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V. Enzo, M.B. B.A.O., M.B.B.Ch., Ph.D.

Vice Chair, University of Houston

The diffusion hypothesis is supported by the fact that since 1985, the growth in the homicide arrest rate of juveniles who are white has grown by 80 percent, and for nonwhite juveniles, it has grown by 120 percent. There are some interesting parallels here to the illicit drug markets: both peddle dangerous products, and we have been obsessed with one and have largely ignored the other. This challenge is clearly a Federal responsibility because so much trafficking in guns is interstate. This could include increasing the amount of resources and the effort put into treatment and prevention. For the longer run, we must face the widespread problem of socializing the growing number of young people who see no hope for their economic future, are willing to take whatever risks are necessary to gain respect and to earn an income, and represent ready recruits for any illicit markets that present themselves. Because carrying handguns is illegal almost everywhere, this usually requires stronger and more focused enforcement of existing legislation rather than any new legislation. An important Federal role here is one of technical assistance to localities who would like to pursue this strategy, but need help in doing so. For example, the recent National Institute of Justice project in Kansas City came out with some important results on approaches to capturing illegal guns. Even if we were to stop the flow of guns from the drug markets, we still have to worry about the guns that are already present in the streets. On a somewhat broader basis, we must find means for exercising tighter control over illicit gun markets, especially those that sell guns to youths in these suggestions encompass a considerable range of activity, from the immediate police-level activity of confiscating illegal guns in the street to the much broader societal problem of helping to socialize young people whose family-too often a single mother with inadequate education, insufficient employment skills, and little or no external support-lacks the competence or structure to do so effectively. Undoubtedly, each alternative will find strong opposition for reasons that will seem legitimate. Failing to meet these challenges, however, makes it seem that the epidemic of guns and homicide-which has been an important source of distress and fear to the Nation-is likely to continue. And, distress and fear have elicited responses that are likely to ignore the central problem and generally make matters worse for the Nation. Criminologists agree that deterrence works well for the average working Policy recommendations person with a family and a role in the community. But for people who are unsocialized, impulsive, s Early child-parent intervention. Both public and mindlessly destructive, deterrence is an inefand private early intervention (birth to age 5) fective tool. If deterrence is to work, people must programs should be implemented immediately be more deterrable. Of all the factors found should be long term, have low student-toto contribute to delinquency, the clearest and most teacher ratios, provide liberal subsidies for exhaustive evidence concerns the adequacy of working parents, and be competently monitored parenting. Poor parenting cannot childhood intervention programs that address be viewed as the sole cause of delinquency. The the needs of the child and the parent should be association between inadequate parenting and expanded and subsidized. The Head Start proother factors is, however, critical in predicting gram should be improved by adding parent future delinquency. These risk factors are parental training and home visits and by extending its criminality and drug abuse, prenatal deficiency, term beyond 1 year, especially in areas having a lack of education, poor supervision, and deficient disproportionate number of children at high risk discipline. The earlier a child commits s Pilot residential schools and foster parenting a youthful offense, the more likely it is that such for abused children. Criminologists beabuse or neglect is established, when there is a lieve that the problem of delinquency is essentially refusal to enter into an existing program of early a problem of socialization. When the family fails childhood intervention, and when parental in this essential function, the task of socialization rights have been terminated by court order, we must be taken up by the educational system. The must have placement alternatives readily at criminal justice system can only "pick up the hand to raise the affected children in a proper pieces" after delinquency has become a fact. Rather than engaging in politicized debate on the issue of "orphanages," we advocate establishing a number of pilot programs for residential schools that contain the following elements: sufficient funding to ensure an education equal to the residential education available to wealthier families, education that begins at the pre-K level, minority staffing and an emphasis on minority values, and provision for voluntary enrollment. After evaluating pilot prevention and treatment programs, a limited number of well-funded major interventions with sufficient provision for adequate research design and long-term evaluation should be implemented. The Department of Justice should coordinate with the Department of Education at the highest level to ensure that the concerns of the law enforcement community are reflected in school curriculums and that the concept of early childhood intervention is accepted as part of a nationwide basic educational policy. Since even the best prevention programs need considerable time to bear fruit, we have no choice but to immediately upgrade our law enforcement alternatives.

Effectiveness of non-pharmacological interventions for the prevention of bloodstream infections in infants admitted to a neonatal intensive care unit: a systematic review. Healthcare-associated bloodstream infections in a neonatal intensive care unit over a 20-year period (1992-2011): trends in incidence, pathogens, and mortality. A statewide quality improvement collaborative to reduce neonatal central line-associated blood stream infections. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Prevention of central line-associated bloodstream infections: brief update review. The project liaison will be the primary individual to prepare this written gap analysis, but the entire improvement project team should be engaged in performing the gap analysis. An assessment of the barriers that need to be addressed before successful implementation of best practices. The best practice elements defined in the Selected Best Practices and Suggestions for Improvement (Tool D. List the expected evidence-based best practice in the header row (shaded in light gray). Be specific and include information such as policies, protocols, guidelines, and staffing. In Column 3, identify barriers that may hinder successful implementation of each best practice strategy. In Column 4, indicate whether your organization will implement the best practice strategy. Set a timeframe and target dates for the completion of tasks/actions and communication/training. The project liaison will be the primary individual to complete this implementation plan, but the document should be used as a working document by the entire improvement project team. Upon completion of the implementation plan, the project team will have a customized project plan that will guide activities through established timeline to completion of implementation. This tool should be used with the other tools found in the Implementing Improvements section of the toolkit (section D). In the header row (shaded in light gray), list the best practice your organization will implement, as identified in the Gap Analysis (Tool D5). In Column 2, assign responsibility to team members for the completion of each detailed task/action. If so, replace the red text with target dates of communication/training in column 5. If target dates are not met, determine the cause and revise the implementation plan. Note: Brainstorming with team members can be helpful for generating the detailed task/action list. The purpose of the implementation measurement tool is to provide a format in which you can determine if best practice processes are successful in your organization. The tool provides general guidance on implementation measurement, as well as an example of an implementation measurement instrument that could be adapted for use at your hospital (using catheter-related bloodstream infections as an example). The tool is intended for use by the quality improvement team to assess adherence to implemented practices. The implementation measurement tool will help you develop an approach to determine whether the selected best practices have been implemented and if your team needs to change any practices. Without studying the process of change implementation, your team cannot determine why an implementation is successful or why it is not. This tool should be used with the other tools found in the Implementing Improvements section of the toolkit (section D).

Roller pumps require a reservoir between the venous drainage cannula and the pump and utilize gravity for drainage into the reservoir. They create high negative pressures in the circuit eliminating the need for drainage by gravity. It is very important to monitor the oxygenation of pre-oxygenator and post-oxygenator blood gas samples to assess the adequacy of the membrane function. Venous blood is drained from the right side of the heart, circulates through the device pump where gas exchange occurs and is reinfused into the aorta. An important consideration is the size of the venous cannula, which should enable a blood flow of at least 50-60 ml/kg/min in adults. Central cannulation allows better venous drainage and higher flows and is suitable for patients with higher metabolic requirements such as patients in septic shock. The adequacy of blood flow is assessed by monitoring mean arterial pressure, mixed venous oxygen saturation (SvO2), lactate 232 levels, and base excess. With poor left ventricular function, this may cause a complete failure of the left heart with increased left atrial and pulmonary venous pressures, and result in pulmonary edema or hemorrhage. Usually a SaO2 of 90% is achieved, as measured from an upper extremity arterial line. Recirculation occurs when the drainage and return cannulas are positioned within the same vessel. In current practice, extracorporeal life support is warranted in patients with severe respiratory failure with an expected mortality risk exceeding 70-80%. When the patient is considered ready for a weaning trial, the pump flow is gradually decreased, while ventilatory support is optimized and the circuit gas flow is then stopped. Potential sites of bleeding include the gastrointestinal tract, 234 surgical sites (eg: tracheostomy) or intracranially. They are extracorporeal, require the presence of valves, and valve malfunction is common long term. These patients usually have acute end organ injury secondary to the associated low flow state. Despite improvement in organ function after mechanical support is initiated, mortality of these patients is high, with only 30-40% surviviving to discharge. Hypovolemia creates a suction effect on the left ventricle, which is potentially detrimental. Fluid overload may aggravate right ventricular dysfunction and thus lead to insufficient flow to the left ventricle. Monitoring fluid status is challenging and requires consideration of the mean arterial pressure, pump flow, and right and left ventricular filling pressures. Noninvasive blood pressure monitoring, using the oscillation method, as well as pulse oximetry are inapplicable.

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• Microcephaly with chorioretinopathy, autosomal dominant form
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