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pneumonia case study Department of Pediatrics, University of Hawaii John A. Burns School of Medicine. Chapter VI.11. Pulmonary Infections. Return to Table of Contents. A previously healthy 4 year old boy is brought to an urgent care center by his mother for difficulty breathing for School Calendar. Downloadable Pdf Calendars, one day. Three days prior he had developed a runny nose, cough, and low grade fevers with a temperature maximum of 101 degrees F (38.3 degrees C). He continued to take liquids well, but his solid intake has decreased. His temperature this morning was 103 degrees F (39.4 degrees C) and he was breathing fast and working hard to breathe. He does not have any ill contacts. He has never been hospitalized or had any surgeries.

He was born at 100% Original Papers | Case Evaluation term without any complications. He is not taking medications other than acetaminophen. His immunizations are up to date for Calendar. Pdf Calendars, his age (except he had not received the pneumococcal conjugate vaccine). His parents and 10 year old sister are healthy and Law Notes And Contract), the remainder of Calendar. Downloadable Academic his family history is non-contributory. There are no smokers in the household, and he has not traveled recently. He does not have a history of choking or vomiting. He has not had frequent ear or skin infections. He does not have a history of foul-smelling stools.

Exam: VS T 40 degrees C (104 degrees F), P 130, RR 40, BP 100/70, oxygen saturation 87% in Original Presentation, room air. His height and weight are in the 50th percentile for his age. Calendar. Downloadable Pdf Calendars! He is awake and alert, in moderate distress. His conjunctiva and TMs are normal. Tex10-13pg01.jpg! His nasal mucosa is erythematous with yellowish discharge. His lips and mucous membranes are dry. His neck is Calendar. Calendar supple, with several small anterior cervical lymph nodes.

Lungs: Moderate subcostal, intercostal, and supraclavicular retractions, symmetric expansion, dullness to percussion at the right base, increased vocal fremitus over Law Notes the right base, decreased air entry over right lower lobe with crackles, no wheezes. Heart: Tachycardia, regular rhythm without murmur. Pulses are 2+, and capillary refill time is 3 seconds. Academic! His abdomen, skin, and neurological examinations are unremarkable. CBC WBC 20,000, 70% segs, 11% bands, 15% lymphs, 3% monos, 1% eos. Hemoglobin 12.4, platelet count 280,000. 100% Original Papers | Case Presentation! Chest x-ray (CXR): Right lower lobe opacity consistent with a round pneumonia (technically air/space disease, commonly called infiltrates by most physicians). Because of the hypoxia, he is given supplemental oxygen (with subsequent improvement in oxygen saturation), as hospitalization arrangements are made. A 20 cc/kg infusion of normal saline was given through an intravenous (IV) line and then maintenance fluids are started. A blood culture is obtained and he is started on IV cefuroxime. He improves over Calendar. Pdf Calendars the next day.

His respiratory distress slowly resolves and he is weaned off supplemental oxygen over the next two days. His blood culture shows no growth. Application. State Application! He is discharged home on high dose amoxicillin for a total of 10 days of therapy. His discharge diagnosis is probably pneumococcal pneumonia. Acute childhood respiratory infections cause significant morbidity and mortality worldwide. Mortality is high in developing countries with up to one-third of deaths in School Calendar. Downloadable Pdf Calendars Calendar, children less than 5 years caused by acute respiratory infections (ARI) (1). The disparity in mortality is due to the severity of infection (perhaps due to differences in nutrition, overall health, immunization practices, and Employee Application. State Application, medical care availability) since the incidence of acute respiratory infections is similar between developed and School Calendar, developing countries with infants experiencing about 4-8 episodes per year (1). In the US, mortality from ARIs has declined since 1968 (1,2). There are 2 basic classification systems used for acute respiratory tract infections: the case-management classification system used by the World Health Organization (WHO) and the traditional clinical classification system (1). The case management system divides ARIs by symptoms (i.e., stridor, wheezing, and Tex10-13pg01.jpg, no wheezing) and their severity (i.e., mild, moderate, severe, and very severe). The traditional system classifies ARIs by Downloadable Academic, upper respiratory tract infections (e.g., acute otitis media, pharyngitis), middle respiratory tract infections (e.g., croup and epiglottitis), and lower respiratory tract infections (e.g., bronchiolitis, bronchitis, pneumonia).

Therefore, studies evaluating ARIs are not uniform and use different definitions from clinical findings alone to clinical findings in combination with other various ancillary tests (e.g., chest radiography). Of the acute respiratory infections, pneumonia has the highest mortality rate accounting for approximately 70% of the Tex10-13pg01.jpg, worldwide 4.5 million deaths from acute respiratory infections (4). Although mortality from pneumonia in children in School Downloadable Academic Calendar, the United States has declined by 97% between 1939 and 1996 (5), pneumonia continues to be a leading cause of morbidity in children. The risk of acquiring pneumonia is highest in children less than 5 years of age (1). The etiology of Law Notes And Contract) pneumonia varies and School Calendar. Downloadable Academic, depends on: the age of the child, where the pneumonia was acquired (i.e., community vs. nosocomial), local epidemiology (e.g., influenza epidemics), host factors (e.g., immunologic status, recent or intercurrent antibiotic use, vaccination, and overall health status of the child), and environmental factors (e.g., travel, season of the Papers | Case Presentation Evaluation, year, daycare, or crowded living conditions) (4,6-9). Determination of the precise etiology of pneumonia often requires invasive testing (e.g., lung biopsy), and Calendar. Calendar, therefore, this is done infrequently. Sample Letter To Whom It May Letter Sample! Rather the etiology of pneumonia is Academic usually based on generalizations in the relevant clinical setting. In the neonatal period, the most common cause of bacterial pneumonia is | Case Study Presentation group B beta-hemolytic streptococci (GBS) and School Calendar. Downloadable Academic Calendar, gram negative enteric bacilli (e.g., E.coli), the same organisms associated with neonatal sepsis (4). Repair, Flyer Templates! In infants and children outside of the neonatal period, viruses are the School, most common cause of pneumonia (4,6,10-11) and respiratory syncytial virus (RSV) is one of the most common causes in infancy, especially in premature infants (9,12).

Of the bacterial pathogens, Streptococcus pneumoniae (pneumococcus) occurs most frequently (6,9,11,13); however, the studies isolating S. pneumoniae were performed prior to Tex10-13pg01.jpg, the licensure of the Calendar. Downloadable Pdf Calendars, pneumococcal conjugate vaccine (6). Letter - The Letter! Outcome analysis of the 7-valent pneumococcal conjugate vaccine demonstrated that up to 33% of chest radiograph confirmed pneumonia were prevented in immunized patients compared to those who were not immunized (14). Therefore, a different bacterial pathogen may supersede S. Calendar. Academic Calendar! pneumoniae as the most common cause of bacterial pneumonia in the coming years. Other organisms to consider are Chlamydia trachomatis in infants 3-19 months of age (4) and Mycoplasma and Chlamydia pneumoniae in children and adolescents (8-9,11-12). In special cases, for example, patients with neuromuscular impairment and 25+ Best Repair, Flyer, impaired swallowing, aspiration pneumonia with anaerobic bacteria should be considered (15). The etiology of Calendar. Calendar pneumonia varies in other conditions including immunosuppressed patients, nosocomial infections, cystic fibrosis patients, and Application. Employee, anatomic airway anomalies (e.g., tracheostomies). In addition, the etiology of pneumonia is complicated since mixed infections (e.g., viral-bacterial) can occur in Calendar, 16-34% of 25+ Best Car Sale, Repair, Wash patients (7,11,13). The lower respiratory tract in healthy persons is sterile (16). Bacteria access the respiratory tract by Pdf Calendars Academic, inhalation, microaspiration, or by hematogenous spread. Templates! If bacteria gain access to alveoli, host immunologic systems begin to work on Downloadable Pdf Calendars, eliminating bacteria.

There are 2 major mechanisms by which lung defenses work to keep the airways sterile: physical defenses (i.e., mucociliary clearance and lymphatic drainage) and mechanisms that destroy bacteria (i.e., opsonization, specific immunoglobulin G antibody (IgG), alveolar macrophage ingestion, or complement mediated bacterial lysis) (17). If these mechanisms fail, polymorphonuclear leukocytes (PMNs) are recruited with a resultant inflammatory response. Perpetuation of this inflammatory response leads to pneumonia. There are 4 major histologic steps seen in 100% Original Papers | Case Study Evaluation, pneumococcal pneumonia described by Tuomanen, et al (18): engorgement, red hepatization, grey hepatization, and resolution. Engorgement is associated with presence of Pdf Calendars Academic Calendar bacteria in the alveoli and an associated serous exudate. This then progresses to red hepatization secondary to leakage of erythrocytes into the alveoli. The next phase, grey hepatization, results from leukocyte migration to Tex10-13pg01.jpg, the affected area with intravascular fibrin deposition disrupting perfusion to the area. The final phase results in resolution, with phagocytosis of pneumococci and Downloadable Calendar, clearance of fibrin and other debris.

Outside of the neonatal period, pneumonia is suspected in patients with clinical signs and symptoms suggestive of And Contract) impairment of the Pdf Calendars Calendar, lower respiratory tract. Distinguishing bacterial from other causes of pneumonia cannot be accomplished by clinical findings alone (7). Symptoms of To Whom It May Concern pneumonia are nonspecific and include: fever, ill appearance, cough, fatigue, decreased appetite and sometimes, abdominal pain. Calendar. Downloadable Academic! Signs of lower respiratory tract involvement include: tachypnea (greater than 50 breaths/minute in children less than 12 months, and greater than 40 breaths/minute for ( Torts, older children) (4), cyanosis, increased work of breathing (i.e., use of accessory muscles, grunting), pleuritic pain, and abnormal auscultatory findings. These signs do not differentiate a viral from bacterial process.

A chest radiograph is School Downloadable Academic used to verify the clinical suspicion of pneumonia and Law Notes And Contract), characterize the School Calendar. Pdf Calendars, disease process, but may not be performed on every patient. Viral respiratory tract infections are often associated with hyperinflation, perihilar peribronchial infiltrates, segmental or lobar atelectasis, and hilar adenopathy (19). State Employee Application! Lobar consolidation and fluffy alveolar infiltrates with air bronchograms are more characteristic of bacterial infection (13). However, there is overlap between these two groups (13). Computed tomography and Pdf Calendars, ultrasound of the chest are used in special circumstances (e.g., evaluate for pleural effusion, adenopathy, improved imaging of lung architecture) but these are not routinely obtained (4). Commonly used screening laboratory tests such as white blood cell count with differential, erythrocyte sedimentation rate (ESR), and the C-reactive protein (CRP) are not accurate in differentiating between bacterial, viral, mixed, or idiopathic causes of childhood pneumonia (7). Determination of precise etiology of pneumonia is difficult due to Business To Whom Concern Letter Sample, the lack of sensitive and specific tests. Downloadable Academic! Many clinicians treat pneumonia empirically with minimal laboratory or radiographic evaluation and thus up to 80% of non-bacterial pneumonia may be treated with antibiotics (6). This approach is Papers Study Presentation satisfactory when clinical risk is deemed to be low.

When a more precise diagnosis is required, more invasive techniques are required. Bacteria found in the blood, pleural fluid (thoracentesis), or lung tissue is considered diagnostic in School Calendar. Pdf Calendars, a patient presumed to have pneumonia (4). Blood cultures are only Tex10-13pg01.jpg positive in School Pdf Calendars Academic Calendar, 1-8% of pneumonia (11) but continue to Employee State Employee Application 11 Employee, be recommended (4). Some question the necessity of blood culture after cost-based analyses (6, 11). Transthoracic needle aspirates, transtracheal aspirates, and open lung biopsy (the gold standard for diagnosis) are rarely performed due to the risk involved for these procedures (11,20), except in School, severe cases or in immunocompromised hosts (4).

Sputum is often contaminated with organisms unrelated to the specific etiology (16) and is difficult to obtain in children less than 8 years old (4). Repair, Wash! A sputum sample that may be helpful is characterized by Downloadable Pdf Calendars Academic, many polymorphonuclear cells and a bacteria of single morphology on gram stain (4). Bronchoalveolar lavage from bronchoscopy is difficult to Tex10-13pg01.jpg, interpret as well. The results are non-specific (i.e., higher neutrophil counts than lymphocyte counts in Downloadable, patients with infection) and the organism found may or may not be the etiologic agent (16). Bacterial serology and bacterial antigen testing are often difficult to interpret (4,6). Bacterial cultures of the nasopharynx or throat correlate poorly with lung tissue cultures and are not helpful in establishing a diagnosis (16). Tex10-13pg01.jpg! Specific viral antigen testing, along with cultures for suspected pathogens, serologies for Mycoplasma and School Downloadable Pdf Calendars Academic Calendar, Chlamydia, and PPD skin testing for tuberculosis may be helpful (6).

Pneumonia is treated with antimicrobials when the clinical suspicion for bacterial etiology is high. Employee Application 11 Employee! Greater pneumonia severity and findings that are consistent with bacterial pneumonia (e.g., lobar consolidation, leukocytosis, high fever) are more likely to warrant antimicrobial treatment. Young infants, unreliable parents, poor access to medical care, and more severe infections often require hospitalization. Treatment of pneumonia is often empirically based and thus, information on antibiotic resistance patterns and mechanisms of resistance is important to determine the most appropriate treatment. School Pdf Calendars Calendar! For S. pneumoniae, the most common mechanism of resistance to Sample Letter Concern Sample, penicillins is alteration of penicillin-binding sites that can be overcome with higher doses of the drug (6). For macrolides, alteration to the 50S ribosomal binding site of the macrolide inhibits binding of the antibiotic and thus, prevents protein synthesis inhibition (6). In addition, there is also an increase in efflux pumps for macrolides and this property can be overcome by using macrolides that achieve high tissue concentrations at the site of infection (e.g. azithromycin) (6). Penicillin resistant pneumococci are often resistant to School Pdf Calendars, multiple drugs including macrolides and trimethoprim-sulfamethoxazole (21). Therefore, high-dose amoxicillin and/or azithromycin are recommended for empiric treatment of ( Torts And Contract) community-acquired pneumonia in children (6,8-9,11-12,20). Some clinicians will use clinical factors and ancillary tests in aggregate such as age, exposures, CXR pattern, fever, and leukocytosis, to stratify the risk to favor pneumococcus (high dose amoxicillin would be better) or Mycoplasma/Chlamydia (macrolide would be better). For those children requiring hospitalization, a second or third generation cephalosporin, occasionally in combination with a macrolide, is generally recommended (8,20).

Most treatment regimens are continued for a total of Calendar. 7-14 days although this is based on little evidence (4). Pneumonia due to Staphylococcus aureus is uncommon, but particularly severe. S. aureus pneumonia usually results from inhalation of organisms, but it may also occur in patients with a cutaneous source (e.g., impetigo, boils, abscesses) with hematogenous spread or staphylococcal bacteremia from 100% Original | Case Study Presentation Evaluation another source (e.g. osteomyelitis, central line infection). Calendar. Pdf Calendars Calendar! If S. 100% Original Study! aureus pneumonia is suspected, vancomycin should be started empirically. Culture and sensitivity data permits changing to an alternate antibiotic later. Pleural effusion (empyema), pneumothorax, and pneumatoceles often complicate S. Calendar. Downloadable Pdf Calendars! aureus pneumonia. Pleural effusions can be classified in several ways. They can be a transudate or an exudate based on their protein content. Law Notes! A subpulmonic effusion versus an empyema is more clinically relevant. The former implies a transudate which is usually sterile, while the term empyema is usually used to describe pus (purulent exudate) with a positive gram stain and culture.

The overall outcome in children with pneumonia is Pdf Calendars excellent. The majority of children will recover without complications (11). Follow up chest radiographs are not required routinely, but should be performed for patients with complicated pneumonia, persistent respiratory problems, pleural involvement, and neonates (4,22). About 80% of infiltrates on CXR will resolve by 3-4 weeks and the remainder will usually resolve by 3 months (22). Recurrent pneumonia with radiologic clearance between episodes requires further evaluation (e.g., immunodeficiencies, gastroesophageal reflux, pulmonary anomalies, etc.) (4). Bronchiolitis is the leading cause of hospitalization for Car Sale, Repair, Wash Flyer Templates, respiratory tract infections in young children (4,23-25). Respiratory syncytial virus (RSV) is the primary cause of bronchiolitis, but parainfluenza virus, human metapneumovirus, and adenovirus may also cause bronchiolitis (23-24). In the United States, the majority of RSV infections occur during the months of November to March (4,23).

RSV infections account for a significant amount of morbidity and health care expense in the young age group (24). RSV is transmitted by Calendar. Downloadable Pdf Calendars Academic, direct contact with large droplets or fomites. 100% Original Presentation Evaluation! Transmission can be limited by good handwashing (23). RSV bronchiolitis results from the Calendar. Academic, spread of RSV to the lower respiratory tract after an incubation period 2-8 days where the virus undergoes replication in the nasopharynx (23). The infection results in infiltration of the Sample Letter To Whom It May Letter Sample, respiratory epithelium with resultant inflammation and necrosis, sloughing of the epithelium and increased mucus production causing airflow limitation in the small airways leading to the hallmarks of the disease (23). Thus, affected infants have signs of airflow limitation including hyperinflation, atelectasis, and wheezing. The diagnosis is often made on clinical grounds during the RSV season. Diagnostic testing can be done by immunofluorescence and enzyme-linked immunoabsorbent assay (ELISA) tests if the diagnosis is unclear. Therapy is often supportive which may include: supplemental oxygen, fluids, and upright positioning.

Aerosolized ribavirin is the only known proven therapy for RSV infection, but its expense, potential toxicity, difficulty of administration, and lack of conclusive evidence for its efficacy (24,26) limit its use. The use of bronchodilators and corticosteroids are controversial and may only be mildly effective at best (i.e., not been proven to be highly efficacious) (24-26). For those with moderate to School Calendar. Downloadable Pdf Calendars, severe disease, helium-oxygen mixtures or nasal continuous positive airway pressure may be beneficial in improving gas-exchange and symptomatology (27-30). Montelukast, a leukotriene antagonist, has recently been reported to make a difference in Letter Concern, future wheezing episodes (31). Prophylaxis with palivizumab (RSV monoclonal antibody) or RSV-IVIG is given to select pediatric populations recommended by School Calendar. Downloadable, the American Academy of Pediatrics during RSV season to reduce RSV infection risk (32). Growing premature infants and infants with congenital heart disease and Application. State Application, other chronic lung conditions are at Calendar. Downloadable Calendar increased risk for RSV pneumonia, apnea and respiratory failure. Healthy term infants with RSV usually develop mild bronchiolitis. Older children, teens and adults with RSV will usually have cold symptoms. Bronchiolitis is usually a self limited disease and complete resolution takes about 4-8 weeks. And Contract)! In neonates and Downloadable Academic, young infants, bronchiolitis may present with apnea and minimal respiratory symptoms, but the Employee Application. State Application 11 Employee, apnea is Calendar. Calendar usually short-lived (33).

Although bronchiolitis self-resolves, patients with RSV bronchiolitis may be predisposed to future episodes of wheezing (34). RSV infection can recur since there is an incomplete and poorly sustained immune response (23). In summary, bronchiolitis and pneumonia significantly impact the pediatric population. Determining likely etiologies of pneumonia and understanding effective treatment modalities will improve patient outcomes. Acknowledgments: I would like to thank Edward Fong, MD, Leslie Barton, MD and John Mark, MD for their critical review of the chapter. 1. Which of the following is the most common cause of pneumonia outside of the neonatal period? 2. S. pneumonia resistance to penicillins is due to: . . . . Tex10-13pg01.jpg! . a. School Academic Calendar! Production of Original Presentation beta-lactamase. . . . . . b. Alteration of penicillin binding proteins. . . . School Calendar. Downloadable Academic Calendar! . . c. Law Notes ( Torts And Contract)! Increased efflux pumps.

. . . . . d. School Calendar! Low tissue bioavailability. 3. True/False: Nasopharyngeal and Letter It May Concern - The, throat cultures are useful in determining etiology of bacterial pneumonia. 4. True/False: Lobar consolidation on chest x-ray provides conclusive evidence for bacterial pneumonia. 5. Which factor does not appear to Downloadable Academic Calendar, affect the etiology of 100% Original pneumonia? . . . School Calendar. Downloadable Academic Calendar! . . b. Vaccination status. . . Tex10-13pg01.jpg! . . . c. Current antibiotic use. 6. The most common cause of bronchiolitis is: . . . . . a. Respiratory syncytial virus.

. . . . . b. Human Metapneumovirus. 7. True/False: Bronchiolitis may initially present with apnea and minimal respiratory symptoms. 8. School Downloadable! Treatment of bronchiolitis should include all of the Original | Case Study Presentation Evaluation, following except: a. Supplemental oxygen for Downloadable Academic, infants with hypoxia. b. Intravenous fluids and ( Torts, close monitoring of nutritional status. c. Good handwashing. d. Calendar. Academic Calendar! Antibiotics. 9. True/False: Corticosteroids and bronchodilators are highly efficacious therapies for RSV bronchiolitis. Pneumonia case presenting with abdominal pain: Yamamoto LG. Abdominal Pain with a Negative Abdominal Examination. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1994, volume 1, case 3. Available online at: Staph pneumonia case: Yamamoto LG, Young LL. Tachypnea and Abdominal Pain.

In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 2, case 5. Available online at: Series of pediatric chest radiographs: Yamamoto LG. Papers Study! Test Your Skill In Reading Pediatric Chest Radiographs. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1995, volume 3, case 20. School Calendar. Pdf Calendars Academic! Available online at:

Another series of pediatric chest radiographs: Yamamoto LG. Test Your Skill In Reading Pediatric Chest Radiographs. In: Yamamoto LG, Inaba AS, DiMauro R (eds). Radiology Cases In Pediatric Emergency Medicine, 1996, volume 4, case 5. Available online at: 1. Graham NMH. The Epidemiology of Application. State Application Acute Respiratory Infection in Children and Adults: A Global Perspective. Downloadable Pdf Calendars Academic Calendar! Epidemiol Rev 1990;12:149-178. 2. National Center for Health Statistics. National Vital Statistics report ( 2001;49(1):14. 3. Dixon RE.

Economic Costs of Respiratory Tract Infections in the United States. Am J Med 1985;78(6B): 45-51. 4. Miller MA, Ben-Ami T, Daum RS. Sample Business It May Concern - The Letter Sample! Chapter 39-Bacterial Pneumonia in Neonates and Older Children. In: Taussig LM, Landau LI (eds). Calendar. Academic Calendar! Pediatric Respiratory Medicine, first edition. 1999, St.

Louis: Mosby, pp. 100% Papers Presentation Evaluation! 595-664. 5. Dowell SF, Kupronis BA, Zell ER, Shay DK. Mortality From Pneumonia in Children in the United States, 1939 Through 1996. N Engl J Med 2000;342(19):1399-1407. 6. Bradley JS. Management of Community-Acquired Pediatric Pneumonia in an Era of Increasing Antibiotic Resistance and Conjugate Vaccines. Pediatr Infect Dis J 2002;21(6):592-598. 7. Nohynek H, Valkeila E, Leinonen M, Eskola J. Erythrocyte Sedimentation Rate, White Blood Cell Count and Serum C-reactive Protein in Assessing Etiologic Diagnosis of Acute Lower Respiratory Infections in Children. Pediatr Infect Dis J 1995;14(6): 484-490.

8. Nelson J. Community-Acquired Pneumonia in Children: Guidelines for Treatment. Pediatr Infect Dis J 2000;19(3):251-253. 9. Heiskanen-Kosma T, Korppi MN, Jokinen C, et al. Etiology of Childhood Pneumonia: Serologic Results of Downloadable Pdf Calendars Academic a Prospective, Population-Based Study. Pediatr Infect Dis J 1998;17(11):986-991. 10. McIntosh K. Community-Acquired Pneumonia in Children. Application. State Employee! N Engl J Med 2002;346(6);429-437. 11.

Ruuskanen O, Mertsolon J. Childhood Community-Acquired Pneumonia. Sem Resp Infect 1999;14(2):163-172. 12. McCraken, GH Jr. Etiology and Treatment of School Downloadable Academic Calendar Pneumonia. Pediatr Infect Dis J 2000;19(4):373-377. 13.

Korppi M, Kiekara O, Heiskanen-Kosma T, Soimakallio S. Comparison of Radiological Findings and Microbial Aetiology of Childhood Pneumonia. Acta Paediatr 1993;82: 360-363. 14. 25+ Best Repair, Templates! Overturf GD, Committee on Infectious Diseases, American Academy of Pediatrics. Technical Report: Prevention of Pneumococcal Infections, Including the Use of Pneumococcal Conjugate and Polysaccharide Vaccines and Antibiotic Prophylaxis. School Calendar. Pdf Calendars Calendar! Pediatrics 2000;106(2):367-376. 15. Brook I, Finegold SM. Bacteriology of Tex10-13pg01.jpg Aspiration Pneumonia in Children.

Pediatrics 1980;65(6):1115-1120. 16. Calendar. Pdf Calendars! Laurenzi GA, Potter RT, Kass EH. Bacteriologic Flora of the Lower Respiratory Tract. N Engl J Med 1961;265:1271-1278. 17. Green GM, Kass EH.

The Role of the Alveolar Macrophage in the Clearance of Bacteria from the | Case Study Evaluation, Lung. J Exp Med 1964;119:167-175. 18. Tuomanen EI, Austrian R, Masure HR. Pathogenesis of Pneumococcal Infection. School Downloadable! N Engl J Med 1995(19);332:1280-1284. 19. Original Papers Study Evaluation! Wildin SR, Chonmaitree T, Swischuk LE. Roentgenographic Features of Common Pediatric Viral Respiratory Tract Infections.

Am J Dis Child 1988;142:43-46. 20. Hart CA, Duerden BI. Respiratory Infections. J Med Microbiol 2002;51:903-914. 21. Whitney CG, Farley MM, Hadler J, et al. Increasing Prevalence of Multidrug-Resistant Streptococcus Pneumoniae in the United States. N Engl J Med 2000;343(26):1917-1924. 22. Grossman LK, Wald ER, Nair P, Papiez J. Roentgenographic Follow-Up of Acute Pneumonia in Children.

Pediatrics 1979(1);63:30-31. 23. Hall CB. Respiratory Syncytial Virus and Parainfluenza virus. N Engl J Med 2001;344(25):1917-1928. 24.

Greenough A. Respiratory Syncytial Virus Infection: Clinical Features, Management, and Prophylaxis. Curr Opin in Pulm Med 2002;8:214-217. 25. Jartti T, van den Hoogen B, Garofalo RP, et al. Metapneumovirus and Acute Wheezing in Children. Lancet 2002;360:1393-1394.

26. Patel H, Platt RW, Pekeles GS, Ducharme FM. A Randomized Controlled Trial of the Effectiveness of Nebulized Therapy with Epinephrine Compared with Albuterol and Saline in Infants Hospitalized for Acute Viral Bronchiolitis. J Pediatr 2002(6);141:818-824. 27. School Calendar. Downloadable Academic! Hollman G, Shen G, Zeng L, et al.

Helium-Oxygen Improves Clinical Asthma Scores in Law Notes And Contract), Children with Acute Bronchiolitis. Crit Care Med 1998;26(10):1731-1736. 28. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Heliox Therapy in School Calendar. Calendar, Infants with Acute Bronchiolitis.

Pediatrics 2002(1);109:68-73. 29. Sample Letter To Whom Concern Letter Sample! Beasley JM, Jones SEF. Continuous Positive Airway Pressure in Bronchiolitis. British Medical Journal 1981;283:1506-1508. 30.

Soong W, Hwang B, Tang R. Continuous Positive Airway Pressure by Nasal Prongs in Bronchiolitis. Pediatr Pulmonol 1993;16:163-166. 31. Bisgaard H for the Study Group on School Calendar. Pdf Calendars, Montelukast and Respiratory Syncytial Virus. Business To Whom - The! A Randomized Trial of Montelukast in School Downloadable Academic, Respiratory Syncytial Virus Postbronchiolitis. Am J Respir Crit Care Med 2003;167:379-383. 32. Application. Employee Application 11 Employee! Halsey NA, Abramson JS, Chesney PJ, et al.

American Academy of Pediatrics: Prevention of Respiratory Syncytial Virus Infections: Indications for the Use of Palivizumab and Update on the Use of RSV-IGIV. Pediatrics 1998;102(5):1211-1216. 33. Bruhn FW, Mokrohisky ST, McIntosh K. Apnea Associated with Respiratory Syncytial Virus Infection in Young Infants. J Pediatr 1977;90:382-386. 34. Sigurs N, Bjarnason R, Sigurbergsson F, Kjellman B. Respiratory Syncytial Virus Bronchiolitis in Infancy is an Important Risk Factor for Downloadable Calendar, Asthma and Allergy at Sample Letter To Whom Concern - The Letter Sample Age 7. Am J Respir Crit Care Med 2000;161:1501-1507. Answers to questions. 1.c. Overall, viruses cause the majority of Calendar. Downloadable Academic Calendar pneumonias in children; however, the incidence of viral pneumonia decreases with age, becoming less common in older children and adolescents. 4.False.

Lobar pneumonias are more likely to be of bacterial etiology, but this is not definitive since some lobar pneumonias will still be viral.

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Support human rights. There are four views of ethics: Utilitarian view – Decisions which are based on outcomes or results. Rights view of ethics – Decisions that are concerned to shielding individual liberties and privileges and rights of confidentiality, freedom of principles, freedom of speech and life safety. Theory of justice view of ethics – Decisions which are enforced to rule honestly and independently. Integrative social contracts theory – Decisions which are based on practical and normative factors.

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It has to depend on the society. The business cannot provide all the School Pdf Calendars Academic Calendar factors for the business excepting capital and organization. For the supply of other essential factors it has to depend on the society. From the society he may get the cooperation of the supplier, customer, worker and Employee State Employee investors etc. The social responsibility involves in conducting the business activities in accordance with principles and functions recognized by School Calendar. Downloadable Pdf Calendars Academic Calendar and acceptable to the society. Sample Business Letter To Whom Concern Sample. On behalf of the business, the managers discharge various social responsibilities.

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d. specification of personal qualification for managers and. e. special work process in its actualisation. C. Arnst and others, “When Green Begets Green,” Business Week , November 10, 1997, pp. 98–106. Joseph M Katz Graduate School of Business, University of Pittsburgh — ethics/Australia/case.html JTB_Journal of Technology and Business. School Calendar. Pdf Calendars Calendar. October 2007 Kanter, R. 100%. M. (1979, July–August). Power failure in School Calendar. Academic Calendar management circuits. Harvard Business Review, 57, 65–75. Kellerman, B. (2004).

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E. Acceptance of draft, certified check; acceptance varying draft (§§ 3-409 through 3-410) F. Refusal to Employee State pay cashier's, teller's and certified checks (§ 3-411) G. Obligations of issuer, acceptor, drawer, indorser (§§ 3-412 through 3-415) H. Transfer and presentment warranties (§§ 3-416 through 3-417) I. Payment or acceptance by mistake (§ 3-418) J. Instruments signed for Downloadable Pdf Calendars Academic, accommodation (§ 3-419) K. Conversion of instrument (§ 3-420) VI. Dishonor (presentment, dishonor, notice, excuse, evidence of dishonor) (§§ 3-501 through 3-505)

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Financing the organization. A. Sources of finance. B. Securities issuance and characteristics. C. Calendar. Pdf Calendars Academic Calendar. Dividends and distributions. D. Redemptions and repurchases. V. Management and control.

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D. Downloadable Pdf Calendars Academic Calendar. Members and managers. VI. Fiduciary duties. A. Directors, officers, and shareholders. B. Managers and members. VII. Close corporations and special control devices. A. Share transfer restrictions. B. Special agreements allocating authority.

C. Resolutions of disputes and deadlocks. D. Option or buy/sell agreements. VIII. Organizational structure including relationships between parents and subsidiaries. 1. Articles of incorporation and bylaws.

2. Articles of organization, certificates of formation, and operating agreements. B. Mergers and consolidations. C. Sales of substantially all assets. E. Exchanges of securities. F. Dissolution of organization. IX. Shareholder and member litigation: direct, derivative, and class litigation.

I. Law Notes ( Torts. Intestate succession. A. Share of the surviving spouse. B. Share of children and more remote descendants. 1. Adopted children. 2. Child born out of wedlock.

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1. Downloadable Pdf Calendars Academic. Lapsed legacies. 6. Slayer statutes. 8. Simultaneous death. 10.Classification of 100% | Case legacies and devises. 11.Gifts to classes. 12.Gifts to children and Downloadable Academic Calendar issue. J. Will contests. 1. Age requirement.

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VIII. Alternatives to adoption. A. Artificial insemination by donor. B. Surrogacy arrangements. C. In vitro fertilization, gestational surrogacy, and embryo transplantation. Federal Civil Procedure. I. Jurisdiction and venue. A. Subject matter jurisdiction.

1. Federal courts. B. Jurisdiction over parties. C. Jurisdiction over property. D. Service of process and notice. E. Venue, forum nonconveniens, and School Calendar. Downloadable Academic transfer. II. Law applied by federal courts. A. State law in federal court. B. Federal common law. III.

Injunctions and provisional remedies. IV. Pretrial procedures. B. Abstention doctrines. C. Joinder of parties and claims (including class actions) E. Adjudication without a trial. F. Pretrial conference and order. V. The trial process. B. Nonjury trials. C. Jury instructions. VI.

Verdicts and judgments. A. Jury verdicts. B. Judicial findings and Car Sale, Repair, Wash conclusions. C. Directed verdicts and nonsuits. D. Post-trial motions. E. Effect; claim and issue preclusion. F. Appealability and review. (*All citations to the UCC are to the 1999 Official Text.)

I. General UCC principles* A. Rules of School Pdf Calendars construction and application (§ 1-101, et seq.) B. General definitions and principles of Car Sale, interpretation (§1-201, et seq.) II. School Calendar.. Scope and applicability (§ 2-101, et seq.)

A. Applicable to transactions in goods (§ 2-102) B. Definitions—merchant, between merchants, goods (§§ 2-104, 2-105) C. Definitions relating to existence and formation of ( Torts And Contract) contracts (§ 2-106) III. Form, formation, and readjustment of contracts (§ 2-201, et seq.) A. Statute of frauds and exceptions (§ 2-201) B. Parol evidence (§ 2-202) C. Formation (§§ 2-204, 2-206, 2-207) D. Calendar. Downloadable Academic Calendar. Firm offers (§ 2-205)

E. Course of performance or practical construction (§ 2-208) F. Modification, rescission, waiver (§ 2-209) G. Delegation and Formal Business Memo Template Jpg Microsoft Word assignment (§ 2-210) A. School Calendar.. Unconscionability (§ 2-302) B. Open price term (§ 2-305) C. Output/requirement contracts (§ 2-306) D. Mode and terms of delivery and particulars relating to performance (§ 2-307 through 2-311) 1. Including tender of delivery, shipment and payment (§§ 2-503 through 2-505, 2-507 through 2-508; 2-511 through § 2-512) 2. Including risk of loss (§ 2-509 through § 2-510) 3. Including right of inspection and preserving evidence of goods in dispute (§§ 2-513, 2-515)

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A. Law Notes. Buyer's rights on improper delivery (§ 2-601) B. Academic Calendar. Rejection of goods; rights, obligations, and consequences (§ 2-602 through § 2-605) C. Acceptance, revocation of acceptance, and consequences (§ 2-606 through § 2-608) D. Adequate assurances; anticipatory repudiation(§ 2-609 through § 2-611) E. Installment contract (§ 2-612) VII. Template Jpg Microsoft Word. Remedies (§ 2-701, et seq.) A. Seller's remedies in general (§ 2-703)

1. Seller's rights to deal with goods as yet unde- livered (§ 2-704 through § 2-706) 2. Damages—measure, incidental damages (§ 2-708 through § 2-710) B. Buyer's remedies in Downloadable Calendar, general (§ 2-711) 1. Cover; nondelivery, repudiation, noncon- forming goods, incidental damages, deduction of damages from price (§§ 2-712 through § 2- 715; 2-717) 2. Specific performance (§ 2-716) C. Liquidated damages (§ 2-718) D. Contractual modification, limitation of remedies (§ 2-719) (*All citations to the UCC are to the 1999 Official Text.) I. ( Torts And Contract). General UCC principles* A. Rules of School Academic construction and application (§ 1-101, et seq.) B. General definitions and principles of interpretation (§1-201, et seq.)

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F. Including sufficiency of description (§ 9-108) G. Including security interests arising under Article 2 (§ 9-110) H. Priority of consignments (§ 9-103, 9-324) III. Validity of security agreements and rights of parties (§§ 9-201, et seq.) A. Title to collateral immaterial (§ 9-202) B. Enforceability (§ 9-203) C. After-acquired property; future advances (§ 9-204)

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holders and purchasers of negotiable instruments (§ 9-331) D. Priority of liens arising by law (§ 9-333) E. Alienability of debtor's rights (§ 9-401) F. Original Papers Study Presentation Evaluation. Priority among conflicting security interests (§§ 9-322 through 9-329) G. Fixtures (§ 9-334) H. Accessions; commingling (§§ 9-335, 9-336) I. Calendar. Downloadable Pdf Calendars Calendar. Subordination (§ 9-339) J. Defenses against assignee; modification of contract (§§ 9-404 through 9-406)

K. Termination statement (§ 9-513); release of collateral (§ 9-512) V. Default (§ 9-601, et seq.) A. Rights and remedies on default (§§ 9-601 through 9-606) 1. Including secured party's collection rights (§ 9-607) 2. Including secured party's right to Tex10-13pg01.jpg take possession and dispose of collateral (§§ 9-608 through 9-624) B. Debtor's rights (§§ 9-625 through 9-628) Trusts and Future Interests. A. Classification of trusts. B. Creation of trusts.

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