity is of more concern in detecting amphetamines, ben zodiazepines, and opioids than cocaine or the Meaning of Test Results marijuana. Despite a client’s use of the tar that causes the target drugs and metabo geted substance, results could be negative lites to move up a porous strip, leaving col because (1) most evidence may have been ored spots at different distances that can excreted or metabolized before testing took be compared with known standards. The place, (2) the specimen may have been results are reported as positive or nega diluted or switched, (3) the client may have tive, without any quantitative information, consumed an excessive amount of fluids and require skill to interpret. Alternative Testing Urine-Testing Methods Techniques Several other body products are gaining Most screening tests are immunoassays that prominence in the search for simpler, less take advantage of antigen-antibody inter expensive, noninvasive, and more accurate actions—using enzymes, radioisotopes, or techniques for detecting the recent and cur fluorescent compounds—and compare the rent use of substances. Exhibit B-2 compares specimen with a calibrated quantity of the the effectiveness of urine, breath, saliva, substance being tested (Bureau of Justice sweat, blood, and hair testing methodologies Assistance 1999).

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When a child is playing with an be provided to treatment vaginal yeast infection purchase generic aricept on line an electrical switch that controls the pump medicine hat lodge quality aricept 10mg. The adult supervisor needs immediate access to medications quizlet order aricept 5mg online because of the strong suction forces treatment with cold medical term 5mg aricept. Chapter 6: Play Areas/Playgrounds 280 Caring for Our Children: National Health and Safety Performance Standards 6. Caregivers/ teachers should be trained on the proper use of this equip Where applicable, swimming pools and built-in wading pool ment so that in emergencies, caregivers/teachers will use equipment and materials should meet the health effects and equipment appropriately. Children should be familiarized performance standards of the National Sanitation Founda with the use of the equipment based on their developmental tion or equivalent standards as determined by the local level. As a result, there are no uniform national Pool equipment and chemical storage rooms should be standards governing design, construction, operation, and locked, ventilated, and used only for pool equipment and maintenance of swimming pools and other treated recre pool chemicals. Access to these haz Family Child Care Home ards must be carefully controlled (1). Electrical equipment should be installed and inspected at and around the pool at intervals as required by the regula 6. Water should be sampled and a feet from the water and for receptacles within a twenty-foot bacteriological analysis conducted to determine absence of perimeter (1,2). Standard for water quality in public of body heat and cool enough to prevent overheating. Pool time infants should usually spend in the water and how to treatment 101: Introduction to chlorine sanitizing. If From 2003-2005, eleven children under the age of fve died pucks are used, they must be dissolved before children from drowning in buckets or containers that were being enter the pool. It is nearly impossible for top-heavy infants is a concentrated form of chlorine and is very caustic. Pool and spa submersion: Estimated injuries Family Child Care Home and reported fatalities, 2008 report. Use of fotation devices such as tub drownings are equally distributed in both sexes. Use of properly ftted and age-appropriate life 283 Chapter 6: Play Areas/Playground Caring for Our Children: National Health and Safety Performance Standards jackets according to the manufacturer’s instructions should Magnets generally are small enough to pass through the di be permitted with close supervision. All toys appropriate for gestive tract, however, they can attach to each other across water play should be removed from the pool after use so intestinal walls, causing obstructions and perforations within children are not tempted to reach for them. When children put toys in their mouths, they may be a child who could reach for it and fall into the water. American Academy of Pediatrics, Committee on Injury, Violence, be kept away from children at least up to three years of age. Policy statement: Prevention of Also, children occasionally have choked on toys or toy parts drowning. The following toys or objects should not tion Hazards Because of Small Parts” – which defnes the be accessible to children under three years of age: method for identifying toys and other articles intended a) Toys or objects with removable parts with a diameter for use by children under three years of age that present less than one and one-quarter inches and a length choking, aspiration, or ingestion hazards because of small between one inch and two and one-quarter inches; parts. To obtain this publication, contact the Superinten b) Balls and toys with spherical, ovoid (egg shaped), or dent of Documents of the U. Government Printing Offce elliptical parts that are smaller than one and three or access online at. Ob givers/teachers should be aware of items such as small jects should not be small enough to ft entirely into a child’s computer components, batteries in talking books, mobile mouth. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention. City doctor warns about aspiration, eye injuries, and other types of injuries (1). These children can fall across the crib gym balloons or infated latex objects that are treated as balloons and not be able to remove themselves from that position (1). Aspiration injuries occur from latex bal loons or other latex objects treated as balloons, such as Soft objects/toys can cause suffocation. The crib is not recommended as a place or gloves, these objects may break suddenly and blow an to entertain an infant or to “contain” an infant. Even though this is best practice for infants in any environ ment, the recommendation for prohibiting all crib gyms, Underinfated or uninfated balloons of all types could be mobiles, and all toys/objects in or attached to cribs may chewed or sucked and pieces potentially aspirated. The prevention of a potential brain injury Riding toys (such as tricycles) and wheeled equipment (such heavily outweighs a possible case of head lice. While it is as scooters) used in the child care setting should: best practice for each child to have his/her own helmet, a) Be spokeless; this may not be possible. If helmets need to be shared, it is b) Be capable of being steered; recommended to clean the helmet between users. Wiping c) Be of a size appropriate for the child; the lining with a damp cloth should remove any head lice, d) Have a low center of gravity; nits, or fungal spores. More vigorous washing of helmets, e) Be in good condition, work properly, and free of using detergents, cleaning chemicals, and sanitizers, is sharp edges or protrusions that may injure the not recommended because these chemicals may cause children; the physical structure of the impact-absorbing material to f) Be non-motorized (excluding wheelchairs). However, because of their high center of grav Effectiveness of bicycle safety helmets in preventing head injuries: ity and speed, they often cause injuries in young children. Children should remove their helmets ftted and approved helmets while riding toys with wheels when they are no longer using a riding toy or wheeled (tricycles, bicycles, etc. Helmets should be re hazard if they are worn for other activities (such as playing moved as soon as children stop riding the wheeled toys or on playground equipment, climbing trees, etc. The standards sticker should be located Motorized wheeled equipment (excluding wheelchairs) used on the bike helmet. Bike helmets should be replaced if they by children in a child care setting does not promote good have been involved in a crash, the helmet is cracked, when physical activity (2). Vehicles used by children in child care straps are broken, the helmet can no longer be worn prop need to be child propelled rather than battery propelled. Helmet use is as departments for scooter-related injuries were age eight or sociated with a reduction in the risk of any head injury by 69%, under (1). Infants are just learning to sit unsupported at permitting bicycling as an activity, the bike routes allowed about nine months of age. Until this age, infants have not should be reviewed and approved in writing by the local po developed suffcient bone mass and muscle tone to enable lice and taught to the children in the facility. Review and approval of bike routes be exacerbated by the added weight of a bicycle helmet on by the local police minimizes the potential danger (1). At least one adult who accompanies or drives children for the prevention of a potential brain injury heavily outweighs a feld trips and out-of-facility activities should receive training possible case of head lice. While it is best practice for each by a professional knowledgeable about child development child to have his/her own helmet, this may not be possible. The If helmets need to be shared, it is recommended to clean caregiver should hold a valid pediatric frst aid certifcate, the helmet between users. Wiping the lining with a damp including rescue breathing and management of blocked air cloth should remove any head lice, nits, or fungal spores. Any emergency medications that a child might ing chemicals, and sanitizers, is not recommended because require, such as self-injecting epinephrine for life-threatening these chemicals may cause the physical structure of the allergy, should also be available at all times as well as a mo impact-absorbing material to deteriorate inside the helmet bile phone to call for medical assistance. Tip #7: Play it accordance with state and federal child restraint laws safe: Walking and biking safely. Should you take your baby (such as asthma, diabetes, or seizures), the driver or along This standard plans, and should: also applies when caregivers/teachers are walking with 1) Recognize the signs of a medical emergency; children to and from a destination. This may include use of an attendance list of all reach of children; children being transported so it can be checked against 4) Know specifc medication administration (ex. Also, have another staff child who requires EpiPen or diazepam); member do a thorough and complete inspection of the 5) Know about water safety when feld trip is to a vehicle to see that the vehicle is empty before locking. Heat related deaths to young information (name, address, and telephone number) about children in parked cars: An analysis of 171 fatalities in the United the child care center. Guidelines for developing educational materials to address surroundings or routine changes. American Academy of Pediatrics, Committee on Injury, Violence, and Poison Prevention, and Council on School Health. Policy Children have died from heat stress from being left unat statement: School transportation safety. Temperatures in hot motor vehicles can reach dangerous levels within ffteen minutes. Children left unattended also can should be at least twenty-one years of age and should have: be victims of backovers (when an unseen child is run over a) A valid commercial driver’s license that authorizes the by being behind a vehicle that is backing up), power window driver to operate the vehicle being driven; strangulations, and other preventable injuries (1,2). Training by someone with appropriate knowledge and impaired ability to drive, within twelve hours prior to experience is needed to appropriately address these issues.

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