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For each milestone there is an average age, as well as a range of ages in which the milestone should be reached. Babies on average are able to hold up their head at 6 weeks old, and 90% of babies achieve this between 3 weeks and 4 months old. Sitting involves both coordination and muscle strength, and 90% of babies achieve this milestone between 5 and 9 months old. Fine motor skills focus on the muscles in our fingers, toes, and eyes, and enable coordination of small actions. Newborns cannot grasp objects voluntarily but do wave their arms toward objects of interest. At about 4 months of age, the infant is able to reach for an object, first with both arms and within a few weeks, with only one arm. At this age grasping an object involves the use of the fingers and palm, but no thumbs. The use of the thumb comes at about 9 months of age when the infant is able to grasp an object using the forefinger and thumb. Now the infant uses a Pincer Grasp, and this ability greatly enhances the ability to control and manipulate an object and infants take great delight in this newfound ability. They may spend hours picking up small objects Source 78 from the floor and placing them in containers. By 9 months, an infant can also watch a moving object, reach for it as it approaches, and grab it. Gross motor skills focus on large muscle groups that control our head, torso, arms and legs and involve larger movements. Examples include moving to bring the chin up when lying on the stomach, moving the chest up, and rocking back and forth on hands and knees. This may be easier than reaching for an object with the hands, which requires much more practice (Berk, 2007). Sometimes an infant will try to move toward an object while crawling and surprisingly move backward because of the greater amount of strength in the arms than in the legs. Sensory Capacities Throughout much of history, the newborn was considered a passive, disorganized being who possessed minimal abilities. However, current research techniques have demonstrated just how developed the newborn is with especially organized sensory and perceptual abilities. This means an object 20 feet away from an infant has the same clarity as an object 300 feet away from an adult with normal vision. By 3-months visual acuity has sharpened to 20/200, which would allow them the see the letter E at the top of a standard eye chart (Hamer, 2016). The fovea, which is the central field of vision in the retina and allows us to see sharp detail, is not fully developed at birth, and does not start to reach adult levels of development until 15 months (Li & Ding, 2017). Even by 45 months some of the sensory neurons (cones) of the fovea are still not fully grown. Young infants can perceive color, but the colors need to be very pure forms of basic colors, such as vivid red or green rather than weaker pastel shades. Newborn infants prefer and orient to face-like stimuli more than they do other patterned stimuli (Farroni et al. They also prefer images of faces that are upright and not scrambled (Chien, 2011). Infants also quickly learn to distinguish the face of their mother from faces of other women (Bartrip, Morton, & De Schonen, 2001). By two months of age, their eye movements are becoming smoother, but they still lag behind the motion of the object and will not achieve this until about three to four months of age (Johnson & deHaan, 2015). By two to three months, stimuli in both fields are now equally attended to (Johnson & deHaan, 2015). Binocular vision, which requires input from both eyes, is evident around the third month and continues to develop during the first six months (Atkinson & Braddick, 2003). By six months infants can perceive depth perception in pictures as well (Sen, Yonas, & Knill, 2001).

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A case of early onset cyclosporine-induced hemolytic uremic syndrome resulting in renal graft loss. A review of hemolytic uremic syndrome in patients treated with gemcitabine therapy. Dumontet C, Morschhauser F, Solal-Celigny P, Bouafia F, Bourgeois E, Thieblemont C, Leleu X, Hequet O, Salles G, Coiffier B. Hemolytic-uremic syndrome associated with gemcitabine: a case report and review of literature. Hemolytic uremic syndrome following prolonged gemcitabine therapy: report of four cases from a single institution. Is therapeutic plasma exchange indicated for patients with gemcitabine-induced hemolytic uremic syndrome? Three cases of hemolytic uremic syndrome in ovarian cancer patients treated with combination gemcitabine and pegylated liposomal doxorubicin. Thrombotic microangiopathy as a complication of long-term therapy with gemcitabine. Thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation: an autopsy study. Transplant-associated microangiopathy in patients receiving tacrolimus following allogeneic stem cell transplantation: risk factors and response to treatment. Diagnosis and treatment of transplantation-associated thrombotic microangiopathy: real progress or are we still waiting? Diagnostic criteria for hematopoietic stem cell transplant-associated microangiopathy: results of a consensus process by an International Working Group. Risk factors and severe outcome in thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation. Christidou F, Athanasiadou A, Kalogiannidis P, Natse T, Bamichas G, Salum R, Sakellari I, Anagnostopoulos A, Fassas A, Sombolos K. Therapeutic plasma exchange in patients with grade 2­3 hematopoietic stem cell transplantation-associated thrombotic thrombocytopenic purpura: a ten-year experience. Posttransplantation thrombotic thrombocytopenic purpura: a single-center experience and a contemporary review. Improved survival in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Thrombotic microangiopathy, hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura. Thrombotic microangiopathy with renal failure in two patients undergoing gemcitabine chemotherapy. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: diagnosis and management. Quinine-induced renal failure as a result of rhabdomyolysis, haemolytic uraemic syndrome and disseminated intravascular coagulation. Quinine-induced disseminated intravascular coagulation and haemolytic-uraemic syndrome. Quinine-induced immune thrombocytopenia with hemolytic uremic syndrome: clinical and serological findings in nine patients and review of literature. Hemodialysis, peritoneal dialysis, plasmapheresis and forced diuresis for the treatment of quinine overdose. Quinine-induced immune thrombocytopenic purpura followed by hemolytic uremic syndrome. Quinine-associated thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: frequency, clinical features, and long-term outcomes. Posttransplant thrombotic microangiopathy: sensitivity of proposed new diagnostic criteria. Clinical impact of thrombotic microangiopathy on the outcome of patients with acute graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Antibodies to von Willebrand factor-cleaving protease in acute thrombotic thrombocytopenic purpura. Rituximab for chronic recurring thrombotic thrombocytopenic purpura: a case report and review of the literature.

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In addition to the change in floor level between the interior floor and exterior landing discussed on page 4. The Guidelines further state that changes in level at these locations must be beveled with a slope no greater than 1:2. In the case of primary entry doors where the exterior landing surface is impervious, the exterior landing surface is permitted to be below the finish floor level by 1/2 inch. Therefore, the Guidelines allow an overall change in level of 1-1/4 inch on the exterior side of the primary entry door. Note, however, as already stated, these changes in level must be beveled with a slope no greater than 1:2. Exterior door thresholds of 3/4 inch, even when beveled, can be extremely difficult to navi gate for some persons who use wheelchairs, and the additional change in level when outside landing surfaces are impervious adds to this difficulty. Because of this, it is recommended that other solutions be considered which both provide for less of a change in level at the door threshold and also are designed to prevent water infiltration. One such solution is to use a threshold that rises a maximum of 1/4 inch on the inside and drops 3/4 inch at a slope of 1:2 at the exterior. An even better solution is to bring the exterior surface up to the same level as the interior floor using an interlocking threshold. Accessible Route onto Balcony Created with the Addition of a Raised Platform (Added by the Resident) wooden platform to raise floor level of balcony to level of interior of dwelling unit (not required at initial construction but is a later resident modification) 4. The Fair Housing Accessibility Guidelines (the Guidelines) do not require controls to be fully accessible but specify that light switches, electrical outlets, thermostats and other environ mental controls, which are operated on a regular or frequent basis in the daily use of a dwelling unit, be in accessible locations. Force and type of motion required to operate controls are not covered by the Guidelines. All these covered controls and outlets must be in accessible locations, with a few exceptions. The Guidelines allow, for example, con trols or outlets that do not satisfy the requirements, if comparable controls or outlets in accessible locations are provided within the same area. For example, floor outlets (which are inaccessible) or outlets mounted in the corner of kitchen counters are permitted under the Guidelines, provided other outlets are available to serve the same space or area. Controls and outlets not covered by the Guidelines include circuit breakers or electrical outlets dedicated to individual appliances such as refrigerators, built-in microwave ovens, washing machines, and dryers because neither circuit breakers nor these outlets are accessed frequently by residents. Appliance controls are not required to be in accessible locations because the Fair Housing Act is not intended to regulate the design of appliances. Thus, when appliance controls are built into or are located on the appliance itself, they are not considered to be covered controls. Range or washing machine controls need not be within the reach range of seated users, although certainly it is preferred that such controls be within reach. However, if the range hood fan and light are wired to a separate switch on a wall or any location other than on the hood, range, or cooktop, then the control must be in an accessible location. The operat ing switch for a garbage disposal is not mounted on the appliance itself but is wired to another location. Although not a covered control, since garbage disposals are used frequently and since it is relatively simple to place operating switches for garbage disposals in accessible locations, it is recommended that it be done. Emergency interrupt switches to mechani cal systems such as furnaces or hot water heaters also are not covered by the Guidelines. However, it is recommended that such switches be in locations that can be reached from a seated position. Even when the mechanical system is located behind a narrow door in a small closet dedicated specifically to that purpose, it is recommended that the interrupt switch be positioned so it can be reached from outside the closet by a person using a wheelchair. One of these positions, a side reach from a parallel position without an obstruction, requires a 48-inch long clear floor space parallel and close to the wall so a user can get close enough to reach controls and switches. Once a dwelling unit is furnished, suffi cient room to execute such a parallel approach usually is not available; thus this specification was omitted from the Guidelines. To accommodate all users in situations where there may or may not be a built-in counter, base cabinet, or other obstruction to interfere with reach, the Guidelines include specific requirements for mounting controls and switches so a person using a wheelchair can execute: 1. There must be a clear floor space of 30 inches x 48 inches perpendicular to the wall, adjoining a 36-inch wide accessible route, to allow a person using a wheelchair to approach and get into position to execute a for ward reach to the control or outlet. Even though people using wheelchairs may be able to execute a forward reach of 48 inches at a clear wall, they may have difficulty seeing the small numerals and indicators generally found on thermostats.

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A major neurocognitive disorder is diagnosed as a significant cognitive decline from a previous level of performance in one or more cognitive domains and interferes with independent functioning, while a minor neurocognitive disorder is diagnosed as a modest cognitive decline from a previous level of performance in one of more cognitive domains and does not interfere with independent functioning. There are several different neurocognitive disorders that are typically demonstrated in late adulthood and determining the exact type can be difficult because the symptoms may overlap with each other. Diagnosis often includes a medical history, physical exam, laboratory tests, and changes noted in behavior. Current estimates indicate that Alzheimer disease affects approximately 50% of those identified with a neurocognitive disorder (Cohen & Eisdorfer, 2011). Confusion, difficulty with change, and deterioration in language, problem-solving skills, and personality become evident Figure 9. In the later stages, the individual loses physical coordination and is unable to complete everyday tasks, including self-care and personal hygiene (Erber & Szuchman, 2015). People who inherit these genes tend to develop symptoms in their 30s, 40s and 50s. Traumatic brain injury is also a risk factor, as well as obesity, hypertension, high cholesterol, and diabetes (Carlson, 2011). Beta-amyloid comes from a larger protein found in the fatty membrane surrounding nerve cells. These plaques appear to block cell communication and may also trigger an inflammatory response in the immune system, which leads to further neuronal death. When tau malfunctions, it changes into twisted strands called tangles that disrupt the transport system. Consequently, nutrients and other supplies cannot move through the cells and they eventually die. The death of neurons lead to the brain shrinking and affecting all aspects of brain Figure 9. For example, the hippocampus is involved in learning and memory, and the brain cells in this region are often the first to be damaged. It appears that weakening microglia cause the amyloid plaques to injure nearby neurons, thus creating a toxic environment that increases the formation and spread of tau tangles. These findings support other studies that have found that the hippocampus and thalamus are involved in mood disorders. Once tau begins to accumulate in brain tissue, the protein can spread from one brain area to the next along neural connections. The researchers followed a diverse group of 2765 participants for 9 years and focused on five low-risk lifestyle factors: healthy diet, at least 150 minutes/week of moderate to vigorous physical activity, not smoking, light to moderate alcohol intake, and engaging in cognitively stimulating activities. Vascular Neurocognitive Disorder is the second most common neurocognitive disorder affecting 0. Personality is not as affected in vascular neurocognitive disorder, and more males are diagnosed than females (Erber and Szuchman, 2015). Risk factors include smoking, diabetes, heart disease, hypertension, or a history of strokes. Neurocognitive Disorder with Lewy bodies: According to the National Institute on Aging (2015a), Lewy bodies are microscopic protein deposits found in neurons seen postmortem. They affect chemicals in the brain that can lead to difficulties in thinking, movement, behavior and mood. Neurocognitive Disorder with Lewy bodies is the third most common form and affects more than 1 million Americans. It typically begins at age 50 or older and appears to affect slightly more men than women. Lewy bodies can occur in both the cortex and brain stem which results in cognitive as well as motor symptoms (Erber & Szuchman, 2015). Individuals diagnosed with Neurocognitive Disorder with Lewy bodies also experience sleep disturbances, recurrent visual hallucinations, and are at risk for falling. Work, Retirement, and Leisure Work: According to the United States Census Bureau, in 1994, approximately 12% of those employed were 65 and over, and by 2016, the percentage had increased to 18% of those employed (McEntarfer, 2019). Looking more closely at the age ranges, more than 40% of Americans in their 60s are still working, while 14% of people in their 70s and just 4% of those 80 and older are currently employed (Livingston, 2019). Even though they make up a smaller number of workers overall, those 65- to 74-year-old and 75-andolder age groups are projected to have the fastest rates of growth in the next Figure 9.

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Assessment of tumor response was conducted at weeks 12 and 24, and every 3 months thereafter. Patients with evidence of objective tumor response at 12 or 24 weeks had assessment for confirmation of durability of response at 16 or 28 weeks, respectively. Enrollment required complete resection of melanoma with full lymphadenectomy within 12 weeks prior to randomization. Patients with prior therapy for melanoma, autoimmune disease, and prior or concomitant use of immunosuppressive agents were ineligible. Tumor assessment was conducted every 12 weeks for the first 3 years then every 24 weeks until distant recurrence. Other disease characteristics of the trial population were: clinically palpable lymph nodes (58%), 2 or more positive lymph nodes (54%), and ulcerated primary lesions (42%). The median age was 61 years (range: 21 to 85) with 38% 65 years of age and 8% 75 years of age. Tumor assessments were conducted every 6 weeks for the first 24 weeks and every 12 weeks thereafter. The median age was 58 years (range: 21 to 88), with 32% 65 years of age and 9% 75 years of age; 59% were male and 92% were white. A total of 49 patients received the combination regimen, which was administered every 3 weeks for four doses, followed by single-agent nivolumab at 240 mg every 2 weeks until disease progression or unacceptable toxicity. The median age was 60 years (range: 18 to 80); 88% were male; 74% were Asian, and 25% were White. Prior treatment history included surgery (74%), radiotherapy (29%), or local treatment (59%). All patients had received prior sorafenib, of whom 10% were unable to tolerate sorafenib; 29% of patients had received 2 or more prior systemic therapies. Patients with treated brain metastases were eligible if neurologically returned to baseline at least 2 weeks prior to enrolment, and either off corticosteroids, or on a stable or decreasing dose of <10 mg daily prednisone equivalents. Study treatment continued until disease progression, unacceptable toxicity, or for up to 24 months. Treatment continued beyond disease progression if a patient was clinically stable and was considered to be deriving clinical benefit by the investigator. The median age was 64 years (range: 26 to 87) with 49% of patients 65 years and 10% of patients 75 years, 76% White, and 65% male. Study treatment continued until disease progression, unacceptable toxicity, or for up to 2 years. Tumor assessments were performed every 6 weeks from the first dose of study treatment for the first 12 months, then every 12 weeks until disease progression or study treatment was discontinued. The median age was 65 years (range: 26 to 86) with 51% of patients 65 years and 10% of patients 75 years. Efficacy results from the prespecified interim analysis when 351 events were observed (87% of the planned number of events for final analysis) are presented in Table 28. The trial included patients with histologically confirmed and previously untreated malignant pleural mesothelioma with no palliative radiotherapy within 14 days of initiation of therapy. Patients with interstitial lung disease, active autoimmune disease, medical conditions requiring systemic immunosuppression, or active brain metastasis were excluded from the trial. Study treatment continued for up to 2 years, or until disease progression or unacceptable toxicity. Treatment could continue beyond disease progression if a patient was clinically stable and was considered to be deriving clinical benefit by the investigator. The median age was 69 years (range: 25 to 89), with 72% of patients 65 years and 26% 75 years; 85% were White, 11% were Asian, and 77% were male. Efficacy results from the prespecified interim analysis are presented in Table 29 and Figure 7. This Medication Guide does not take the place of talking with your healthcare provider about your medical condition or your treatment. These problems can sometimes become severe or life-threatening and can lead to death. These problems may happen anytime during treatment or even after your treatment has ended. Call or see your healthcare provider right away if you develop any new or worse signs or symptoms, including: Intestinal problems. Call or see your healthcare provider right away for any new or worsening signs or symptoms.

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First, the Department proposed a safe harbor for elements in existing facilities that were compliant with the 1991 Standards. The public accommodation would thus be deemed to have met its barrier removal obligation with respect to that element. The Department received many comments on Department of Justice this issue during the 60-day public comment period. These proposals elicited many comments from both the business and disability communities. This proposed small business safe harbor was based on suggestions from small business advocacy groups that requested clearer guidance on the barrier removal obligations for small businesses. This safe harbor would have provided some protection from litigation because compliance could be assessed easily. Such a rule, the Department believed, also could further accessibility, because qualified small businesses would have an incentive to incorporate barrier removal into short- and long-term planning. After consideration of the many comments received on this issue, the Department has decided not to include a qualified small business safe harbor in the final rule. Public accommodations have a continuing obligation to remove certain architectural, communications, and transportation barriers in existing facilities to the extent readily achievable. The 2010 Standards introduce technical and scoping specifications for many elements that were not included in the 1991 Standards. Accordingly, public accommodations will have to consider these supplemental requirements when evaluating whether there are covered barriers in existing facilities, and, if so, remove them to the extent readily achievable. Also included in the 2010 Standards are revised technical and scoping requirements for elements that were addressed in the 132 - Guidance and Analysis 1991 Standards. The proposed element-by-element safe harbor provided that in existing facilities elements that are, as of the effective date of the 2010 Standards, fully compliant with the applicable technical and scoping requirements in the 1991 Standards, need not be modified or retrofitted to meet the 2010 Standards, until and unless those elements are altered. The Department posited that it would be an inefficient use of resources to require covered entities that have complied with the 1991 Standards to retrofit already compliant elements when the change might only provide a minimal improvement in accessibility. In addition, the Department was concerned that covered entities would have a strong disincentive for voluntary compliance if every time the applicable standards were revised covered entities would be required once again to modify elements to keep pace with new requirements. The Department recognized that revisions to some elements might confer a significant benefit on some individuals with disabilities and because of the safe harbor these benefits would be unavailable until the facility undergoes alterations. The Department received many comments on this issue from the business and disability communities. Business owners and operators, industry groups and trade associations, and business advocacy organizations strongly supported the element-by-element safe harbor. These commenters argued that the financial cost and business disruption resulting from retrofitting elements constructed or previously modified to comply with 1991 Standards would be detrimental to nearly all businesses and not readily achievable for most. They contended that it would be fundamentally unfair to place these entities in a position where, despite full compliance with the 1991 Standards, the entities would now, overnight, be vulnerable to barrier removal litigation. They further contended that public accommodations will have little incentive to undertake large barrier removal projects or incorporate barrier removal into long-term planning if there is no assurance that the actions taken and money spent for barrier removal would offer some protection from litigation. Some business commenters urged the Department to expand the element-by-element safe harbor to include supplemental requirements. Some of these same commenters urged the Department to include within the safe harbor those elements not covered by the 1991 Standards, but which an entity had built in compliance with State or local accessibility laws. Other commenters requested safe harbor protection where a business had attempted barrier removal prior to the estabDepartment of Justice lishment of technical and scoping requirements for a particular element. These groups contended that allowing permanent compliance with the 1991 Standards will ensure readily accessible and usable facilities while also mitigating the need for expensive and time-consuming documentation of changes and maintenance. A number of commenters inquired about the effect of the element-by-element safe harbor on elements that are not in strict compliance with the 1991 Standards, but conform to the terms of settlement agreements or consent decrees resulting from private litigation or Federal enforcement actions. These commenters noted that litigation or threatened litigation often has resulted in compromise among parties as to what is readily achievable. Business groups argued that facilities that have made modifications subject to those negotiated agreements should not be subject to the risk of further litigation as a result of the 2010 Standards. Lastly, some business groups that supported the element-by-element safe harbor nevertheless contended that a better approach would be to separate barrier removal altogether from the 2010 Standards, such that the 2010 Standards would not be used to determine whether access to an existing facility is impeded by architectural barriers. Nearly all commenters from the disability community objected to the proposed element-byelement safe harbor. These commenters asserted that the adoption of this safe harbor would permit and sanction the retention of outdated access standards even in cases where retrofitting to the 2010 Standards would be readily achievable.

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Residents who do not have adequate vision, despite using a visual appliance, might benefit from a re-evaluation of the appliance or assessment for new causes of vision impairment. Prior to beginning the assessment, ask the resident whether he or she uses eyeglasses or other vision aids and whether the eyeglasses or vision aids are at the nursing home. Observe whether the resident used eyeglasses or other vision aids during reading vision test (B1000). Check the medical record for evidence that the resident used corrective lenses when ability to see was recorded. Code 1, yes: if corrective lenses or other visual aids were used when visual ability was assessed in completing B1000, Vision. A structured cognitive test is more accurate and reliable than observation alone for observing cognitive performance. The structured cognitive interview is helpful for identifying possible delirium behaviors (C1310). Determine if the resident is rarely/never understood verbally, in writing, or using another method. If rarely/never understood, skip to C0700­C1000, Staff Assessment of Mental Status. Review Language item (A1100), to determine if the resident needs or wants an interpreter. Coding Instructions · rarely/never understood; cannot respond verbally, in writing, or using another method; or an interpreter is needed but not available. If it is not possible for a needed interpreter to participate on the day of the interview, code C0100 = 0 to indicate interview not attempted and complete C0700-C1000, Staff Assessment of Mental Status, instead of C0200-C0500, Brief Interview for Mental Status. Do not complete the Staff Assessment for Mental Status items (C0700-C1000) if the resident interview should have been conducted, but was not done. In this case, the assessor should enter 0, No in C0100: Should Brief Interview for Mental Status Be Conducted? Cognitively intact residents may appear to be cognitively impaired because of extreme frailty, hearing impairment or lack of interaction. When cognitive impairment is incorrectly diagnosed or missed, appropriate communication, worthwhile activities and therapies may not be offered. Awareness of possible impairment may be important for maintaining a safe environment and providing safe discharge planning. Refer to Appendix D for a review of basic approaches to effective interviewing techniques. Interview any resident not screened out by Should Brief Interview for Mental Status Be Conducted? If the resident expresses concern that you are testing his or her memory, he or she may be more comfortable if you reply: "We ask these questions of everyone so we can make sure that our care will meet your needs. Directly ask the resident each item in C0200 through C0400 at one sitting and in the order provided. Coding Tips · · · On occasion, the interviewer may not be able to state the items clearly because of an accent or slurred speech. Rules for stopping the interview before it is complete: - Stop the interview after completing (C0300C) "Day of the Week" if: 1. Code 1, yes in C0600 Should the Staff Assessment for Mental Status (C0700C1000) be Conducted? Cues may help residents with memory impairment who can store new information in their memory but who have trouble retrieving something that was stored. Staff can use cues when assisting residents with learning and recall in therapy, and in daily and restorative activities. If the interview is being conducted with an interpreter present, the interpreter should use the equivalent words and similar, relevant prompts for category cues. Immediately after presenting the three words, say to the resident: "Now please tell me the three words. Putting words in context stimulates learning and fosters memory of the words that residents will be asked to recall in item C0400, even among residents able to repeat the words immediately. If the resident recalled two or fewer words, say to the resident: "Let me say the three words again. If he or she is unable to hear, attempt to maximize hearing (alter environment, use hearing amplifier) before proceeding.

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In addition, older adults who have divorced often desire the companionship of intimate relationships without marriage. As a result, cohabitation is increasing among older adults, and like remarriage, cohabitation in later adulthood is often associated with more positive consequences than it is in younger age groups (King & Scott, 2005). No longer being interested in raising children, and perhaps wishing to protect family wealth, older adults may see cohabitation as a good alternative to marriage. This trend has been found in several nations and is motivated by: · · · · A strong desire to be independent in day-to-day decisions Maintaining their own home Keeping boundaries around established relationships Maintaining financial stability Besides the desire to be autonomous, there is also a need for companionship, sexual intimacy, and emotional support. In contrast, 80% older adults reported that they did not wish to cohabitate or marry. By 2025 that number is expected to rise to more than 7 million (National Gay and Lesbian Task Force, 2006). Despite the increase in numbers, older lesbian and gay adults are one of the least researched demographic groups, and the research there is portrays a population faced with discrimination. According to the Centers for Disease Control and Prevention (2011), compared to heterosexuals, lesbian and gay adults experience both physical and mental health differences. More than 40% of lesbian and gay adults ages 50 and over suffer from at least one chronic illness or disability and compared to heterosexuals they are more likely to smoke and binge drink (Hillman & Hinrichsen, 2014). When compared to heterosexuals, lesbian and gay elders have less support from others as they are twice as likely to live alone and four times less likely to have adult children (Hillman & Hinrichsen, 2014). Lesbian and gay older adults who belong to ethnic and cultural minorities, conservative religions, and rural communities may face additional stressors. Ageism, heterocentrism, sexism, and racism can combine cumulatively and impact the older adult beyond the negative impact of each individual form of discrimination (Hillman & Hinrichsen, 2014). David and Knight (2008) found that older gay black men reported higher rates of racism than younger gay black men and higher levels of perceived ageism than older gay white men. Although lesbian and gay older adults face many challenges, more than 80% indicate that they engage in some form of wellness or spiritual activity (Fredrickson-Goldsen et al. They also gather social support from friends and "family members by choice" rather than legal or biological relatives (Hillman & Hinrichsen, 2014). An important consideration when reviewing the development of gay and lesbian older adults is the cohort in which they grew up (Hillman & Hinrichsen, 2014). The oldest lesbian and gay adults came of age in the 1950s when there were 421 Figure 9. The baby boomers, who grew up in the 1960s and 1970s, began to see states repeal laws that criminalized homosexual behavior. Future lesbian and gay elders will have different experiences due to the legal right for same-sex marriage and greater societal acceptance. Consequently, just like all those in late adulthood, understanding that gay and lesbian elders are a heterogeneous population is important when understanding their overall development. This may be because younger older adults more often live with adult children or a spouse, two groups with the most likely abusers. Cognitive impairment, including confusion and communication deficits, is the greatest risk factor for elder abuse, while a decline in overall health resulting in greater dependency on others is another. Having a disability also places an elder at a higher risk for abuse (Youdin, 2016). Definitions of elder abuse typically recognize five types of abuse as shown in Table 9. Psychological and emotional abuse is considered the most common form, even though it is underreported and may go unrecognized by the elder. Continual emotional mistreatment is very damaging as it becomes internalized and results in late-life emotional problems and impairment. Financial abuse and exploitation is increasing and costs seniors nearly 3 billion dollars per year (Lichtenberg, 2016). Financial abuse is the second most common form after emotional abuse and affects approximately 5% of elders. Abuse and neglect occurring in a nursing home is estimated to be 25%-30% (Youdin, 2016). Abuse of nursing home residents is more often found in facilities that are run down and understaffed Table 9. Additionally, a family history of violence makes older women more vulnerable, especially for physical and sexual abuse (Acierno et al.

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It is intended that a minimum of 40% of participants will be in the >55-year stratum. The first 360 participants enrolled (180 to active vaccine and 180 to placebo, stratified equally between 18 to 55 years and >55 to 85 years) will comprise the "Phase 2" portion. Enrollment may continue during this period and these participants would be included in the efficacy evaluation in the "Phase 3" portion of the study. In Phase 3, up to approximately 2000 participants, enrolled at selected sites, are anticipated to be 12 to 15 years of age. A random sample of 250 participants from each of the 2 age groups (12 to 15 years and 16 to 25 years) will be selected as an immunogenicity subset for the noninferiority assessment. Participants are expected to participate for up to a maximum of approximately 26 months. Therefore, the use of a highly effective method of contraception is required (see Appendix 4). Based on previous clinical and nonclinical experience, it was expected that doses of up to 100 µg would be well tolerated. End of Study Definition A participant is considered to have completed the study if he/she has completed all phases of the study, including the last visit. Note that participants enrolled in Phase 1 in groups that do not proceed to Phase 2/3 may be followed for fewer than 24 months (but no less than 6 months after the last vaccination). The end of the study is defined as the date of last visit of the last participant in the study. The following eligibility criteria are designed to select participants for whom participation in the study is considered appropriate. All relevant medical and nonmedical conditions should be taken into consideration when deciding whether a particular participant is suitable for this protocol. Prospective approval of protocol deviations to recruitment and enrollment criteria, also known as protocol waivers or exemptions, is not permitted. Inclusion Criteria Participants are eligible to be included in the study only if all of the following criteria apply: Age and Sex: 1. Male or female participants between the ages of 18 and 55 years, inclusive, and 65 and 85 years, inclusive (Phase 1), or 12 years (Phase 2/3), at randomization. Participants who are willing and able to comply with all scheduled visits, vaccination plan, laboratory tests, lifestyle considerations, and other study procedures. Healthy participants who are determined by medical history, physical examination (if required), and clinical judgment of the investigator to be eligible for inclusion in the study. Note: Healthy participants with preexisting stable disease, defined as disease not requiring significant change in therapy or hospitalization for worsening disease during the 6 weeks before enrollment, can be included. Exclusion Criteria Participants are excluded from the study if any of the following criteria apply: Medical Conditions: 1. History of severe adverse reaction associated with a vaccine and/or severe allergic reaction (eg, anaphylaxis) to any component of the study intervention(s). Immunocompromised individuals with known or suspected immunodeficiency, as determined by history and/or laboratory/physical examination. Bleeding diathesis or condition associated with prolonged bleeding that would, in the opinion of the investigator, contraindicate intramuscular injection. Individuals who receive treatment with immunosuppressive therapy, including cytotoxic agents or systemic corticosteroids, eg, for cancer or an autoimmune disease, or planned receipt throughout the study. Inhaled/nebulized (except for participants in Phase 1 ­ see exclusion criterion 14), intra-articular, intrabursal, or topical (skin or eyes) corticosteroids are permitted. Receipt of blood/plasma products or immunoglobulin, from 60 days before study intervention administration or planned receipt throughout the study. Participation in other studies involving study intervention within 28 days prior to study entry and/or during study participation. Previous participation in other studies involving study intervention containing lipid nanoparticles. Phase 1 only: Any screening hematology and/or blood chemistry laboratory value that meets the definition of a Grade 1 abnormality. Note: With the exception of bilirubin, participants with any stable Grade 1 abnormalities (according to the toxicity grading scale) may be considered eligible at the discretion of the investigator.

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Total Oral 500 250 250 350 500 250 350 2,450 Tube 2,000 2,250 2,250 2,250 2,000 2,250 2,000 15,000 Coding: K0710A columns 2 and 3 would be coded 3, 51% or more. Rationale: Total Oral intake is 2,450 calories Total Tube intake is 15,000 calories Total calories is 2,450 + 15,000 = 17,450 Calculation of the percentage of total calories by tube feeding: 15,000/17,450 =. She is able to take oral fluids by mouth with supervision, but not enough to maintain hydration. She received the following daily fluid totals by supplemental tube feedings (including water, prepared nutritional supplements, juices) during the last 7 days. Rationale: the total fluid intake by supplemental tube feedings = 6,300 cc 6,300 cc divided by 7 days = 900 cc/day 900 cc is greater than 500 cc, therefore code 2, 501 cc/day or more is correct. Therefore, he received the following fluid amounts over the last 7 days via supplemental tube feedings while in the hospital and after he was admitted to the nursing home. Average fluid intake while a resident totaled 507 cc (1,520 cc divided by 3 days). Average fluid intake during the entire 7 days was 489 cc (3,420 cc divided by 7 days). L0200: Dental Item Rationale Health-related Quality of Life · Poor oral health has a negative impact on: - quality of life - overall health - nutritional status · Assessment can identify periodontal disease that can contribute to or cause systemic diseases and conditions, such as aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes. Planning for Care · Assessing dental status can help identify residents who may be at risk for aspiration, malnutrition, pneumonia, endocarditis, and poor control of diabetes. Ask the resident about the presence of chewing problems or mouth or facial pain/discomfort. Ask the resident, family, or significant other whether the resident has or recently had dentures or partials. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. If the resident is unable to self-report, then observe him or her while eating with dentures or partials, if indicated, to determine if chewing problems or mouth pain are present. Oral examination of residents who are uncooperative and do not allow for a thorough oral exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents and any resident who exhibits dental or oral issues. Coding Instructions · Check L0200A, broken or loosely fitting full or partial denture: if the denture or partial is chipped, cracked, uncleanable, or loose. A denture is coded as loose if the resident complains that it is loose, the denture visibly moves when the resident opens his or her mouth, or the denture moves when the resident tries to talk. Check L0200B, no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous/lacks all natural teeth or parts of teeth. Check L0200C, abnormal mouth tissue (ulcers, masses, oral lesions): · · · · · · · select if any ulcer, mass, or oral lesion is noted on any oral surface. Check L0200D, obvious or likely cavity or broken natural teeth: if any Check L0200E, inflamed or bleeding gums or loose natural teeth: if gums appear irritated, red, swollen, or bleeding. Teeth are coded as loose if they readily move when light pressure is applied with a fingertip. Check L0200F, mouth or facial pain or discomfort with chewing: if the resident reports any pain in the mouth or face, or discomfort with chewing. The dental status for a resident who has some, but not all, of his/her natural teeth that do not appear damaged. However, for individualized care planning purposes, consideration should be taken for these residents to make sure that they are in possession of their dentures or partials and that they are being utilized properly for meals, snacks, medication pass, and social activities. This section also notes other skin ulcers, wounds, or lesions, and documents some treatment categories related to skin injury or avoiding injury. A complete assessment of skin is essential to an effective pressure ulcer prevention and skin treatment program.

References:

  • https://melissainstitute.org/documents/Meichenbaum_THE_EVOLUTION_OF_PSYCHOTHERAPY.pdf
  • https://www.atsdr.cdc.gov/toxprofiles/tp24.pdf
  • https://www.coloplast.us/Global/US/Coloplast%20Academy/Peristomal%20Fungal%20Infection.pdf