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L. Gembak, M.A., M.D., Ph.D.
Professor, University of Puerto Rico School of Medicine
The administration of fluids at a rate sufficient to maintain a urinary output of 1. When an adequate urinary output has been established and the pigment density decreases, the fluid rate can be titrated down. Administration of a diuretic or the osmotic effect of glycosuria precludes the subsequent use of hourly urinary output as a guide to fluid therapy; other indices of volume replacement adequacy must be relied upon. Blood Pressure In the first few hours post-burn, the patient should have a relatively normal blood pressure. Early hypovolemia and hypotension can be a manifestation of associated hemorrhage due to trauma. It is important recognize and treat hemorrhage in cases of combined burn/trauma injuries. Blood pressure cuff measurement can be misleading in the burned limb where progressive edema is present. Even intra-arterial monitoring of blood pressure may be unreliable in patients with massive burns because of peripheral vasoconstriction and hemoconcentration. In such instances, it is important to place more emphasis on markers of organ perfusion such as urine output. A rate of 110 to 120 beats per minute is common in adult patients who, on the basis of other physiologic indices of blood volume, appear to be adequately resuscitated. On the other hand, a persistent severe tachycardia (>140 beats per minute) is often a sign of under treated pain, agitation, severe hypovolemia or a combination of all. The levels of tachycardia in pediatric patients should be assessed on the basis of the irage-related normal heart rate. Hematocrit and Hemoglobin As fluid resuscitation is initiated, in the early post-burn period, it is very common to see some degree of hemoconcentration. In massive burns, hemoglobin and hematocrit levels may rise as high as 20 g/dL and 60% respectively during resuscitation. When these values do not correct, it suggests that the patient remains under-resuscitated. Whole blood or packed red cells should not be used for resuscitation unless the patient is anemic due to preexisting disease or blood loss from associated mechanical trauma at the time of injury. Serum Chemistries Baseline serum chemistries should be obtained in patients with serious burns. Subsequent measurements should be obtained as needed based on the clinical scenario. To ensure continuity of care and patient safety during transfer, the treatment of hyperkalemia and other electrolyte abnormalities should be coordinated with the burn center physicians. The Difficult Resuscitation Estimates of resuscitation fluid needs are precisely that - estimates. Individual patient response to resuscitation should be used as the guide to add or withhold fluid. The following groups are likely to be challenging and may require close burn center consultation: · Patients with associated traumatic injuries · Patients with electrical injury · Patients with inhalation injury · Patients in whom resuscitation is delayed · Patients with prior dehydration · Patients with alcohol and/or drug dependencies (chronic or acute) · Patients with very deep burns · Patients burned after methamphetamine fire or explosion · Patients with severe comorbidities (such as heart failure, or end-stage renal disease) In patients requiring excessive fluids, resuscitative adjuncts should be considered to prevent major complications such as pulmonary edema and compartment syndromes. Typical scenarios are: the provider is unable to achieve sufficient urine output at any point, or the patient develops oliguria when crystalloid infusion is reduced. Colloids in the form of albumin (and less commonly plasma) can be utilized as a rescue therapy. Synthetic colloids in the form of starches should be avoided due to their increased risk of harm. Close consultation with the nearest burn center is advised when initiation of colloid is being considered. The goal of resuscitation is to maintain tissue perfusion and organ function while avoiding the complications of inadequate or excessive therapy. Excessive volumes of resuscitation fluid can exaggerate edema formation, thereby compromising the local blood supply. In the event that the patient transfer must be delayed beyond the first 24-hours, close consultation with nearest burn center is recommended regarding ongoing fluid requirements. Effects of differences in percent total body surface area estimation on fluid resuscitation of transferred burn patients. A biopsy of the use of the Baxter formula to resuscitate burns or do we do it like Charlie did it?
India faces a challenge because inadequate primary education is widespread in the poorer regions and top-flight educational institutions cater to a relatively privileged few. These demographic reconfigurations will offer social and economic opportunities for some powers and severely challenge established arrangements in others. The populations of more than 50 countries will increase by more than a third (some by more than two-thirds) by 2025, placing additional stresses on vital natural resources, services, and infrastructure. Two-thirds of these countries are in Sub-Saharan Africa; most of the remaining fast-growing countries are in the Middle East and South Asia. Populations Growing, Declining, and Diversifying-at the Same Time World population is projected to grow by about 1. Although the global population increase is substantial-with concomitant effects on resources-the rate of growth will be slower than it was, down from levels that added 2. Demographers project that Asia and Africa will account for most of the population growth out to 2025 while less than 3 percent of the growth will occur in the "West"- Europe, Japan, the United States, Canada, Australia, and New Zealand. In 2025, roughly 16 percent of humanity will live in the West, down from the 18 percent in 2009 and 24 percent in 1980. The largest increase will occur in India, representing about one-fifth of all growth. Between now and 2025, Russia, Ukraine, Italy, almost all countries in Eastern Europe, and Japan are expected to see their populations decline by several percent. These declines could approach or exceed 10 percent of the current populations in Russia, Ukraine, and a few other Eastern European countries. By 2025, the already diverse array of national population age structures promises to be more varied than ever, and the gap between the youngest and oldest profiles will continue to widen. The "oldest" countries-those in which people under age 30 form less than one-third of the population-will mark a band across the northern edge of the world map. In contrast, the "youngest" countries, where the under-30 group represents 60 percent of the population or more, will nearly all be located in Sub-Saharan Africa. This number has never before been so high and, according to experts, in all likelihood will never be so high again. In almost every developed country, the period of most rapid growth in the ratio of seniors (age 65 and older) to the working-age population will occur during the 2010s and 2020s, boosting the fiscal burden of old-age benefit programs. By 2010, there will be about one senior for every four working-age people in the developed world. Japan is in a difficult position: its working-age population has been contracting since the mid-1990s and its overall population since 2005. Large and sustained increases in the fertility rate, even if they began now, would not reverse the aging trend for decades in Europe and Japan. If fertility rose immediately to the replacement level in Western Europe, the ratio of seniors to people in their working years would continue to rise steadily through the late 2030s. The annual level of net immigration would have to double or triple to keep working-age populations from shrinking in Western Europe. By 2025, non-European minority populations could reach significant proportions-15 percent or more-in nearly all Western European countries and will have a substantially younger age structure than the native population (see page 20). Given growing discontent with current levels of immigrants among native Europeans, such steep increases are likely to heighten tensions. The cost of trying to maintain pensions and health coverage will squeeze out expenditures on other priorities, such as defense. Persistent Youth Bulges Countries with youthful age structures and rapidly growing populations form a crescent stretching from the Andean region of Latin America across Sub-Saharan Africa, the Middle East and the Caucasus, and then through the northern parts of South Asia. By 2025, the number of countries in this "arc of instability" will have decreased by 35 to 40 percent owing to declining fertility and maturing populations. Three quarters of the three dozen "youth bulge countries" projected to linger beyond 2025 will be located in SubSaharan Africa. The emergence of new economic tigers by 2025 could occur where youth bulges mature into "worker bulges. Potential beneficiaries include Turkey, Lebanon, Iran, and the Maghreb states of North Africa (Morocco, Algeria and Tunisia), Colombia, Costa Rica, Chile, Vietnam, Indonesia, and Malaysia. The current youth bulges in the Maghreb states, Turkey, Lebanon, and Iran will diminish rapidly but those in the West Bank/Gaza, Iraq, Yemen, Saudi Arabia and adjacent Afghanistan and Pakistan will persist through 2025. Unless employment conditions change dramatically, youth in weak states will continue to go elsewhere-externalizing volatility and violence. In this scenario, 25 million to 30 million people would need anti-retroviral therapy to survive during 2025.
Both the routine practice of efficient energy use and the development of renewables will help take pressure off traditional fuels, which are most needed to enable developing countries to realize their growth potential worldwide. Energy is not so much a single product as a mix of products and services, a mix upon which the welfare of individuals, the sustainable development of nations, and the life-supporting capabilities of the global ecosystem depend. In the past, this mix has been allowed to flow together haphazardly, the proportions dictated by short-term pressures on and short-term goals of governments, institutions, and companies. Footnotes 1/ World Bank, World Development Report 1986 (New York: Oxford University Press, 1986). Kasperson, International Radwaste Policies (Stockholm: the Beijer Institute, in press). Industry is central to the economies of modern societies and an indispensable motor of growth. It is essential to developing countries, to widen their development base and meet growing needs. And though industrialized countries are said to be moving into a post industrial, information-based era, this shift must be powered by a continuing flow of wealth from industry. Many essential human needs can be met only through goods and services provided by industry. The production of food requires increasing amounts of agrochemicals and machinery. Beyond this, the products of industry form the material basis of contemporary standards of living. Thus all nations require and rightly aspire to efficient industrial bases to meet changing needs. Industry extracts materials from the natural resource base and inserts both products and pollution into the human environment. As recently as 1950, the world manufactured only one-seventh of the goods it does today, and produced only one-third of the minerals. Industrial production grew most rapidly between 1950 and 1973, with a 7 per cent annual growth in manufacturing and a 5 per cent growth in mining. Since then growth rates have slowed, to about 3 per cent yearly between 1973 and 1985 in manufacturing and virtually zero growth in mining. That earlier, rapid growth in production was reflected in the rising importance of manufacturing in the economies of virtually all countries. Manufacturing has declined in importance relative to other sectors of the economy. The relative importance of industry as an employer has been declining for some time in developed countries. But the shift in jobs towards the service sector has accelerated sharply over the past 15 years with the increasing adoption of new processes and technologies. Economists continue to argue over whether the advent of an information-based economy will further depress employment in industry or will expand job opportunities overall. Most developing countries started at independence with virtually no modern industry. Then during the 1960s and 1970s their industrial production, employment, and trade consistently grow faster than these sectors in developed market economies. The international trade in manufactured goods, which has consistently grown fatter than has world manufacturing output, is one of the factors underlying the changing geography of industrialization. Taking the Third World as a whole, exports of manufactured goods have grown steadily relative to primary exports, rising from 13. In general, developing-country industrial production is diversifying and moving into more capital intensive areas such as metal products, chemicals, machinery, and equipment. And heavy industries, traditionally the most polluting, have been growing in relation to light industries. At the same time, the share of industries involved in food products, and to a lesser extent in textiles and clothing, has fallen significantly. Industry and its products have an impact on the natural resource base of civilization through the entire cycle of raw materials exploration and extraction, transformation into products, energy consumption, waste generation, and the use and disposal of products by consumers. These impacts may be positive, enhancing the quality of a resource or extending its uses. Or they may be negative, as a result of process and product pollution and of depletion or degradation of resources.
The procedural safeguards also give parents and schools ways to solve problems and settle disagreements. If you have good reason to believe that your child is not receiving a free appropriate public education, you may want to make use of your rights, including your right to mediation, to file a state complaint, and to request a due process hearing. In Florida, this transfer of rights happens when the student turns 18, unless the student has been declared incompetent under state law or has a guardian advocate who has been appointed to make educational decisions. If you do not understand the notice, call the school or appropriate contact right away. If you do not agree with what the notice says, there are steps you can take: First, contact the person named in the notice. The school must ask you to participate whenever they hold a meeting related to the identification, evaluation, or placement of your child or to the provision of a free appropriate public education to your child. No matter who asked for the meeting, when you participate, you make it easier for the school to serve your child. Be sure to let the school know before the meeting if you need a translator or an interpreter. Read over your records and the parts of this book that are about the type of meeting you will be attending. Make notes about things you want to say or the questions you want to ask and take them to the meeting. You may also take someone with you to the meeting-such as a friend, relative, or other person who has knowledge of your child and can help you. It is helpful to let the school know when you are bringing someone with you to the meeting. The Right to Give, Not Give, or Withdraw Consent For some actions, the school only has to let you know what they have decided to do or not do (give you notice). You will be asked to sign a form that says you agree to what the school is planning. If the school staff refuses to make the change, they will let you know in writing. The school staff may try to help your child in another way, or they may suggest mediation or ask for a due process hearing. Most of the time you and the school staff will be able to work together and agree on what will be done for your child. Remember, for some actions, the school must give you a written notice but does not need your consent. Steps in Solving Problems From time to time, you and the school staff may disagree about what is fair or needed for your child. Some disagreements can be solved easily, while others may take more time and effort. The first step in solving a problem is to make sure that everyone understands the problem. Taking a complaint to someone who cannot make decisions is not a good use of time for you or your child. Dispute Resolution If you and the school district are still not able to agree about what is needed for your child, you may decide to ask for mediation, file a state complaint, or ask for a due process hearing. Mediation, formal complaints, and due process hearings all have the same purpose: to solve problems. They are designed to make sure that children with disabilities receive a free appropriate public education. More information about the dispute resolution methods below and the forms you need to complete if you want to use one of them can be found online at. During a mediation session, a trained and impartial mediator will help you and the school district resolve your disagreement about the identification, evaluation, placement, or free appropriate public education of your child. You may ask for mediation at any time-even at the same time that you file a complaint or ask for a due process hearing. The purpose of mediation is not for one side to win, but for both sides to come to an agreement.
All efforts should be made to resettle the entire family unit together, but this is not always possible due to the dispersal of family members. Some States have created separate quotas for such cases under humanitarian categories, and others do not limit the number of family reunification cases. Some States, however, consider family reunification cases only within their overall quota. The definition of eligible family members, the criteria for eligibility, and the procedures involved varies considerably among resettlement countries. States are encouraged to grant the same status to reuniting family members as resettled refugees. However, in some States a family member may be granted a residency status that provides less protection against deportation, possibly amounting to refoulement, than does refugee status. Particular challenges to family reunification arise from certain State policies and procedures as described below. While it may not always be possible to reunite entire groups which, in the country of origin, formed part of a family in the broad or traditional sense, States are encouraged to give positive consideration to the inclusion of dependent family members regardless of their age, level of education or marital status. Requirementsfordocumentaryevidence A related problem is that of proving the marital or civil status of family members for admission purposes. These circumstances may make it difficult or even impossible for a refugee to meet formal requirements or to bring the documentary evidence normally required before family reunification can be authorized. Limitedquotas the demand for family reunification in certain contexts may lead to long waiting periods for family reunification due to limited annual processing quotas and competing migration priorities. Specialmeasures Family reunification is often prevented or delayed by the operation of general domestic immigration regulations requiring that individuals sponsoring applicants be able to provide accommodation and support them. Refugees are often unable to fulfil such requirements especially if family members are experiencing economic, employment or housing problems in the country of resettlement. As it is known that prolonged separation creates serious social problems for both sides of split families, it is highly desirable that in such cases receiving States adapt their legal provisions in this respect or take special measures to assist refugees to accommodate their dependants, thereby facilitating early reunification. Statusofjoiningfamilymembers the status provided for refugees under the relevant international instruments and national legislation has as one of its principal aims to facilitate their integration in new national communities and to help them to cease being refugees as rapidly as possible. In order to promote the smooth and timely integration of refugee families in the country of settlement, it is necessary to grant joining family members the same legal status and facilities as those family members already present. This assistance may also be relevant to refugees accessing other humanitarian migration programmes, even if these are not specifically family reunification programmes. In such cases, the role of the Office is limited to informing refugees of the procedures to be followed and monitoring the process. Traveldocuments When it is not feasible for family members to use passports issued by their country of origin, some other form of travel documentation will be necessary. In States party to the 1951 Convention and/or its 1967 Protocol, a Convention Travel Document shall be granted to family members who also qualify for refugee status. Entryvisa Refugees residing in a country of settlement who wish to be reunited with other family members who are still in the country of origin or in third countries should be advised, in the first instance, to apply to the competent authorities for the necessary entry visas or immigration authorization for their family members. Since the objective is reunification of the refugee family, the Office should ensure that any visa issued allows indefinite stay. Exitvisa In many cases, family members are required to make a formal application for authorization to leave the country of origin or temporary refuge. Where this is feasible, family members in the country of origin should try to obtain these authorizations themselves provided they can do so without placing themselves or others at risk. Family members should be counselled in advance however, that interventions may be a very delicate matter and are not always successful. FamilyReunificationTravelAssistanceProject Unless travel is arranged within the framework of an ongoing resettlement operation, the financing of the travel of family members from abroad is in principle the responsibility of the refugee family. At least one of the family members has been determined as a refugee under the separation of the refugee family was involuntary and related to persecution or flight. The anticipated country of resettlement (destination country) will grant an entry visa and legal residence to the family members upon arrival. The family members are in need and therefore unable to meet the travel expenses themselves. Assessing the needs for family reunification travel assistance includes ascertaining family links and the financial needs of the refugees concerned; therefore supporting documents such as birth or marriage certificates are also requested.
Additional information: