Alex E. Proimos/Flickr Putting it into Practice: Pediatric

Alex E. Proimos/Flickr Putting it into Practice: Pediatric

Alex E. Proimos/Flickr Putting it into Practice: Pediatric Environmental Health Training Resource Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Reprinted with permission from the National Environmental

Education Foundation 2014 National Environmental Education Foundation Author This presentation was developed for the National Environmental Education Foundation by: James R. Roberts, MD, MPH Medical University of South Carolina Pediatric Asthma Most prevalent chronic medical condition in

childhood 7.1 million (9.6%) US children in 2009 Low income children more likely to have increased morbidity from asthma2 Low income children less likely to receive preventive care2 Akinbami LJ, Moorman JE, Liu X. Asthma Prevalence, Health Care Use, and Mortality: United States, 20052009. National Health Statistics Reports; no 32. Hyattsville, MD: National Center for Health Statistics. 2011. 2Akinbami LJ, Moorman JE, et al. Pediatrics 2009: 123; S131-S145 Variation in Asthma Severity by Race/Ethnicity African-American and Latino children worse

asthma status than comparable white children1 African-American children as compared to white children >2 times as likely to be hospitalized >3 times as likely to die from asthma Bloom B, Cohen RA, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(244). 2009. Akinbami LJ, Moorman JE, et al. Pediatrics 2009: 123; S131-S145. 2 Variation in Asthma Care by

Race/Ethnicity African-American children less likely to have made office visit for asthma (OR 0.77)1 African-American and Latino children less likely to use inhaled corticosteroids (OR 0.78 and 0.66 respectively)2 Kim H, et al. Prev Chronic Dis 2009;6(1):A12 2 Crocker et a. Chest 2009;136(4):1063-71. 1 National Survey on Environmental Management of Asthma Assessed publics knowledge of environmental

asthma triggers and their actions to manage environmental triggers. People from low income, low education households are more likely to have asthma. Less than 30% of people with asthma are taking all the essential actions recommended to reduce their exposure to indoor environmental asthma triggers. People with written asthma action plans are more likely to take actions to reduce exposure to environmental asthma triggers; however, only 30% of people with

asthma have written asthma action plans. Children with asthma are just as likely to be exposed to environmental tobacco smoke (ETS) in their home as children in general. US Environmental Protection Agency 2004 National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (2007) Guidelines Implementation Panel Report for Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (2008)

GIP Report: Six Priority Messages Use inhaled corticosteroids Use a written asthma action plan Assess asthma severity Assess and monitor asthma control Schedule periodic asthma visits

Control environmental exposures Message #1: Use Inhaled Corticosteroids Inhaled corticosteroids are the most effective medications for persistent asthma Well tolerated Small decrease in linear growth, but diminishes over time Superior to montelukast alone as preventive agent1,2 Rachelefsky G. Pediatrics 2009;123:353-66

2 Castro-Rodriguez JA, & Rodrigo GJ. Arch Dis Child 2009;95: 365-70. 1 Message #2: Use Written Asthma Action Plan All medications written in one place

Based on peak flow monitoring Find out predicted based on height Green Zone: 80% of predicted or more Yellow Zone: 50-80% of predicted Red Zone: 50% of predicted or less Asthma Action Plan Message #3: Assess Asthma Severity Classify all patients asthma based on measures of current impairment and future risk

Impairment: Think Rule of 2s Intermittent -- < 2 days/week of symptoms and less than 2 days/week of bronchodilators Persistent if at least 2 days/ week of symptoms and bronchodilator use Persistent asthma also includes activity limitations Risk: # exacerbations requiring oral steroids 0-1/year = Intermittent asthma 2/year = Persistent asthma Message #4: Assess and Monitor Asthma Control Well Controlled (regardless of classification)

2 days/week of symptoms 1 nighttime awakening/month 2 days/week of bronchodilator Not well controlled > 2 days/week symptoms 2 nighttime awakenings/month > 2 days/ week of albuterol Very Poorly Controlled Daily symptoms and multiple doses of albuterol/day *No limit in activity indicates good control

Message #5: Schedule Follow-up Visits Schedule planned follow-up visits at periodic intervals to assess asthma control and modify treatment if needed 1-6 months depending on control 3 month interval if step down in therapy is anticipated Consider a patient reminder system for these visits Message #6: Control Environmental Exposures

Review the environmental history of exposures Develop a multi-pronged strategy to reduce exposure to those triggers to which a patient is sensitive Remainder of presentation focuses on evidence of exposure mediation and recommendations for your patient Indoor Exposures and Exacerbation of Asthma Sufficient evidence of Causal Relationship Cat Cockroach

ETS House dust (preschooler) mite Sufficient evidence of an Association Dog Molds Rhinovirus NO2 & NOx

Limited evidence of Association Formaldehyde Fragrances RSV ETS (school-aged and older children) Clearing the Air. Committee on the Assessment of Asthma and Indoor Air; Division of Health Promotion and Disease Prevention; Institute of Medicine, 2000. What is the Evidence of Environmental Trigger Control? Dust Mite Control Randomized Controlled Trial (RCT) Group 1-- polyurethane casings for bedding, tannic acid on the carpets Group 2-- Benzyl benzoate on mattresses and

carpets at time 0, and 4 & 8 months Group 3-- Placebo foam on the mattresses and carpets at time 0, and 4 & 8 months Decreased mite allergen on Group 1 mattresses Children of Group 1 with reduced airway reactivity Enhert B, et al. Allergy Clin Immunology 1992;90:135-8 Dust Mite Control Improvements from dust mite encasements1 Reduced dust mite allergen Improved bronchial hyper-responsiveness

Improved allergen level, but No improvement in symptoms, medication needs or bronchial hyper-responsiveness2 Mattress encasement + immunotherapy Encasements alone reduced dust mite concentration Immunotherapy with additional symptomatic improvement Van der Heide S Allergy 1997:52:9121-7 Frederick JM Eur Respir J 1997;10:361-66. Paul K Eur J Pediatrics 1998;157:109-113. Dust Mite Control Danish study in children (n= 60)

Allergen impermeable mattress covers Significant reduction in dust mite allergen for intervention group Significant decrease in effective dose of inhaled steroid by 9 months and by 12 months was half the dose of control group No effect on bronchial hyper-responsiveness Is comprehensive trigger control a better idea? Halken S, et al. J Allergy Clin Immunol 2003;111:169-176 Cats Stick with You Classrooms with many (>25% of class) cat owners had more cat allergen than other

classrooms Allergen levels in non-cat owners clothes increased after one day in that classroom Exposure through school can exacerbate asthma in sensitized children even if they dont own a cat Almqvist C. J Allergy Clin Immunol 1999;103:1002-4 Almqvist C et al. Am J Respir Crit Care Med 2001;163:694-8 Control of Cat Ag RCT with 35 cat-allergic (and owner) subjects High-efficiency particulate arresting (HEPA) air cleaner Mattress and pillow covers

Cat exclusion from bedroom Reduced airborne cat allergen levels No effect on disease activity In cat allergic individuals with asthma, intranasal steroids were effective Wood RA Am J Respir Crit Care Med 1998;158:115-20 Wood RA, Eggleston PA. Am J Respir Crit Care Med 1995;15:315-20 Control of Cat/Dog Ag RCT 36 subjects sensitized and exposed to cat and/or dog allergen; 30 completed study Intervention was HEPA air cleaner only Control used a sham air cleaner filter

Higher concentrations of cat/dog Ag were filtered in the HEPA cleaner than sham filter No change in bulk dust Ag from home samples Decrease in nocturnal symptoms Trend towards improvement in bronchial hyperresponsiveness, but not significant Sulser C, et al. Int Arch Allergy Immunol. 2009;148:23-30 Mouse Ag Inner city population in Boston 42% had mouse allergen in home1 Associated with black race, reported visible evidence of mice exposure, cockroach allergen

Potentially greater mouse exposure in school Matched classroom and home samples in 23 asthmatic children2 46 rooms in 4 urban, Northeastern schools Mouse Ag levels significantly higher in school samples v. bedroom samples (6.45 mcg/g v. 0.44 mcg/g) Phipatanakul W, et al. Allergy 2005;60:697-701 2 Sheehan WJ, et al. Ann Aller Asthma Immunol 2009; 102:125-30. 1 Mouse Ag 18 homes of children with persistent

asthma and positive mouse allergen Integrated pest management Filled holes Vacuum and cleaning Low-toxicity pesticides and traps Mouse allergen levels significantly reduced during 5 month period Phipatanakul W et al. Ann Allergy Asthma Immunol 2004;92:420-5 Cockroach Ag Control Home extermination 2 applications Abamectin, Avert

Directed education on cockroach allergen removal 50% of families followed cleaning instructions, no greater effect was found in these homes At 12 months, allergen had returned to or exceeded baseline levels Gergen PJ et al. J allergy Clin Immunol 1999;103:501-6 Cockroach Ag Control Occupant education, professional cleaning Insecticide bait Substantial reductions in cockroach allergy levels achieved1 Second Study Professional cleaning

Bait traps with insecticide Bait traps without insecticide Significant reduction in cockroach allergen 2 Arbes SJ et al. J Allergy Clin Immunol 2003;112:339-45 2 McConnell R et al. Ann Allergy Asthma Immunol 2003;91:546-52 1 Integrated Pest Management Pest control strategy that involves least toxic methods first Strategies vary, but often may include:

Mousetraps Sealing cracks/ small holes Resident education Plastic food storage containers Generalized cleaning Strategic placement of pest control treatments, often in the form of bait traps or gels Integrated Pest Management

New York City Public Housing (NYCPH) Randomized 13 buildings to either IPM or Control groups Trained public housing resident to become IPM technician for their building IPM as described above No scheduled visits, but solid or gel baits applied if needed Control group received standard NYCPH pest control on a scheduled basis Baseboard spraying with pyrethroid insecticide IPM group had significantly lower cockroach counts Noticed by 3 months, sustained through 6 months IPM group with lower cockroach allergen levels Kitchen by 3 months,

Beds by 6 months Kass D, et al. Environ Health Persp 2009;117:1219-25. Mold Control RCT 62 patients Pre-remediation period-- ~120 days Before randomization, all received information on improving indoor air quality, home fungal sampling, and spirometry Both groups had decrease in number of asthma symptomatic days Post remediation (Remediation Group) Remediation group had significant decrease in mold levels, persisting through 12 months (p = 0.009)

Decrease in symptom days for remediation (p = 0.003) No further change in symptom days in control group Remediation group with lower rate of exacerbations compared to control group 1 of 29 v. 11 of 33; p = 0.003 Kercmar CM, et al. Env Health Persp 2006;114:1574-80 The Community Guide: Asthma Control Centers for Disease Control & Prevention Systematic review of available studies Findings: Strong evidence of effectiveness in

reducing symptom days, improving quality of life or symptom scores, and in reducing the number of school days missed Recommendations: Use of home-based, multitrigger, multicomponent interventions with an environmental focus for children and adolescents with asthma CDC Task Force Findings and Rationale Statement Interventions for Children and Adolescents with Asthma Last updated: 6/15/2010 Combined Asthma Trigger

Management Patients can be sensitive and exposed to numerous triggers RCT-- 100 subjects Treatment group received Home-based education Roach and Rodent extermination Mattress and pillow encasings HEPA cleaner

Control group did get treatment at end of 12 month period Eggleston PA, et al. Annal Allergy Asthma Immunol 2005;95:518-24 Combined Asthma Trigger Management 84% received cockroach extermination 75% used the HEPA cleaner 39% decline in PM10 levels in treatment group Increase in the control group (p < 0.001) 52% decrease in cockroach allergens in treatment group

Decrease in daytime symptoms in treatment group Increased in control group (p = 0.04) Eggleston PA, et al. Annal Allergy Asthma Immunol 2005;95:518-24 Inner City Asthma Study Evaluates multiple trigger management 937 urban children with asthma 1 year of intervention, 1 additional year of follow up Evaluation --questionnaire and skin testing Home sampling --dust, cockroach, cat and dog allergen Interventions aimed at patient-specific triggers

Allergen impermeable mattress and pillow covers HEPA air filters and vacuum cleaners Professional pest control Szefler SJ et al. J Allergy Clin Immun 2010;125:521-6 Morgan WJ, et al. New Engl J Med 2004;351:1068-80 Inner City Asthma Study Results and Cost Effectiveness Fewer days with symptoms1 Greater decline in level of allergens at home2 Persisted through 2nd follow up year Dust and cockroach Ag correlated with fewer complications of asthma

Cost Effectiveness analysis3 38 more symptom free days Under $30 per symptom free day Morgan WJ, et al. New Engl J Med 2004;351:1068-80 3 Kattan M, et al. J allergy Clin Immunol 2005;116:1058-63 1,2 Southern California Childrens Health Study Traffic-related air pollution and childhood asthma Cohort study (n=2,497) examined the effects of traffic-related pollutants near childrens schools and homes

Asthma and wheeze were strongly associated with residential proximity to a major road Greatest risk among children living within 300 m of major roads or freeways and risk increased significantly within 75 m Incident asthma was positively associated with traffic pollution among children at school and home, with a hazard ratio of 1.61, McConnell R, et al. (2006) Traffic, Susceptibility, and Childhood Asthma. Environ Health Perspect 114(5) Jerrett M, et al. (2008) Traffic-Related Air Pollution and Asthma Onset in Children: A Prospective Cohort Study with Individual Exposure Measurement. Environ Health Perspect 116(10) McConnell R, et al. (2010) Childhood Incident Asthma and Traffic-Related Air Pollution at Home and School. Environ Health Perspect 118(7)

Evidence for Outdoor Air Triggers Reducing Traffic:1996 Atlanta Olympics The Intervention: Around-the-clock public transportation 1,000 buses added Downtown city streets closed to private cars Downtown delivery schedules altered Flexible and telecommuting work schedules encouraged Friedman, M. S. et al. JAMA 2001;285:897-905. Reducing Traffic Reduces Asthma

1996 Atlanta Olympics The Result: Weekday morning traffic counts dropped 22.5% Peak daily ozone concentrations decreased 27.9% Friedman, M. S. et al. JAMA 2001;285:897-905. Mean Levels of Major Pollutants Before, During, and After the 1996 Summer Olympic Games as a Percentage of the National Ambient Air Quality Standard (NAAQS) Friedman, M. S. et al. JAMA 2001;285:897-905.

Acute Asthma Events During 1996 Olympics - Atlanta % change in mean # of Asthma claims per day % change in mean # of Non-Asthma claims per day Medicaid Hosp and ED Visits - 41.6%

- 3.1% HMO ED, Urgent Visit, Hosp - 44.1% + 1.3% Type of claim Friedman, M. S. et al. JAMA 2001;285:897-905.

2002 Summer Asian Games Busan, Korea Data from Atlanta are reproducible! Transportation controls similar to those in Atlanta Reduction in hazardous air pollutant levels of up to 25% Relative risk of asthma hospitalization 27% decrease from baseline during reduced pollution period Lee et al. J Air Waste Manag Assoc. 2007 Aug;57(8):968-73.

Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Founded upon NHLBI Guidelines Intended to complement its clinical and pharmacological components Developed for primary care providers Pediatricians, family physicians, internists Nurse practitioners, physician assistants Authored by expert steering committee and peer reviewed Built on scientific literature and best current practices

Overview of Asthma Guidelines Developed for children 0-18 years, already diagnosed with asthma Applies to all settings where children spend time Homes, schools, and daycare centers Cars, school buses Camps, relatives/friends homes, other recreational or housing settings Occupational environments Overview of Asthma Guidelines Endorsed by: Academic Pediatric Association American Association of Colleges of Nursing

Association of Faculties of Pediatric Nurse Practitioners Supported by: American Academy of Pediatrics National Association of Pediatric Nurse Practitioners Components of Asthma Guidelines

Educational competencies Environmental history form Environmental intervention guidelines Sample Patient Flyers and References Supplemented by online list of resources with web-links Available in English and Spanish online, in hard copy, and on CD-ROM Environmental History Form

Quick intake form Administered by health care provider Available online as PDF and Word document Can be pasted or re-copied into electronic medical record template Questions are in yes/no format Follow up yes answer with in-depth questions on Intervention Guidelines fact sheets (p. 17)

Environmental History Form Parent or child will likely answer questions about exposure with own home in mind Remember to consider other places the child spends time: school, daycare, car, work Designed to capture major trigger areas Once identified as a problem, (i.e. dust mites) the intervention sheet provides additional questions Intervention Guidelines Two-visit concept

Short introduction Additional in-depth questions Explore exposure sources Parents current practices Intervention recommendations Sample patient handouts to download Additional resources on initiatives website Allergy Referral? In vitro testing for allergens can be considered, but false positives occur

Should focus on allergens identified in history ImmunoCAP vast improvement over earlier blood allergy testing (RAST) Considered complementary to skin testing due to variability of performance Should not replace timely allergy referral Allergy Referral? (continued) Low cost environmental interventions are reasonable, especially where wide spread exposure occurs (i.e. dust mites in SE) Costly interventions should be done after you have referred for skin testing

Get Rid of the Dust Mites Dust Mites Simple, but Effective Interventions Encase all pillows and mattresses of the beds the child sleeps on with allergen impermeable encasings Wash bedding weekly to remove allergen Wash in HOT water (130F) to kill mites Results generally seen in 1 month Avoid ozone generators and some ionic air cleaners that produce ozone (p. 20)

Dust Mites Other Interventions For non-encased bedding (e.g. blankets and quilts) choose items that can withstand frequent hot water washing Remove or wash and dry stuffed toys weekly Vacuum with a HEPA vacuum cleaner Avoid humidifiers Dust Mites Possible Interventions Replace draperies with blinds

Remove carpet from childs bedroom Remove upholstered furniture These are higher cost and it is recommended that the child have skin test proven allergy to dust mites prior to implementation Animal Allergens Additional Questions What type of pet and how many of each? Indoor v. Outdoor pet? Child sleep with pet? Was asthma improved when pet outside? Furry pet in childs classroom?

(p. 21) Animal Allergens Effective Interventions Find a new home for indoor pets Keep pet outside If these arent possible Similar interventions as with dust mites Encasings, HEPA air cleaner, HEPA Vacuum, Keep pet out of bedroom Takes 24-30 weeks before allergen levels reach those of non-cat households1

Wood RA et al. J Allergy Clin Immunol 1989;83:730-4 1 Animal Allergens Unlikely Interventions Bathing cats MAY be effective at reducing allergen (n = 8 cats) The reduction was not maintained by 1 week1 Therefore it had been recommended to bathe the cat twice a week However, a more recent study of 12 cats suggests the decrease in

dander after bathing lasts about 1 day2 Avner DB et al. J Allergy Clin Immunol 1997;100:307-12 2 Ownby D et al. J Allergy Clin Immunol 2006:118:521-2 1 Cockroach Allergen Dos and Donts of Roach Control Integrated pest management (IPM) Least toxic methods first Clean up food/spills

Food and trash storage in closed containers Fix water leaks Clean counter tops daily Boric acid Bait stations/ gels Dont!!

Spray liquids in house, especially play and sleep space Use industrial strength pesticide sprays that require dilution (p. 22) Mold and Mildew Interventions Ways to control moisture and/or decrease humidity to < 50%

Dehumidifier or central air conditioner Do not use a humidifier Vent bathrooms/clothes dryers to outside Use exhaust fan in bathroom/ other damp areas Check faucets and pipes for leaks and repair Complete mold abatement may be required using a licensed contractor (p. 23)

Mold and Mildew Cleaning up the Mess Discard items too moldy to clean Professional cleaning recommended for areas larger than 3 x 3 ft. Clean small areas with detergent and water Dilute (1:10 with water) chlorine bleach solution provides cosmetic improvement and kills mold but does not remove allergens and the user should be aware of risks Dont mix bleach and ammonia! Be aware of respiratory irritant effect of bleach (asthmatics) Identify and stop sources of water intrusion

Environmental Tobacco Smoke Possible Interventions Keep home and car smoke free Encourage support to quit smoking Recommend aids such as nicotine gum/patch Medication from physician to assist in quitting Choose smoke free social settings At the very least, do not smoke around your child or in the car! (This should not keep us from encouraging parents to quit) (p. 24)

Air Pollution Possible Indoor Air Interventions Eliminate tobacco smoke Install exhaust fan close to source of contaminants Ventilate room if fuel burning appliance used Avoid use of products emitting irritants See control of dust mites and animal allergens (p. 25) Air Pollution Possible Outdoor Air Interventions

Monitor air quality index levels Ozone, Particulate Matter, NOx, SO2 Reduce childs outdoor activities if unhealthy Orange AQI of 101-150 (unhealthy for sensitive groups) Red AQI of 151-199 (unhealthy for all) Contact health care provider if more albuterol is needed the day after AQI level is high (p. 26)

NEEFs Pediatric Asthma Faculty Champions 10 pediatricians at academic institutions, one in each region of the US Integrate environmental management of pediatric asthma into health care using NEEFs Asthma Guidelines Train other faculty, residents, students, and health care professionals Incorporate into curriculum and EMRs Objective

Determine the impact of a standardized and structured lecture, that is focused specifically on environmental trigger identification and control, on physician knowledge and intentions in clinical practice. Evaluation 4 academic pediatricians in various regions of the US New York, Charleston SC, Houston, and Seattle 1 hour structured and standardized presentation Based on scientific evidence for environmental trigger management

Met via bimonthly conference calls to discuss content and delivery to ensure consistency Audience included pediatric faculty, residents, pediatricians in practice Evaluation Pre and post survey obtained Immediately before, and after presentation The following categories of questions were included in a likert scale format Knowledge of environmental triggers Experience with environmental history taking Advice to patients about environmental trigger

reduction Results Analyzed survey data over the first four years of the project Results - Pediatricians knowledge and their management of environmental asthma triggers improved significantly after training - Trained pediatricians are willing to integrate environmental management into asthma care. Improving Pediatrician Knowledge About Environmental Triggers of Asthma--Roberts JR, Karr C, de Ybarrondo L, McCurdy LE, Freeland KD, Hulsey

TC, Forman J. Clinical Pediatrics 2013 June; 52(6):523-30 Who takes the Advice? Seen by Allergists v. Pediatricians Patients seen by an allergist had greater knowledge of environmental allergens Dust mite knowledge (71% v. 18%) Need for mattress encasements (61% v. 13%) Need for pillow encasements (51% v. 11%) Increased knowledge, but not statistically significant More knowledge about carpet removal (23% v. 11%) Stuffed animal removal (10% v. 2%) Made some changes in their home

Use of mattresses encasements (38% v. 11%)-- 0.001 Use of pillow encasements (36% v. 16%) 0.009 Carpet removal (26% v. 36%)-- NS Callahan KA, et al. Annals Aller Asthma Immunol 2003;90:302-7. Summary Written asthma action plans Use inhaled steroids as per NHLBI guidelines for persistent asthma Reassess impairment and risk, preferably during periodic asthma check-ups Environmental management can and should supplement good medical care Ask about environmental exposures and seek ways

to intervene Low cost interventions are effective in children Consider allergy referral to define exposure risk Contact Information Leyla Erk McCurdy Senior Director, Health & Environment National Environmental Education Foundation [email protected] 202.261.6488

Acknowledgments Putting it into Practice: Pediatric Environmental Health Training Resource made possible by support from the W.K. Kellogg Foundation Image in slide #1 courtesy of Alex E. Proimos/Flickr, used under Creative Commons Attribution-NonCommercial 4.0 International License: Contact Information Nsedu Obot Witherspoon, MPH Executive Director Childrens Environmental Health Network Email: [email protected] Phone: 202-543-4033

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