The largest diagnosis group that spent less than 3 hours in the unit was gastroenteritis/rehydration (29%), as many of these children were discharged when it was clear that they were tolerating oral fluids well. BCH PDU -Admission and discharge dates and times were available for 4070 children (fig 1 1).). Of these, 1974 children (49%) stayed less than 3 hours, 1760 (43%) stayed between 3 and 8 hours, and 336 (8%) stayed more than 8 hours. When we looked at the subgroup of children discharged home, for whom we had all the time data (3071), 1514 (49%) stayed less than 3 hours, 1343 (44%) stayed between 3 and 8 hours, and 214 (7%) stayed more than 8 hours. The admitting speciality data were available in 4311 cases: 2608 (61%) under the care of accident and emergency and 1434 (33%) under the care of general paediatrics. Other specialities, such as surgery, orthopaedics, and haematology/oncology admitted the rest (fig 22).). The busiest time was between 12 noon and 12 midnight when 71% of the admissions and 65% of the discharges took place.
////////////////////////////////////Emerg Med J. 2006 Aug; 23(8): 612–613.
Some children need to be observed for a period of time before deciding the severity of their illness and their management. This is partly because of their inability to communicate certain symptoms and they can clinically deteriorate rapidly as they have less physiological reserve. An ED has time constraints set by the government. Children needing a longer time of observation have been traditionally admitted onto a paediatric ward. These usually have a ward round once or twice a day and do not always have a high turn over of the children admitted for observation. An alternative is to assess these children in an observation unit that is part of an ED
life is an enigma. Most strikingly, its organised, self-sustaining complexity seems to fly in the face of the most sacred law of physics, the second law of thermodynamics, which describes a universal tendency towards decay and disorder. The question of what gives life the distinctive oomph that sets it apart has long stumped researchers, despite dazzling advances in biology in recent decades
The opinions of others matter so much because in our caveman days, our survival used to depend on being accepted by the group; if we weren’t part of the group you were more likely to be attacked by a sabre-toothed tiger. That’s why now, even thousands of years later, rejection can feel like death, even if it’s just somebody not returning your email. ////////////////////Rejection can feel like death, even if it’s just somebody not returning your email. //////////////
The authors developed and tested a prognostic score (NEOS) for anti-NMDA receptor encephalitis. In multivariate regression modeling, five independent predictors of a poor outcome were identified: lack of clinical improvement after 4 weeks of treatment (OR, 12.10), need for ICU admission (OR, 5.89), treatment delay >4 weeks (OR, 2.52), abnormal MRI, and CSF WBC count >20/µL. The NEOS score was constructed by assigning 1 point to each of these variables. The score was strongly associated with the probability of a poor functional status at 1 year (mRS score ≥3). Poor outcomes were found in 3% of patients with scores 0 to 1 and 69% of patients with scores of 4 to 5.
The NEOS score may be a useful clinical tool in patients with anti-NMDA receptor encephalitis.
Choking is a ubiquitous and extremely frustrating human weakness – as the stakes are raised, our performance usually improves, but only up to a point, beyond which the pressure gets too much and our skills suddenly deteriorate. Any new psychological tricks to ameliorate this problem will be welcomed by sports competitors, students and anyone else who needs to be at their best under high pressure situations.
A fascinating paper in Social Cognitive and Affective Neuroscience documents a new technique for reducing choking that has to do with altering how you look at what is at stake. Moreover, the research shows how this act of reappraisal is reflected in altered activity in a key brain area that’s previously been implicated in how well we can maintain our fine motor control under pressure.
Important to understanding the new research is a study published a few years ago. A team led by Vikram Chib at Johns Hopkins University School of Medicine first showed – just as you’d expect – that as they raised the monetary stakes, people were more likely to choke at a computer-based task that required fine motor control and coordination, and that this was especially true for people who are more “loss averse”, as identified by their choices in an earlier gambling game – that is, these folk were more motivated to avoid losing money they had, rather than risking what money they had to gain more (loss aversion is a general human tendency, but some people are more loss averse than others).
The researchers also scanned their participants’ brains during the task and found the behavioural results were reflected in the activity of a key brain structure known as the ventral striatum. As the stakes on offer were raised, this was at first mirrored in increased activity in this brain structure (an effect also well-established by prior research). However, among highly loss averse participants, when they began the motor task, activity in their ventral striatum dramatically reduced, and there was less communication between this brain structure and motor control regions at the front of the brain. And the more this happened, the more the participants tended to choke and their performance suffer.
The researchers interpreted this as a kind of neurally mediated switch in mindset – once the loss averse participants started performing, they saw the large monetary prize on offer not as something to be gained, but something to be lost if they failed at the task – thus, triggering an aversive emotional reaction, mediated by lost activity in ventral striatum, and contributing to consequent counterproductive loss of motor control.
This postulated switching process is critical for understanding the new technique for reducing choking, which I’ll come to shortly.
Intriguingly, when the researchers altered the stakes of the task, so that there was no money to be won, but rather success meant keeping (i.e. not losing) money the participants already had, then the more loss averse participants were now less prone to choking at higher monetary amounts (and this was reflected in their showing a smaller reduction of ventral striatum activity during performance of the task, thus avoiding the adverse effect this lost activity could have on motor control).
This earlier surprising finding is the inspiration for the new technique for reducing choking. It seems non-sensical at first: why would loss averse participants be less adversely affected by the pressure of performing to avoid the risk of losing a large amount of money? The researchers think it’s because of the aforementioned neurally mediated mindset switch, but this time operating in the other direction – the participants saw success as a chance to gain the at-risk money, which for them was less aversive than the other “perform-to-win money” scenario (in turn, in the “performing-to-keep their money” situation they did not experience counterproductive emotional and neural effects on their performance).
Now we come to the new research – inspired by their previous results, Chib and his colleagues, including first author Simon Dunne at the California Institute of Technology, wondered if, in a typical “perform-to-win money” scenario, it might be possible for participants to consciously alter how they viewed these stakes – to pretend, in effect, that they were performing to avoid losing their money, thus tricking their brains into staying calmer under pressure.
The researchers used the same computer-based motor task in a brain scanner as before and, in a baseline control condition, they showed that when the monetary reward for success was high, participants were more likely to choke. But then they coached their participants to reappraise the stakes – to simply imagine that they already had the high prize money on offer and were performing for the chance to keep that money.
This mental technique dramatically reduced choking, and in fact it did so for all participants, not just those who were more loss averse (it’s possible the strength of the intervention overshadowed any differences in individuals’ loss aversion tendencies). Also, this beneficial effect of the reappraisal strategy was reflected in reduced activity levels in the ventral striatum specifically at the time that the stakes were first presented to the participants, when activity in this structure would normally encode the greater amounts of money on offer (it’s as if the brain was tricked into being less focused on the size of the stakes). Also, the more that ventral striatum activity was reduced during the presentation of the stakes, the less the participants choked.
In the new study, the researchers also measured participants’ skin conductance on their fingers – a measure of perspiration that signals greater stress levels. They found that in the reappraisal condition participants no longer showed signs of heightened stress when they failed at the task – further evidence that the reappraisal intervention had taken the pressure out of the situation.
Let’s put this new study in context. High stakes or incentives usually trigger choking by having an adverse effect on our emotional and cognitive control. Previously identified strategies for stopping choking have therefore focused on containing or countering these adverse effects – by using distraction, for instance, or forms of bodily relaxation, or visualising success. This new research represents a novel approach that is about reframing how one views the stakes at play, so that they do not even trigger such counterproductive cognitive and emotional processes in the first place.
“Because this intervention targets the incentive directly, it may have the advantage of being applicable to a greater range of domains in which choking is caused by the effect of the incentive …” the researchers said.
The researchers do not give examples of other contexts where this approach might be applied*. While it might be wise to wait for future research to test any such possibilities, I can imagine that in an academic exam context, you could try imagining you already had the university place and were performing to keep it; or in a sports context, you could imagine you already have the league points on the board and were performing to keep them.
When you're stressed, that's a sign to slow down, allow space, allow room to settle.
When you're tired, that's okay—happens to the best of us. It may be time to work harder, for longer—we don't all get a break when we need it. But make sure to take care of yourself as you go, and don't put the additional weight on your shoulders of a guilt-trip, when Instagram quotes tell you to self-care.
When you're confused, ask for advice. Or ask yourself what you think you should do. Your inner wisdom sometimes is right there with an answer.
When you're frustrated, first talk things over with yourself, before taking it out on a loved one or colleague.
Surgical correction should be considered in the presence of significant left to right shunting and pulmonary hypertension. The treatment of scimitar syndrome involves the creation of an inter-atrial baffle in order to redirect the pulmonary venous return into the left atrium. Another option is to re-implant the anomalous vein into the left atrium directly. However, the decision on which treatment to choose solely depends on the doctor. It depends on various factors like the amount of blood flowing to the inferior vena cava, the extent of shunting of the left to right, etc. If at all you are having any of the symptoms of scimitar syndrome, then it is always advisable to seek able guidance from your doctor.
The Enlightened Vagabond, The Life and Teachings of Patrul Rinpoche - Part 6: That's it!
By Matthieu Ricard on January 29, 2019
One day, as Patrul Rinpoche and a student close to his heart, Nyoshul Lungtok, were staying in retreat in the forest of Ari Dza, Patrul asked Lungtok, “Do you miss your mother?”
“Not really,” Lungtok replied.
“A-dzi!” said Patrul. “That’s what happens when you fail to cultivate compassion!” He continued, “Now go into that willow grove over there and train for seven days in accepting all beings as your mother, remembering their kind- ness. Then come back.”
Lungtok then spent seven days contemplating the fact that every sentient being had, in some previous lifetime, been his mother, reflected on their self- less kindness to him, and developed the aspiration to bring them happiness and enlightenment. As a result, genuine loving-kindness, compassion, and bodhichitta arose in his mind for all beings.
He returned to his teacher and explained his experiences during meditation.
“That’s it!” said Patrul, pleased. “That’s what it takes! When mind training is done properly, particular signs arise in your mind! Shantideva said that with practice, everything becomes easy. People just don’t do enough practice. If they did, they’d really make progress.”
This story is from the biography of the famous hermit and spiritual master Patrul Rinpoche translated from the Tibetan and published as The Enlightened Vagabond, and translated by Matthieu Ricard. The book includes excerpts from two biographies written by his direct disciples and over a hundred anecdotes gathered from the oral tradition, as well as a few teachings written by this remarkable 19th century master.
Buddhism at large is reluctant to address questions that other religions would consider crucial. Ideas such as the nature of God, what exactly happens after death, and so forth are fundamental to most faiths; in Buddhism, they are usually considered irrelevant mysteries. Zen Buddhism categorizes all such inquiries as literally impossible to answer and deeply distracting to one’s focus on the now. The combination of living in the moment, personal experience, inwardly directed meditation, and an overt rejection of certain metaphysical questions gives Zen Buddhism an interesting application of the concept of upaya. Strictly speaking, upaya is a spiritual form of pragmatism, best characterized as “whatever works.
The body is our house—and how we live in it and where we occupy it are uniquely ours, as well as being part of the common human experience. The body is a treasure trove and an exquisite vehicle for our practice of waking up and being with what is.
Inan G, Inal S. The Impact of 3 Different Distraction Techniques on the Pain and Anxiety Levels of Children During Venipuncture: A Clinical Trial. Clin J Pain. 2019 Feb;35(2):140-147. doi: 10.1097/AJP.0000000000000666. (Original) PMID: 30362982
Abstract
OBJECTIVES: Invasive procedures are important causes of pain and anxiety during hospitalization. This study aimed to evaluate the effect of 3 different distraction methods on the pain and anxiety levels of children during venipuncture.
METHODS: This was a randomized controlled trial conducted with 180 children of 6 to 10 years of age; data were collected in the months of August to November 2016. Participants were randomized in 4 groups; the children in group 1 watched cartoon movies (CM), the children in group 2 played video games (VG), the children in group 3 were distracted by their parents' verbal interactions (PI), whereas no distraction method was used on the children in group 4 (control group). The levels of anxiety and pain perception were evaluated independently based on the feedback from the children, the nurse observer, and the parents. The Children Fear Scale was used to evaluate anxiety levels and the Wong-Baker Pain Scale was used to evaluate the pain levels of the children.
RESULT: The difference between the groups based on both the anxiety levels and pain scores during venipuncture was statistically significant (P<0.05). The lowest level of anxiety and pain perception was reported in the VG group. The scores observed both in the CM group and the PI group were significantly lower than in the control group (P<0.05).
DISCUSSION: The distraction techniques of playing VG, watching CM, and PI appear to be effective in reducing anxiety and pain perception in children during the procedure of venipuncture. The most effective method was playing VG.
"The universe seems neither benign nor hostile, merely indifferent." ////////////////// B MTP - CALM BALM NUMB AND DUMB STONE //////////////////GET EMO OUT, SHORT CIRCUITS OF THE SAVANNAHS
For most diarrheal diseases, one can rehydrate with the child’s preferred beverage and not a more expensive, less tasty electrolyte solution (even apple juice)
Possible thrush, which looks like a dusting of powdered sugar on the tongue, does not need to be treated. I wait until it looks more like cream cheese or spreads beyond the tongue.
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