Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Policies that expose it especially diffcult for them to buy cheap besivance on-line think deliberatively individuals to buy 5 ml besivance with amex new ways of thinking and alternative (Mullainathan and Shafr 2013) generic 5ml besivance overnight delivery. Individuals who must understandings of the world can expand the available exert a great deal of mental energy every day just to set of mental models and thus play an important role ensure access to necessities such as food and clean in development. Poor people may thus be sion making can help societies achieve broadly shared forced to rely even more heavily on automatic decision goals like higher savings or better health and in this making than those who are not poor (chapter 4). Weekly reminders improved the rate of drug adherence to 53% from a baseline of 40%. Nonmonetary gifts Small nonfnancial incentives and prizes—like lentils Immunization rate and metal dinner plates—were combined with a reliable Among children aged 1–3, rates of full immunization were 39% with the immunization provider within the community in India. Public notices Small stickers were placed in randomly selected buses Trafc accidents encouraging passengers to “heckle and chide” reckless Annual insurance claims rates for accidents declined from 10% to 5%. Making products convenient Chlorine dispensers were provided free of charge at local Take-up of chlorination water sources, and promoters of chlorination to treat the take-up rate was 60% in households with dispensers, compared to water were hired to visit houses in Kenya. Inspirational messages Poor households were shown videos about how people Aspirations and investment like them had escaped from poverty or improved their Aspirations for children increased. Timing of cash transfers Part of a conditional cash transfer was automatically saved Enrollment in higher education and given as a lump sum at the time when decisions about Enrollment increased in the next school year, without a decline in current school enrollment were made in Colombia. Sources: Pop-Eleches and others 2011; Banerjee and others 2010; Habyarimana and Jack 2011; Kremer and others 2009; Bernard and others 2014; Barrera-Osorio and others 2011. The large income difference between just before the In all countries studied to date, whether low, mid harvest and just after affects fnancial decision mak dle, or high income, there is a divergence as early as ing. Right before the harvest, these farmers are much age three in the cognitive and noncognitive skills of more likely to have taken on loans and to have pawned children in households at the bottom of the national some of their belongings. This fnancial distress takes wealth distribution and those in households at the top. Farmers perform worse on the same series of cognitive the problem of insuffcient stimulation to children tests before receiving their harvest income than after is of particular concern for low-income countries. In this sense, pov ing countries found that socioemotional caregiving did erty imposes a cognitive tax. In contrast, the amount of cognitive stimulation that mothers provide is systematically lower in countries with lower Drawing on insights from modern measures of economic, health, and education variables, according to the United Nations Human Development behavioral and social sciences can Index (fgure O. In this study, the level of cognitive stimulation was measured by the number of times generate new kinds of interventions that a caregiver read books, told stories, and engaged in naming, counting, or drawing with the child. Commu ably low (such as moving school enrollment decisions nity health workers made weekly home visits to teach closer to periods when income is higher) or targeting mothers how to play and interact with their children assistance to decisions that may require a lot of band in ways that promote cognitive and emotional develop width (such as choosing a health insurance plan or ment. Children who were randomly selected to partic applying to a higher education program). In particular, it can dull the capacity to imagine a better life (Appadurai 2004). Evidence Household fnance also shows that interventions and policy designs that Making a good fnancial decision is diffcult. It requires alter this mental model so that people can recognize individuals to understand the future cost of money, their own potential more easily—or that at least spare focus on gains and losses evenhandedly, resist the temp poor people from reminders of their deprivation—can tation to consume too much, and avoid procrastinating. Child development High consumer debt often results from a form of High stress and insuffcient socioemotional and cog thinking automatically, in which individuals attach nitive stimulation in the earliest years, which tend to much more weight to current consumption through be associated with growing up poor, can impair the borrowing than to the loss of consumption that development of both the automatic decision-making will occur when they have to pay back a loan in the system (for instance, the ability to cope with stress) future. Some programs have helped individuals attain their An experiment with a low-income population in savings goals through the use of reminders that make Mexico shows how bandwidth constraints may limit the goals more salient. A series of studies in Bolivia, how people process fnancial information (Gine, Peru, and the Philippines show that simple, timely Martinez Cuellar, and Mazer 2014). Low-income indi text messages reminding people to save improve viduals from Mexico City were invited to choose the savings rates in line with their goals (Karlan, Morten, best one-year, 10,000 peso loan product (that is, roughly and Zinman 2012). Other programs have helped indi $800) from a randomized list of loan products resem viduals increase their savings by offering commitment bling ones locally available. Individuals could earn devices in which consumers voluntarily give up access rewards if they identifed the lowest-cost product. When savings accounts were offered in could identify the lowest-cost product when presented the Philippines without the option of withdrawal for with brochures designed by banks for their customers. The three categories of cognitive caregiving activities measured were reading books; telling stories; and naming, counting, or drawing with the child. When using the banks’ could choose a target for the number of accurately descriptions of their products, only 39 percent of the people could identify the typed felds he or she entered. When using the more straightforward summary sheet, achieved her target, she would be paid at the normal 68 percent could identify the cheapest credit. If people can simply do what they intend to do, there is no beneft to choosing this kind of contract because workers do not increase their pay if they meet the target, but lower their pay if they do not. But if workers recognize that there is a gap between intentions and actions, the commitment con tract can serve a useful purpose. Because effort has a cost in the present and a reward in the future, individu als may spend less time on effort than their deliberative minds would prefer. The commitment contract gives the individual an incentive to work harder than she might in the current moment when the work needs to be done. In the case of the data entry workers in India, about one-third chose the commitment contract— indicating that some of the workers themselves had a demand for commitment devices. Workers who opted for them increased their productivity by an amount equivalent to what would have been expected 39% of people could identify the cheapest 68% of people could identify the cheapest from an 18 percent increase in piece-rate wages (Kaur, loan product on the information lea ets loan product on a more straightforward from banks. The way that an identical level of pay is described = 10 people can also affect productivity. Take performance pay for teachers, in which teachers are paid a bonus at the end of the year that depends on the academic performance Source: Gine, Martinez Cuellar, and Mazer 2014. This kind of inter vention failed to improve test scores in low-income neighborhoods in the U. Another variant of the program, how had used the accounts increased savings by 82 percent ever, altered the timing of the bonuses and cast them more than a control group that was not offered such as losses rather than as gains.
Members of the University community and the School of Dentistry have the obligation to order besivance 5 ml overnight delivery respect and to buy discount besivance 5 ml on-line be fair to safe 5 ml besivance faculty, staff, students, and patients, and to foster their intellectual and professional growth and well being. Members must not abuse the authority they have been given and care must be taken to ensure that any personal relationships do not result in situations that might interfere with objective judgment. Workplace, patient care and educational experiences must impart ethical standards of professional conduct through example, instruction and clinical practice. We believe our goal is to maintain an academic, work and patient care environment that is positive and respectful of others. We believe in providing a respectful and positive learning and working environment that maximizes the potential of all individuals. Offensive behavior is defined as action or conduct that has the purpose or effect of unreasonably interfering with an individual’s work, academic or professional performance or creating an intimidating or hostile work environment. Explicit or implicit harassment, unwelcome advances, requests for sexual favors, or unwelcome physical conduct of a sexual nature will be promptly addressed. Advocate and practice affirmative action in employment including the use of recruiting and search processes to enhance participation of racial minorities, women, persons with a disability, and military veterans. Establish and nurture an environment that actively acknowledges and values diversity and is free from racism, sexism, and other forms of prejudice, intolerance or harassment, for all faculty, staff and students. Provide equal educational access to members of under represented groups, and develop affirmative action admission programs where appropriate to achieve this goal. We believe that drug and alcohol abuse affects the health, safety and wellbeing of all employees and students and restricts their ability to perform. This is particularly critical for those who work with and practice dentistry with patients. This policy prohibits the unlawful possession, use, or distribution of alcohol and illicit drugs by employees. The facts shall determine the response to each complaint and each situation will be handled discreetly. Retaliation and intimidation directed toward anyone who makes a complaint is prohibited. This practice applies to each and every full or part time faculty, staff, student and patient in the School of Dentistry. The Dentist Wellness Program can be accessed by calling the Sand Creek Group, Ltd. Sand Creek Group also offers a comprehensive web based information resource that provides dentists and their families with interactive tools and current information about child care, adoption, education, eldercare, wellness and everyday life issues. Professional Attire and Guide for Personal Appearance the personal appearance and demeanor of every person affects, either directly or indirectly, the care and management of patients. All faculty, staff and students are responsible for maintaining a clean, neat and well fitting wardrobe. Long hair should be pinned or held back so that it does not interfere with the field of vision or require handling during treatment procedures. Makeup and perfume/after shave: Strong perfumes and cologne may be offensive to others or may cause allergic reactions; therefore avoid excessive use. Personal hygiene: Body hygiene is required so that offensive body odor is avoided. Jewelry: Rings that may compromise clinical protective barriers should not be worn in clinics. In addition, clean, predominately white, black or color matching shoes (closed toed and fluid resistant) and white socks (crew length or longer) are required. We suggest these shoes be worn only in Moos Tower so they remain clean and professional in their appearance. Legs must be cover with nude, black, or color matching hoses, tights, or scrub pants. Students may wear white, black, or color matching tee shirts underneath their scrub tops, if desired. Updated 6/12 Attendance Policy Please see the School of Dentistry Current Students website. This procedure was established to insure the safety of patients that students may come in contact with and to protect the interests of the patients, students, faculty, and School. The student will be granted a medical leave of absence from the educational program by the Council of Chairs. The request for a leave may be initiated by the student or the Director of Student Affairs/Director of the Division of Dental Hygiene/Director of the Dental Therapy. The Director of Student Affairs/Director of the Division of Dental Hygiene/Director of Dental Therapy will arrange with the student a program for the treatment of chemical dependency. Usually, the student will be counseled to enroll in an inpatient chemical dependency treatment program and provide the Office of Academic Affairs/Division of Dental Hygiene/Division of Dental Therapy with evidence of successful completion of the program. However, the student may select a different treatment modality contingent on the approval of the Director of Student Affairs/Director of the Division of Dental Hygiene/Director of Dental Therapy. If a student and the Director of Student Affairs/Director of the Division of Dental Hygiene/Director of Dental Therapy do not reach an agreement on a treatment and rehabilitation program, either may request a hearing by the Council of Chairs. The Director of Student Affairs/Director of the Division of Dental Hygiene/Director of Dental Therapy will counsel the student to join a sobriety support group. The Associate Dean for Academic Affairs will determine whether to permit the student to resume the program after obtaining evidence regarding the student’s progress in the rehabilitation and monitoring programs that show the student has been chemically free for at least ten weeks. The time and place of the make up exam must be coordinated with the course director and/or Tina Jalivay in the dental hygiene office.
Representatives are asked to buy besivance australia pre-register to generic besivance 5 ml without a prescription assist the Commission in making arrangements for the meeting purchase generic besivance. Pre-registration ensures that the individual receives a copy of the meeting agenda and policy reports at the same time as Commission members. All other Review Committees are chaired by the Commissioner for the respective discipline/specialty. Calibration Protocol: the following protocol used to calibrate Review Committee members: i. Documentation Guidelines for Selected Recommendations is provided to all programs scheduled to submit either a response to a preliminary draft site visit report or a progress report. Documentation Guidelines for Selected Recommendations is provided to all members of Review Committees for use as accreditation reports are reviewed. At the beginning of each committee meeting, the chairperson reminds the committee of the Documentation Guidelines for Selected Recommendations and reviews how the document is to be used. A specific calibration exercise is conducted prior to each committee’s consideration of accreditation reports. Each staff secretary refers the committee to the Documentation Guidelines at appropriate points throughout the committee’s discussion of accreditation reports. At the end of the committee’s accreditation actions, the staff secretary asks for comments and feedback on the calibration process. Following each meeting of the Commission, a staff meeting is convened for the purpose of discussing input received from each committee on the Documentation Guidelines for Selected Recommendations. Appropriate adjustments are incorporated into the document annually, following the July meeting of the Commission. When specific calibration problems are identified, a specific exercise to address the problem will be designed and implemented as soon as feasible, usually at the next meeting. Reports of calibration activities are provided to the committees and the Commission as needed. Procedure To Resolve Differences Between Allied Dental Review Committees: the Dental Assisting, Dental Hygiene and Dental Laboratory Technology Education Review Committees usually consider reports with common recommendations as their first item of accreditation business. The staff secretaries compare the two or three committees’ decisions relative to the common recommendations, accreditation status and changes to the report. At the earliest opportunity convenient to the involved Review Committees, the two reviewers (primary and secondary) from each committee will meet to discuss and resolve any differences. These individuals will be excused, if necessary, from committee deliberations for this purpose and committees will adjust their agendas as much as possible to accommodate this process. The two reviewers from each committee will have delegated authority to act on behalf of their respective committees in reaching consensus. Representatives of the Review Committees should be reminded prior to the joint meeting that every effort should be made to focus on substantive issues affecting accreditation status, to relate report contents to the discipline standards and to reach a consensus whenever appropriate. The agreed-upon decision, or the failure to achieve consensus, will be reported back to the disciplines’ Review Committees. If a decision on a single joint recommendation cannot be reached by consensus, then each committee will prepare a report stating the rationale for its recommendation and all reports will be submitted to the Commission for consideration. The Chairperson and Director of the Commission should be informed promptly when this occurs. The Chairperson of each Review Committee or its designated spokesperson will be expected to speak to the committee’s position during the Commission meeting. The Commission will consider both reports and will determine the accreditation status. Reports from site visits conducted less than 90 days prior to a Commission meeting are usually deferred and considered at the next Commission meeting. Commission staff can provide information about the specific dates for consideration of a particular report. The Commission has established policy and procedures for due process which are detailed in the Due Process section of this manual. Policy On Absence From Commission Meetings: When a Commissioner notifies the Director that he/she will be unable to attend a meeting of the Commission, the Director will notify the Chairperson. The Chairperson determines if another individual should be invited to attend the meeting in the Commissioner’s absence. A substitute will be invited if the Commissioner’s discipline would not otherwise be represented. This individual must be familiar with the Commission’s policies and procedures; and therefore, must be a current or former member of the appropriate Review Committee and must represent the same discipline or appointing organization as the absent Commissioner. The substitute would have the privileges of speaking, introducing business, making motions and voting. New Commissioner Orientation and Training : Newly appointed Commissioners will undergo a six-month training period prior to beginning their official term. This training includes attendance at a Commission meeting, at the discipline-specific review committee meeting, and an appropriate site visit. Protocol For Review Of Report On Accreditation Status Of Educational Programs: Commission staff sends the final listing of programs to be reviewed at the Commission meeting to each Commissioner immediately after Review Committee meetings to allow each Commissioner to identify all conflicts with these programs. A conflict includes, but is not limited to: close professional or personal relationship or affiliation with the institution/program or key personnel in the institution/program which may create the appearance of a conflict; serving as a consultant to the institution/program; being a graduate of the institution/program; being a current employee or appointee of the institution/program; being a current student at the institution/program; having a family member who is employed by or affiliated with the institution; manifesting a professional or personal interest at odds with the institution or program; key personnel of the institution/program having graduated from the program of the Commissioner; having served on the program’s visiting committee; and/or no longer a current employee of the institution or program, but having been employed there within the past five (5) years. Conflicts of interest for Commissioners may also include being from the same state, but not the same program. When a program is being considered, Commissioners must leave the room if they have any of the above conflicts. Prior to each Commission meeting, staff analyze the reported conflicts to determine whether reformatting of the Report on Accreditation Status of Educational Programs (yellow sheet reports) is necessary. Reformatting of yellow sheet reports may include grouping all dental school based programs and/or any institution that sponsors multiple programs so that recusals leave the room once.
Georgians and the state of Georgia were among the biggest proponents of removal buy besivance 5 ml amex, and the pressure that the state exerted on the Cherokee to generic besivance 5 ml otc relocate was tremendous generic besivance 5 ml. Moreover, Indian removal would further the economic development of the region, as Tennessee and Georgia sought to implement internal improvements, such Page | 547 Chapter twelve: JaCksonian ameriCa (1815-1840) as easier river navigation, which would more closely connect the region and stimulate the economy. The Choctaw, however, were the frst of the Five Civilized Tribes to agree to move. For decades, the Choctaw had been pressured to give up lands to white settlers; in the period between 1801 and 1825, the nation signed seven treaties with the U. On September 15, 1830, the nation met with Secretary of War John Eaton and General John Coffee to negotiate the terms for removal west of the Mississippi. It guaranteed that in exchange for Choctaw lands east of the Mississippi (about 11 million acres), the nation would receive 15 million acres in what is now the state of Oklahoma, then known as Indian Territory. It also agreed to continue to pay annuities established in previous treaties the Choctaw had made with the United States; for instance, Choctaw who had fought in the American Revolution would continue to receive annuities. After the signing of the treaty, many reluctantly prepared to leave the Choctaw homeland. In his “Farewell Letter to the American People,” George Harkins voiced this frustration, saying, “We as Choctaws choose to suffer and be free, than live under the degrading infuence of laws, where our voice could not be heard in the formationMuch as the state of Mississippi has wronged us, I cannot fnd in my heart any other sentiment than an ardent wish for her prosperity and happiness. Since this was the frst, Jackson was anxious to make this the model for Indian removal. The Choctaw removal came to be called “the trail of tears and death,” a phrase which was used to describe the removal of other nations as well. A few groups and villages did remove to Indian Territory, but most chose to remain in Florida. Army company, killing 107 of 110 men; the event became known as the Dade Massacre and began the Second Seminole War, with the Third Seminole War following a few years later. Over the next ten years, the Seminole attempted to resist removal with mixed success. Under the leadership of Osceola, the war was largely fought using guerilla tactics against the army, which vastly outnumbered the Seminole forces. Ultimately, some 4,000 people were forcibly removed to Indian Territory, but between 100 and 400 Seminoles remained in the Everglades, having Page | 548 Chapter twelve: JaCksonian ameriCa (1815-1840) resisted and eluded the American military. The wars were tremendously expensive for the United States, costing approximately $40,000,000. They had been under increasing pressure from the state of Georgia since the 1790s, which intensifed in the wake of the discovery of gold in 1827, resulting in the nation’s frst gold rush as prospectors and settlers began pouring into Cherokee land. The state responded by passing a resolution that declared its sovereignty over Cherokee lands within the state and asserted that state laws were to be extended to Cherokee land. Georgia passed a series of laws specifcally targeting the Cherokee and created a special police force called the Georgia Guard to patrol Cherokee lands and harass and intimidate the population. The Guard arrested principal chief John Ross and closed down and seized the press for the Cherokee Phoenix. The state simultaneously attempted to undermine and weaken the Cherokee governing structure, closing down the tribal courts and preventing the council from meeting. Finally, in 1832, after the Indian Removal Act but before the Cherokee had signed any treaties ceding land, Georgia created a state land lottery to distribute Cherokee lands to white settlers. The Cherokee decided to contest removal legally, asserting that it was illegal for Georgia to enforce state laws on Cherokee lands. The nation tried again the next year when a missionary from Vermont was arrested by the Georgia Guard. The Court decided in favor of the Cherokee, ruling that only the national government, not the states, had authority in Indian affairs. Despite this ruling, both Jackson and the Georgia state government were determined to enforce removal for the Cherokee and continued to pressure the Cherokee to migrate. After the landslide reelection of Jackson in 1832, a minority of Cherokee leaders began to question how long the nation could hold out against Jackson and Georgia. A small group, mostly elite Cherokee, decided that they now had no choice but to remove. This group, known as the Treaty Party, led by Major Ridge, his son John, and family members Elias Boudinot, editor of the Cherokee Phoenix, and Stand Watie, began unauthorized talks with Washington. Principal Chief John Ross, the majority of Cherokees, and the Cherokee government remained staunchly against removal. The Ridges and their followers responded by forming a breakaway council government, and in December 1835 they signed the Treaty of New Echota. The treaty gave up all Cherokee lands east of the Mississippi in return for lands in Indian Territory, fve million dollars, and compensation for property left in the east. It also provided for a two-year Page | 549 Chapter twelve: JaCksonian ameriCa (1815-1840) Figure 12. Author: John Bowen (both images) Source: Library of Congress period to voluntarily leave. Soon after the signing, members of the Treaty Party, along with a few hundred Cherokee, migrated to the new lands. John Ross and the majority of the Cherokee population remained, protesting that the Treaty Party had no authority and the document was a fraud. This was refected in the Senate’s vote to approve the treaty, which passed by only one vote. In the spring of 1838, Martin Van Buren, Jackson’s successor, sent General Winfeld Scott and 7,000 troops to Georgia. Over a period of almost a month, troops forcibly removed thousands of Cherokee from their homes at gunpoint. Several hundred Cherokee managed to escape to the mountains of North Carolina, evading removal. Although we cannot know with absolute certainty how many died, 4,000 deaths, nearly one-fourth of the tribe in total, is the most cited and well-supported fgure.
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If more hemoglobin F than S is identified generic besivance 5ml with visa, the child likely has sickle cell trait buy besivance with paypal. Sickle cell anemia occurs when both alleles of the beta globin gene on chromosome 11 are affected by a single amino acid substitution of valine for glutamic acid (resulting in hemoglobin S) cheap besivance online amex. The presence of hemoglobin S within the red blood cells causes an unnatural stiff folding, or sickling of the red blood cell, especially under conditions of oxidative stress. These sickled cells have a tendency to stack up on one another, and thus causes intravascular clogging in the microvasculature. This in turn leads to a vascular occlusion crisis with infarction of local tissue, and severe pain (vaso-occlusive crisis). The presence of sickle hemoglobin alone, decreases erythrocyte survival leading to chronic hemolytic anemia. The clinical syndromes as a result of this sickling vary depending on whether one is seeing a pediatric or adult patient. Sickle cell anemia does not present clinically before 6 months of age because of the protective effect from the uninvolved Hemoglobin F. But after 6 months of age, the usual clinical manifestations include infection (usually respiratory), failure to thrive, unexplained fever, and irritability. Before routine newborn screening for sickle cell disease, young children often presented with dactylitis (hand-foot syndrome), which is a swelling of the dorsum of the hands or feet, associated with pallor and fever. Since appropriate and prompt attention is given to symptoms such as fevers, pain, and swelling without a delay in diagnosis, children presenting with dactylitis from sickle cell anemia has become mostly a thing of the past. The pediatrician is most often confronted with infectious complications of sickle cell anemia. These children are especially prone to bacterial infections such as pneumococcus, Haemophilus influenzae B and Salmonella. Historically, infections have been the primary cause of death during early childhood. One reason for the high rate of infections in children with sickle cell disease is that they are functionally asplenic. Because the spleen acts as a sponge for these abnormal sickled cells, subclinical intermittent episodes of intrasplenic vaso-occlusion occur causing local splenic infarcts. Therefore, by the age of 8 years, sickle cell patients are completely functionally asplenic (due to infarction). All sickle cell patients are given prophylactic penicillin, especially during childhood. Additionally, by now identifying children with sickle cell disease at birth, prophylactic pneumococcal vaccine, plus strict attention to the routine childhood vaccinations have been shown to dramatically decrease childhood morbidity and mortality from infection. Rarely, infants have massive splenic congestion of red blood cells called the splenic sequestration crisis. When this occurs, it is frequently fatal, since it rapidly removes enormous amounts of red blood cells from the circulation, which can lead to circulatory collapse. A pain crisis is one of the most common reasons for hospitalizing an older child with sickle cell anemia. In a pain crisis, a specific limb or other body part is affected by the vaso-occlusive effects of the sickling cells in the microvasculature. The biggest challenge to the treating clinician in managing this condition, is to administer sufficient analgesia to stop the pain. Success in treating a painful crisis is reached when the analgesic is effective in stopping the pain. Many painful crises can be managed at home with oral analgesics and oral hydration. Meperidine (Demerol) should never be used because patients receiving this have a higher incidence of seizures. There is presently no role for serial intramuscular analgesic injections for pain management. Acute chest syndrome is another common reason for hospital admission in the older child. Clinically, this is an acute pneumonia like illness characterized by fever, dyspnea, chest pain, and fatigue. Another unique complication of sickle cell disease is aplastic crisis, especially erythroid aplasia. Other complications of sickle cell disease include devastating cerebral strokes, leg ulcers, bone infarction, bone marrow hyperplasia, priapism, gallstones, biliary tract disease, or splenic sequestration crisis in the young child. Hydration is the mainstay of treatment for vaso-occlusive crises, pain crises, strokes, and infections associated with sickle cell disease. Vigorous intravenous hydration should be given to the very young child (<5 years). Above this age, outpatient oral hydration can be considered for mild complaints only. Intravenous hydration with at least twice maintenance fluids, after deficits are corrected, is mandatory in treating dehydration, and strongly recommended in all other situations. Prevention of the clinical symptoms associated with sickle cell anemia is not considered a universal goal because, unlike other hemoglobinopathies, the clinical course of each patient is unpredictable. An individual patient can go for years without any significant problems, and then have many crises for months or years. Allogenic transplantation carries its own serious morbidity (graft versus host reaction, immunosuppression, etc. Bone marrow transplantation in an older child would only be considered in the presence of significant morbidity from sickle cell disease itself. However, at that point, end organ tissue damage has occurred, further increasing the morbidity of transplantation.