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These behaviors make pelicans susceptible to plumage oiling if they feed in areas with surface oil or an oil sheen. They may also capture prey that has been physically contaminated with oil or has ingested oil. The Bald Eagle may also be at risk from direct and indirect impacts from spilled oil. It is expected that impacts to coastal birds from a large oil spill and/or cleanup activities resulting in the death of individual birds would be adverse but not significant at population levels. Superimposed on this low-productivity condition are productive "hot spots" associated with entrainment of nutrient-rich Mississippi River water and mesoscale oceanographic features. Anticyclonic and cyclonic hydrographic features play an important role in determining biogeographic patterns and controlling primary productivity in the northern Gulf of Mexico (Biggs and Ressler, 2000). Most fishes inhabiting shelf or oceanic waters of the Gulf of Mexico have planktonic eggs and larvae (Ditty, 1986; Ditty et al. Positive fish associations with offshore rigs and platforms in the Gulf of Mexico are well documented (Gallaway and Lewbel, 1982; Wilson et al. Drilling rig noise could potentially cause masking in fishes, thereby reducing their ability to hear biologically relevant sounds (Radford et al. However, no consistent behavioral thresholds for fish have been established (Hawkins and Popper, 2014). Noise may also influence fish behaviors, such as predator-avoidance, foraging, reproduction, and intraspecific interactions (Picciulin et al. Fish aggregating is likely to occur to some degree due to the presence of the drilling rig, but the impacts would be limited in geographic scope and no population level impacts are expected. Generally, it is believed that larval fish will have similar hearing sensitivities as adults, but may be more susceptible to barotrauma injuries associated with impulsive noise (Popper et al. Larval fish were experimentally exposed to simulated impulsive sounds by Bolle et al. Non-impulsive noise sources (such as drilling rig operations) are expected to be far less injurious than impulsive noise. Impacts of Effluent Discharges Muds and cuttings discharges may have a slight effect on the benthic environment near the wellsite, including a localized increase in water turbidity, the limited blanketing of seafloor sediments and slightly increased concentrations of hydrocarbons and metals (Neff et al. Contaminants released into the water column will be diluted rapidly within the open ocean environment. Treated sanitary and domestic wastes may have a slight effect on the pelagic environment in the immediate vicinity of these discharges. These wastes may have elevated levels of nutrients, organic matter, and chlorine, but should be diluted rapidly to undetectable levels within tens to hundreds of meters from the source. Deck drainage from contaminated areas will be passed through an oil-and-water separator prior to release, and discharges will be monitored for visible sheen. The discharges may have slightly elevated levels of hydrocarbons but should be diluted rapidly to undetectable levels within tens to hundreds of meters from the source. Impacts of Water Intake Seawater will be drawn from the ocean for once-through, non-contact cooling of machinery on the drilling rig. The low intake velocity should allow most strong-swimming juvenile fishes and smaller adults to escape entrainment or impingement (Electric Power Research Institute, 2000). However, drifting plankton would not be able to escape entrainment with the exception of a few fast-swimming larvae of certain taxonomic groups. The drilling rig chosen for this project is expected to be in compliance with all cooling water intake requirements. A small fuel spill in offshore waters would produce a slick on the water surface and increase the concentrations of petroleum hydrocarbons and their degradation products. A small fuel spill could have localized impacts on phytoplankton, zooplankton, and nekton. Due to the limited areal extent and short duration of water quality impacts, a small fuel spill would be unlikely to produce detectable impacts on pelagic communities and ichthyoplankton.

Many patients with type 2 diabetes eventually require and benefit from insulin therapy. Providers may wish to consider regimen flexibility when de vising a plan for the initiation and adjustment of insulin therapy in people with type 2 diabetes. The progressive nature of type 2 diabetes and its therapies should be regularly and objectively explained to patients. For patients with type 2 diabetes who are not achieving glycemic goals, providers should promptly initiate insulin therapy. Providers should avoid using insulin as a threat or describing it as a failure or punishment. Basal Insulin Basal insulin alone is the most convenient initial insulin regimen, beginning at 10 units or 0. Basal insulin is usually prescribed in conjunction with metformin and possibly one additional noninsulin agent. Concentrated preparation of basal insulin such as U-500 regular is five times as potent per volume of insulin. U-300 glargine and U-200 degludec are three and two times, respectively, as potent per volume, have a longer duration of action, and may allow higher doses of insulin administration in smaller volumes. These concentrated preparations may be more comfortable for the patient and allow better absorption. If basal insulin has been titrated to an acceptable fasting blood glucose level, but A1C remains above target, consider advancing to combination injectable therapy. A less studied alternative, transitioning from basal insulin to twice-daily premixed (or biphasic) insulin analogs (70/30 aspart mix, 75/25 or 50/50 lispro mix), could also be considered; pharmacodynamic profiles make them suboptimal to cover postprandial glucose excursions. Bolus Insulin current insulin dose and then providing one-half of this amount as basal and one-half as mealtime insulin, the latter split evenly between three meals. Inhaled Insulin Inhaled insulin is now available for prandial use with a more limited dosing range and may require serial lung function testing prior to and after starting therapy. Treatment Strategies Some individuals with type 2 diabetes may require bolus insulin dosing in addition to basal insulin. Rapid-acting analogs are preferred due to their prompt onset of action after dosing. Once an insulin regimen is initiated, dose titration is important, with adjustments made in both mealtime and basal insulins based on the prevailing blood glucose levels and an understanding of the pharmacodynamic profile of each formulation (pattern control). Its effects are discussed in Section 6 "Obesity Management for the Treatment of Type 2 Diabetes. Most youth with type 1 diabetes in the T1D Exchange clinic registry do not meet American Diabetes Association or International Society for Pediatric and Adolescent Diabetes clinical guidelines. Insulin pumps improve control and reduce complications in children with type 1 diabetes. Dietary fat acutely increases glucose concentrations and insulin requirements in patients with type 1 diabetes: implications for carbohydrate-based bolus dose calculation and intensive diabetes management. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. Outpatient insulin therapy in type 1 and type 2 diabetes mellitus: scientific review. An ultra-rapid acting insulin treatment to improve glycemic control in adult patients with diabetes mellitus [Internet], 2014. Metformin in patients with type 2 diabetes and kidney disease: a systematic review. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Controversies in the management of patients with type 2 diabetes [Internet], 2014. Safety, effectiveness, and cost of long-acting versus intermediate-acting insulin for type 1 diabetes: protocol for a systematic review and network meta-analysis. Glucagon-like peptide-1 receptor agonist and basal insulin combination treatment for the management of type 2 diabetes: a systematic review and meta-analysis.

Exposures- Family members or classmates with similar recent onset skin findings could indicate an infectious condition, such as scabies. Elicit a medication history as well, as drug reactions can cause a wide variety of rashes. Past medical history- A chronic, relapsing history of pruritic rash is more supportive of atopic dermatitis. Children with a history of asthma, allergies, or atopic dermatitis are three times as likely to develop a second component of the atopic triad; so patients presenting with one component should always be screened for symptoms of the other disorders. A history of P a g e 303 recurrent skin or sinopulmonary infections suggests a possible associated immune deficiency such as Wiscott-Aldrich or Job syndrome. Family history- Children with a first-degree family member (parents, siblings) with a history of asthma, allergies, or atopic dermatitis are more likely to develop atopic dermatitis. Flexor more often than extensor surfaces of the extremities and the atecubital fossae are classic locations for eczema in this age group. However in practice, flares can occur on any part of the body and can present with patches, papules, plaques, scale, dry skin, and lichenification. The differential diagnosis includes atopic dermatitis (ie eczema), contact dermatitis, seborrheic dermatitis, scabies, tinea, psoriasis, impetigo, drug eruptions, immune deficiency syndromes (Wiscott-Aldrich, Job syndrome), ichthyosis vulgaris, and zinc deficiency. Frequent follow-up to monitor response to therapy is important, given the similar presentations of many of these skin disorders. Moisturize and hydrate dry skin- Patients should apply a thick, dye-free, fragrance-free moisturizer such as an ointment or cream at least twice daily. Moisturizers should be applied after application of topical medications and after bathing. Patients should pat skin dry (rubbing can irritate the skin) after bathing in luke warm water to hydrate the skin and then immediately apply the moisturizer. Avoid irritants- In general, switching to fragrant-free bath products and detergents may help prevent flares, as well as avoiding dryer sheets and bubble baths. Patients should be attentive to their personal triggers, such as certain metals, fabrics, or dust, and limit their exposures to a reasonable extent. Decrease inflammation Topical steroids- Classic pharmacologic treatment for eczema flares involves a limited course of a topical steroid. Selection of a steroid should be based on the severity of the flare, generally using the lowest strength steroid that achieves remission. Generally, topical steroids should be used until the patient achieves reasonable control of symptoms and then either discontinued between flares or switched to a low-potency long-term treatment. Treatment decisions should involve a discussion of risks and benefits with parents and should include frequent follow-ups to evaluate for improvement. Education on the chronic, relapsing nature of P a g e 304 eczema and specific indications for when to use steroids is important for compliance with and effectiveness of management. Studies on the long-term safety of these agents are ongoing, but current data do not support an increased association with systemic immunosuppression or skin cancer. Treat secondary infections- Patients with atopic dermatitis have an increased risk of secondary infection. Consider bacterial, viral, and fungal culture of the skin in patients who do not respond to typical antibiotics for cellulitis. Local adverse effects of topical steroids include skin atrophy, striae, telangiectasias, hypopigmentation, rosacea, perioral dermatitis, acne, cataracts, and glaucoma. Lower potency preparations, shorter courses of therapy, and avoiding application to areas of thin skin (face, neck, groin) decrease the risk of adverse effects. Many parents are concerned about the systemic side effects of steroids, including hypothalamicpituitary-adrenal axis suppression, stunted growth, and decreased bone density. However, systemic complications with topical steroids are rare when used properly. Constant itching can impair sleep and affect school performance, as well as decrease quality of life for the patient and caregiver. Unfortunately, there are no good medications to treat the pruritis associated with atopic dermatitis. First-generation antihistamines are often used at night for their sedating side effects to help with sleep disturbance, but no rigorous trials have evaluated their effectiveness. Diagnosis: Atopic dermatitis Suggestions for Learning Activities: Identify a reliable patient education resource on atopic dermatitis for children and caregivers.

Furthermore, description of how to check the wash volume per slide may be provided in the user guides or can be requested from the supplier. Check that the wash buffer used is the buffer specified for the assay or has been validated for the assay by the laboratory Check that the wash buffer used for the slide has been within the expiry limits when used for the slide in question General: If a positive control has been run for the assay on the slide in question an evaluation of the effect of any deviations can be made based on the positive control. Based on this evaluation it can be determined if the slide can be used even though not processed inside the allowed limits. Special care shall be taken if the time has been reduced because the level of positivity in the samples is not known and can differ from the positive control and thereby potentially result in a false negative result. The information can be obtained either from the user guides for the automated platform or requested from the the supplier. It is important to check the level of the slide as a slide which is not in level during staining can lead to the area of interest not receiving the necessary reagents. Comments If problems with the automated platform is indentified it is recommended to check other samples processed in the same period on the same platform or platforms in order to identify potential relations. To confirm or discharge the automated platform as the reason to problems with the staining quality it is a good idea to search for related samples. It is important to take into account the potential evaporation of the reagent over time. Drying out of the tissue during the staining process can result in staining effects including no staining, inconsistent staining, extensive background and other staining artifacts Contamination: Contamination of the probe on the automated platform can lead to mixing of reagents in the probe and/or on the slide. The inclusion of negative tissue controls can help identify if a contamination has taken place. A contamination of the visualization system in the substratechromogen will not be identified by the negative control as it will be present both on the positive control and the negative control. Inspection of the visual parts of the instrument as well as keeping the maintenance schedule can prevent the contamination from happening. If growth is expected normal microbiological methods can be used to determine the presence of both bacteria and fungus. After identification the automated platform has to be cleaned according to specifications listed in the user guides or the supplier can be contacted for advice on how to clean. After the probe aspirates reagent it has to be washed before transferred to another reagent bottle. If this wash is not adequate then the second bottle can be contaminated with reagent from the previous bottle. Contamination of the tissue by the probe dropping a drop of unrelated reagent onto the slide. This will be recognized as a false positive reaction either being in the wrong structure or wrong location. Use of positive tissue controls including multiple organ types on each slide will make it possible to identify contamination of this origin. Waste separation: Automated platform separates hazardous from non-hazardous waste. Failure of this separation does not impact the staining process and thereby should not influence the staining result. Bulk fluid supply: the automated platforms normally have a function which makes it possible to check whether the supply of bulk fluids is working adequately. This check can be a prime of the bulk fluid trough the system securing that there are no leakages or clots preventing the fluid from flowing. Check of the bulk fluid supply is described in the user guides or can be requested from the supplier. General: If in doubt about the performance of the instrument, thorough observation of the automated platform during the staining process can give an indication of whether the individual steps is being executed as expected. Check that the instrument is closed correctly as the performance depends on the surrounding conditions for optimal staining. Improper closing can result in inability to start or create staining conditions which are sub-optimal do to the air getting into the instrument through the open cabinet. Suppression of endogenous avidin-binding activity in tissues and its relevance to biotin- avidin detection systems. Azure B as a counterstain in the immunohistological evaluation of heavily pigmented nevomelanocytic lesions.

East Africa includes Burundi, Comoros, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mauritius, Mozambique, Rwanda, Seychelles, Somalia, South Sudan, Sudan, Tanzania, Uganda, Zambia, and Zimbabwe. The group does not include Somalia, for which inadequate data are available for classification. It concludes that poverty reduction in Africa has not been overestimated and in fact may be slightly greater than traditional estimates suggest, although even the most optimistic estimates of poverty reduction imply that more than 330 million people were living in poverty in 2012. The chapter also presents a very broadstroke profile of poverty and trends in poverty in the region. In contrast to the dearth of good-quality and comparable surveys on household expenditures, there has been a surge in survey-based information on these and related nonmonetary dimensions of poverty. In addition to patterns of monetary inequality, it examines other dimensions, including inequality of opportunity and intergenerational mobility in occupation and education. Viewing inequality from beyond the realm of household surveys, this work also explores extreme wealth (billionaires and millionaires) in Africa. Independent Expert Advisory Group on a Data Revolution for Sustainable Development, New York. Global Monitoring Report 2015/2016: Development Goals in an Era of Demographic Change. The State of Data for Measuring Poverty 1 frica has grown robustly for two decades-performance that lies in stark contrast to the "growth tragedy" of the 1980s (Easterly and Levine 1997). The lack of good-quality and accessible data to assess socioeconomic changes now regularly features in discussions of the development agenda for Africa (Devarajan 2013; Jerven 2013). There is no doubt that Africa needs better data to monitor the evolution of both the monetary and nonmonetary dimensions of living conditions. To be sure, there have been improvements in data availability in Africa in recent years. The this chapter was written with Rose Mungai, Nga Thi Viet Nguyen, and Shinya Takamatsu. The frequency and coverage of data on citizen opinions on a wide range of topics, including governance, political leadership, democracy, and corruption, have increased, and data tracking salient events, such as conflict and weather events, are now widely available. For the remaining population, the poverty rate was imputed from surveys that were often several years old. For five countries (Equatorial Guinea, Eritrea, Somalia, South Sudan and Zimbabwe), which together represent 5 percent of the African population, no data were available with which to measure poverty. Equally if not even more important are concerns about the comparability and quality of the underlying household survey and price data. Guinea and Mali, for example, each fielded four surveys since the mid-1990s, but no two of these surveys is considered comparable for measuring poverty. Against this background and as a starting point in revisiting estimates of poverty in Africa, this chapter takes stock of the data available to measure the evolution of monetary poverty in the region. It focuses on household-level consumption and price data but also briefly reviews auxiliary data sources needed to estimate poverty. The cornerstone of poverty estimates in Africa (and most other developing regions) are consumption data from household surveys that are representative of the population. Estimating global or regional poverty levels requires setting a common poverty line, such as the international poverty line of $1. Population censuses are needed to derive population statistics from sample surveys and, when used jointly with a consumption survey, estimate poverty for small areas in a country. It reflects on the governance and political incentives that influence data production, in order to help understand why multiple challenges beset the data for poverty measurement, and discusses some approaches for addressing data shortfalls. Types of Data for Measuring Monetary Poverty Estimating poverty requires consumption or income data from household surveys, but other data are also needed.