A Case of Reactivation Tuberculosis

Approximately 22 percent of the world population is estimated to be infected with Mycobacterium tuberculosis. The largest number of cases are seen in Sub-Saharan Africa, India, and the islands of Southeast Asia, while North America and Western Europe are “low incidence” regions.1 In the US, most cases are seen in foreign-born individuals who emigrate from high-incidence countries. Despite the low incidence in the US, prevention and control of Tuberculosis (TB) remain an important component of Public Health.2 Here we present a case of a patient of Vietnamese origin with reactivation TB and rare manifestations of TB

Management of intracranial bleeding associated with dabigatran use in a neuroscience hospital

Dabigatran, an alternative to warfarin for prevention of stroke with non-valvular atrial fibrillation (AF), offers advantages of a fixed dosage, minimal laboratory monitoring and limited medication interactions. Dabigatran requires dosage adjustment in renal dysfunction and is contraindicated if severe dysfunction. No identified dabigatran reversal agent exists. Methods: As part of an ongoing quality initiative, novel anticoagulant associated adverse events (AE) are monitored at a dedicated neuroscience hospital. Results: 5 cases of intracranial bleeding associated with dabigatran occurred from 12/2011-4/2012. All patients were on anticoagulation for AF, the most common dose of dabigatran was 150 mg BID. Mean admission values were as follows: age 83.2 yrs (range 79-90), serum creatinine 1.48 mg/dL (range 0.9- 3.5), creatinine clearance 45.6 mL/min (18-59) and aPTT 49 seconds (range 32- 60). Strategies for the management of bleeding included withholding dabigatran, supportive care, administration of blood products and hemodialysis, when required. Dialysis was initiated on 3 patients. One patient had 3 dialysis sessions in an effort to normalize coagulation assays and had transfusions with 10 units of platelets and 4 units of fresh frozen plasma in an effort to stabilize bleeding. One patient died. Mean time for aPTT to normalize when abnormal on admission was 30.8 hours (range 21-37). Conclusions: Appropriate patient selection is required to prevent dabigatran associated AE, especially in the setting of advanced age and kidney dysfunction. aPTT values may remain prolonged for extended periods, despite efforts to normalize. Hospitals need a defined management plan for major bleeding associated with novel anticoagulants

Oncolog, Volume 37, Issue 01, January-March 1992

Clinician and chemist forge new approach to liposome research Computerized network enhances interdisdplinary patient management Neurofibromatosis: a new clinic brings new opportunitieshttps://openworks.mdanderson.org/oncolog/1037/thumbnail.jp

Hybrid Laparoscopic and Endoscopic Management of Gastric Band Erosion Resulting in Bowel Obstruction

While laparoscopic gastric banding is not as prevalent, the management of patients with a history of gastric banding remains a concern. Gastric bands have been noted to erode and can migrate through the bowel leading to a variety of issues. We were able to successfully manage this almost completely endoscopically without the need for a bowel enterotomy for retrieval. This allowed for enhanced patient recovery and avoided the morbidity associated with bowel enterotomy which is commonly done in these settings

Bronchoalveolar Lavage Neutrophils and Matrix Metalloproteinase-9 in Sarcoidosis Clinical Phenotypes: Implications for Tissue Remodeling Leading to Pulmonary Fibrosis

Introduction Pulmonary sarcoidosis may resolve or progress to advanced stages. Increased lung neutrophils obtained by bronchoalveolar lavage are found in advanced pulmonary sarcoidosis. Persistence of a neutrophilic alveolitis has been postulated to result in tissue injury and remodeling that leads to fibrosis and clinical features of advanced disease. Since neutrophils are a source of matrix-degrading proteins like matrix metalloproteinases (MMPs), we hypothesized that PMNs promote disease progression through the release of MMPs. This work explores the relationship between lung neutrophils and MMP9 levels and activity and how they are associated with sarcoidosis clinical phenotypes.https://jdc.jefferson.edu/pulmcritcareposters/1005/thumbnail.jp

Perceptions of English Language Learning and Teaching among Primary and Secondary Teachers and Students Participating in English in Action: Second Cohort (2013)

Executive summary a) Background The purpose of the Perceptions Study 2013 was to explore the perceptions of English language (EL) practices within schools participating in English in Action (EIA) from the point of view of both the teachers and the students. The first part of the study focused on primary and secondary teachers’: - Perceptions of their practices in teaching English; - Attitudes to the communicative language teaching (CLT) approaches being promoted through EIA; -Perceptions of their students’ responses to these approaches; - Opinions of the general usefulness of the EIA programme. The second part of the study explored primary and secondary students : - Current experience in English lessons in EIA intervention schools; - Perceptions and attitudes to EL and learning English. The Perceptions Study 2013 is a repeat of the study of the pilot EIA programme (Cohort 1), carried out in 2010. In addition to understanding the views of the current cohort (Cohort 2), one aim was to see the extent to which there are any changes from Cohort 1 to 2. This 2013 study is part of a set of three studies – including one on teachers’ classroom practice (EIA 2014a), and another on the EL competence of students and teachers (EIA 2014b). b) Research methodology The design of this study was a repeat of that of the previous study (2010) and looked to reveal the perceptions of students and teachers in EIA Cohort 2, enabling a comparison with the study carried out on Cohort 1 in 2010. The research question for the study was thus: - To what extent has the programme been successful in repeating the mid-intervention changes in perceptions of students and teachers seen in Cohort 1, at the much larger scale of Cohort 2? Fieldwork was carried out by researchers from the Institute of Education and Research (IER) at the University of Dhaka in September and October 2013, some 12 months after Cohort 2 teachers began participating in the EIA programme. It took place in a sample of EIA schools across six divisions in Bangladesh and used a multi-layer stratified sampling strategy. Teacher data were collected by a self-completion questionnaire: 269 primary teachers, 123 primary head teachers (HTs) and 143 secondary teachers participated in the study. Primary student data were collected by interview survey, while secondary student data were collected by self-completion questionnaire; a total of 376 primary students and 457 secondary students participated. As this study was carried out using questionnaires only, either self-completed and through interview, the comparison is with the quantitative element of the 2010 study only. c) Key findings: Teachers i) Primary teachers 99% of the primary teachers reported that taking part in EIA helped improve their own English (53% strongly agreed). 89% also felt that EIA has had an impact on their confidence to use more English, and 92% agreed it has had an impact on the way they teach. Primary teachers seemed to be fairly confident about their competence in English, with 87% agreeing that they felt comfortable modelling English for students to repeat. This is reflected in their classroom practice, where they used English three-quarters of the time they talked (EIA 2014a: 17). This links also with the fact that 70% of primary teachers agreed that they use mostly English in the classroom, i.e. their perceptions matched their practice; 80% agreed that it is essential that English teachers speak in English in the classroom for their students to learn English. Primary teachers had mixed opinions about the use of Bangla to support student learning: when asked whether Bangla should be used frequently in English classes for students’ better understanding, 43% felt that students preferred it when their teachers spoke Bangla most of the time; a slightly smaller proportion (38%) felt their students did not prefer it. Most primary teachers (87%) agreed that the focus in their English classes is communication, but that they explain grammar when necessary. 47% of primary teachers thought that grammar rules should be explicitly explained in class, and over half of the teachers (73%) agreed that students’ English improves most quickly if they study and practise grammar. 89% of primary teachers reported they often use activities where the students interact with each other in English. 81% agreed that students like these activities. 98% reported using more pair and group work as a result of EIA and 91% agreed that students play games or sing songs more often now. 99% of primary teachers reported that changes in teaching have improved student motivation, with 57 strongly agreeing. 82% reported that changes in teaching have had a positive impact on student learning. Primary teachers still retained some more traditional notions as being important to their practice, with 95% agreeing that drilling and repetition is common practice, while EIA approaches promote fluency and creativity in language use. 81% felt that error correction was important, while EIA approaches suggest that teachers pay less attention to errors, as this can inhibit students experimenting with language. 81% of primary teachers agreed that students like to interact in English with classmates. (This positive attitude was confirmed by data from the primary students.) In terms of a comparison with the Cohort 1 study in 2010 and the baseline (2009), this study of Cohort 2 confirmed that primary teachers supported the view that English is seen as an important language and that it is necessary to learn it for both jobs and study. For primary teachers, there was a slight increase in the perceived difficulty of English compared with the baseline study (2009). In terms of their reported practice and views in relation to a communicative approach, primary teachers supported it but were somewhat less supportive in 2013 than those in 2010 were. In addition, there was some increase in reported practice and views of traditional elements of English language teaching (ELT), including the role of grammar, error correction and drill and repetition. ii) Secondary teachers 96% of secondary teachers agreed that taking part in EIA helped them to improve their own English. 88% also felt that it has had an impact on their confidence to use more English, and 94% agreed that it has had an impact on the way they teach. Secondary teachers seemed to be fairly confident about their competence in English, with 87% agreeing that they feel comfortable modelling English for students to repeat. 80% of secondary teachers agreed that they use mostly English in the classroom (this finding is corroborated by direct observation [EIA 2014a]); 88% agreed that it is essential that English teachers speak in English in the classroom for their students to learn English. Secondary teachers had mixed opinions about the use of Bangla to support student learning: when asked whether Bangla should be used frequently in English classes for students’ better understanding, 57% disagreed while 27% agreed. About two fifths of secondary teachers felt that their students liked it when the teacher spoke Bangla most of the time (40%), but a similar proportion (38%) felt that their students do not prefer it. A large proportion of secondary teachers (89%) agreed that the focus in their English classes is on communication, but that they explain grammar when necessary. However, over half (58%) thought that grammar rules should be explicitly explained in class and 70% agreed that students’ English improves most quickly if they study and practise grammar. 88% of secondary teachers reported that they often use activities to have the students interact with each other in English. 74% agreed that students like these activities. 92% reported using more pair and group work, whilst 71% agreed that students now play games or sing songs more often than before EIA. 97% of secondary teachers reported that changes in teaching have improved student motivation, with 60% ‘strongly agreeing’. 79% reported that changes in teaching have had a positive impact on student learning. Secondary teachers still perceived some more traditional notions as being important to their practice, with 85% agreeing that drilling and repetition is common practice, in contrast to EIA approaches, which promote fluency and creativity in language use. 88% felt that error correction was important, while EIA approaches suggest teachers pay less attention to errors, as this can inhibit students experimenting with language use. 74% of secondary teachers agreed that students like to interact in English with classmates. In terms of a comparison with the Cohort 1 study in 2010 and the baseline (2009), this study of Cohort 2 confirmed that secondary teachers supported the view that English is seen as an important language and that it is necessary to learn it for both jobs and study. For secondary teachers, there was a slight decrease in the perceived difficulty of English compared with the baseline study (2009). In terms of their reported practice and views in relation to a communicative approach, secondary teachers supported it in 2013 much as they did in 2010. Although their reported practice and views of traditional elements of ELT (including the role of grammar, error correction and drill and repetition) still exist, they are much as they were in 2010. iii) Comparison of teacher perceptions: Primary and secondary - Almost all teachers (99% primary; 96% secondary) reported that taking part in EIA is helping improve their own English. - Most teachers (87% primary; 87% secondary) were comfortable in their competence to model English in the classroom. - Most teachers (70% primary; 80% secondary) reported mostly using English in the classroom. - Most teachers (87% primary; 89% secondary) said the focus of their lessons is on communication, with grammar being explained as required. - Most teachers (89% primary; 88% secondary) reported often using activities to have students interact in English, though singing and playing games are more popular classroom activities for primary teachers than for secondary. - Most teachers (99% primary; 97% secondary) reported improved student motivation as a result of changes to classroom practice. - Over half of secondary teachers (58%) thought grammar rules should be explained explicitly and over two-thirds (70%) thought that students’ English improves most quickly through grammar practice. Less than half of primary teachers (47%) thought that grammar rules should be explained explicitly, and similarly over two-thirds (70%) thought that students’ English improves most quickly through grammar practice. - Most teachers (95% primary; 85% secondary) reported they still commonly practise traditional techniques, such as drilling and repetition. d) Key findings: Students i) Primary students Over half of primary students (64%) reported that their English teachers used English most of the time in their lessons. 69% reported they liked it when their teacher spoke Bangla most of the time. The majority of the primary students reported regularly participating in classroom activities that are promoted in the EIA materials, such as talking in English with classmates, playing games and singing songs. Most primary students reported that these kinds of activities, promoted by EIA, are enjoyable (interacting in English: 79%; games: 95%; songs: 93%). Most also reported that more traditional activities were enjoyable, such as learning grammar rules (95%) and being corrected by the teacher (98%). Most primary students liked learning English (99%). Almost all said that they liked learning English because it is important for them (96%), even if just under a third felt it was difficult to learn (32%). There are no direct comparisons with Cohort 1 in terms of primary students’ views of their teachers’ practice and of their own learning of English, or with the 2009 baseline in terms of difficulty of learning English or its importance to them and to their future. ii) Secondary students About a third of secondary students reported that their English teachers used English most of the time in their lessons (36%). Also, 37% reported that they prefer their teacher speaking Bangla to speaking English, which is a lot lower than in the previous study (61%). Most (69%) said that they liked to speak English in their English lessons. Secondary students also reported participating in classroom activities that are promoted in the EIA materials, including speaking English with classmates (80%), but also playing and singing (though a lot less: 33%). Secondary students reported speaking English with classmates to be an enjoyable aspect of their English lessons (82%); a minority reported playing and singing as enjoyable (35%). Secondary students reported that some EIA teachers still carry out more traditional language learning activities in their English lessons, such as drilling, memorising grammar rules and correcting errors. Secondary students also reported they enjoyed these traditional practices: the large majority (89%) believed that repeating teachers’ sentences helps them learn English. 86% agreed that they liked learning grammar rules in English classes and two-thirds (69%) believed that learning English means learning grammar rules. The majority (95%) said that their English teachers should correct all errors and most liked it (93%). Most secondary students reported having a strong motivation to learn English. 94% agreed that learning English is important in their life; 92% felt that English will help them find a good job and improve their income (74%). Students had mixed feelings about whether English was difficult to learn – a third (33%) felt it was, while 44% felt it wasn’t. In terms of a comparison with the Cohort 1 study in 2010 and the baseline (2009), this study of Cohort 2 confirmed that secondary students supported the view that English is seen as an important language and that it is necessary to learn it for both jobs and study. For secondary students, there is no difference in the perceived difficulty of English compared with the baseline study (2009). In terms of their reporting of their teachers’ practice and their own views in relation to a communicative approach, secondary students show more support for some elements in 2013 - much as they did in 2010 - and less support for other elements. Although their reports of their teachers’ practice and their own views of traditional elements of ELT (including the role of grammar, error correction and drill and repetition) still exist, they are generally less strong than in 2010