Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Transmission of tuberculosis from smear negative patients: a molecular epidemiology study purchase pioglitazone 45mg online diabetes symptoms constipation. Predictive model to identify positive tuberculosis skin test results during contact investigations buy cheap pioglitazone 30 mg on line type 2 diabetes diet video. The public health consequences of smear-positive pulmonary tuberculosis in patients with typical versus atypical chest radiographs discount pioglitazone 45 mg with mastercard managing diabetes. International Union against Tuberculosis and Lung Disease North American Regional Meeting. The use of environmental factors as adjuncts to traditional tuberculosis contact investigation. The infectiousness of laryngeal tuberculosis: appropriate public heath action based on false premises. Aerial dissemination of pulmonary tuberculosis: a two year study of contagion in a tuberculosis ward. Tuberculosis disseminators: a study of the variability of aerial infectivity of tuberculosis patients. Infectiousness of air from a tuberculosis ward— ultraviolet irradiation of infected air: comparative infectiousness of different patients. The early bacteriocidal activity of drugs in patients with pulmonary tuberculosis. Relative versus absolute noncontagiousness of respiratory tuberculosis on treatment. Factors influencing the transmission and infectivity of Mycobacterium tuberculosis: implications for clinical and public health management. Reduced transmissibility of East African Indian Strains of Mycobacterium tuberculosis. Some observations on the pathogenicity of isoniazid-resistant variants of tubercle bacilli. Childhood drug-resistant tuberculosis in the Western Cape Province of South Africa. A city wide outbreak of a multiple-drug-resistant strain of Mycobacterium tuberculosis in New York. Drug-resistant tuberculosis, clinical virulence, and the dominance of the Beijing strain family in Russia. Transmission of Mycobacterium tuberculosis Beijing strains, Alberta, Canada, 1991-2007. This cough is initially dry but after several weeks to months will become productive. Cough of 2 weeks duration is a more sensitive criterion, but cough of 3 weeks duration will be more specific. Fever and night sweats are common but may be absent in the very young and the elderly. Hemoptysis, anorexia, weight loss, chest pain and other symptoms are generally manifestations 1,2 of more advanced disease. This results in irregular, poorly defined, small nodular shadows, which represent acinar shadows. Inter-reader variability: 4 One of the greatest problems of chest x-ray reading is that the interpretation is highly variable. There is very poor agreement among readers regarding the presence of cavitation, hilar 4 lymphadenopathy and the likelihood of active disease. If processing within o 1 hour is not possible, samples should be refrigerated at 4 C (not frozen) and protected from light. Clinical specimens should be handled, processed and transported in an environment in which biosafety procedures are in place. Sputum At least three sputum specimens of 5-10 mL each should be collected and tested with microscopy as well as culture. Compared with the standard approach of examination of two smears with Ziehl-Neelsen microscopy over 2 days, examination of two smears taken on the same day had much the same sensitivity (64% [95% confidence interval 60% to 69%] for standard microscopy vs 63% [58% to 68%] for same-day microscopy) and specificity (98% [97% to 99%] vs 98% [97% to 99%]). Another recent systematic review of 23 studies reported that the overall success of sputum induction was high, ranging from 76. The sensitivity of microscopy compared with culture on induced sputum samples ranged from 0% to 100%. Yield was generally higher for 14 sputum induction than nasopharyngeal aspiration and gastric lavage. It is important that sputum induction be performed with large volumes of 3% hypertonic saline. For best results, an ultrasonic nebulizer should be used that can administer 5 to 6 mL per minute 1 over 15 minutes. With the use of this, virtually all patients will produce sputum, and a single 15 sputum induction will have equivalent or better yield than fibreoptic bronchoscopy. Sputum 16 induction has been performed successfully in very young children (please see Chapter 9, Pediatric Tuberculosis). It is important to indicate on the requisition that the sputum was induced, because the resulting specimen often appears watery. However, it can be handled in the 2,17 laboratory in the same way as spontaneously expectorated sputum. Bronchoscopy is very useful if other pulmonary diseases, such as lung cancer, are also suspected. In addition, the overall yield of bronchoscopy in prospective series of patients 18-21 is only 77%. The technique is relatively simple and is described in Chapter 9, Pediatric Tuberculosis.
If a child experiences a headache contact may cause allergic reactions in some individuals buy 15mg pioglitazone overnight delivery diabetes in dogs insipidus. Tose that mimic juvenile hormones keep insects Picaridin generic pioglitazone 45 mg without a prescription managing diabetes journals, a synthetic compound frst made in the 1980s discount pioglitazone 30mg line blood sugar jumps, in immature stages and prevent insect reproduction. Chitin resembles a natural compound found in the group of plants synthesis inhibitors prevent insects from molting and grow used to produce black pepper. Although uncommon, some people poisonings or adverse reactions in exposed workers have have experienced skin irritation. Some examples of insect growth regulators are irritation if it gets into a persons eyes. Examples of trade While children may be especially sensitive to pesticides names are in parenthesis. Difubenzuron (Adept®, Clarify®) Methoprene (Bio Spot®) Oil of Citronella was registered in 1948 as an insect and Hexafumuron (Shatter™) Novifumuron (Recruit®) animal repellent. It is found in many familiar insect repellent Hydroprene (Gentrol®) Pyriproxyfen (First Shield™) products, including candles, lotions, gels, sprays, and tow elette wipes. Tese products vary in efectiveness and may re Mosquito Repellents pel various insects, such as mosquitoes, biting fies, and feas. The Army in 1946 as an insect repellent and has been available only concern in studies involving laboratory animals is skin to the general public since 1957. If lef on skin for an nella is not expected to pose health risks to people, including extended period, some people have experienced irritation, children and other sensitive populations, if used according to redness, a rash, and swelling. Fumigants can completely fll a space, and used under hot, humid conditions and not washed of before many have tremendous penetrating power. The skin became red and tender, then blistered to treat objects such as furniture, structures, grain, and soil for and formed ulcers, leaving painful weeping bare areas that insects and other pests. Permanent scarring resulted from most of ardous pesticide products to use, due to danger of inhalation. Headache, dizziness, nausea, and vomiting are common such as redness or blisters that rupture, leaving raw skin or early signs and symptoms of excessive exposure. Prompt medical treatment is critical with fumigant poi Acrolein (Magnacide H®) is an extremely irritating gas soning. Keep the individual in the upper respiratory tract, which may lead to a buildup of quiet in a semi-reclining position even if initial signs and fuids in and narrowing of the air passages. If ingested, it attacks the stomach lining, to-mouth or mouth-to-nose resuscitation. Contact with skin may no pulse, immediately give cardiopulmonary resuscitation cause blistering. Dazomet is highly toxic if swallowed and spiratory tract, eyes, and mucous membranes. Frequent or prolonged exposure to skin can exposure include burning eyes, tearing, coughing, difculty result in irritation or more serious skin problems for some breathing, headaches, nausea, and vomiting. Exposure to the eyes can cause irreversible eye may be a stand-alone fumigant or may be combined with damage. Inhalation can cause a variety of acute and chronic other fumigants to increase their potency. Chloropicrin can lung conditions, including local irritation, infammation, cause eye irritation and tearing in concentrations as low fuid buildup, and lung disease. Some fumigant formulations include small Metam sodium (Vapam®) is a soil fumigant used to kill amounts as a warning agent to clear people from an area. When Sulfuryl fuoride (Vikane®) poisoning symptoms include combined with water, it produces a gas that is very irritating depression, slowed walking pattern, slurred speech, nausea, to respiratory mucous membranes, eyes, and lungs. Inhala vomiting, stomach pain, stupor, itching, numbness, twitching, tion can cause severe respiratory distress, including coughing and seizures. It can only be used outdoors, and the respiratory tract and may be fatal due to respiratory failure. Sulfuryl fuoride almost always is applied with chloropicrin, Dichloropropene (Telone®) is very irritating to skin, so the frst signs of poisoning are ofen associated with severe eyes, and the respiratory tract. Although limited with gaseous sulfuryl fuoride normally poses no hazard, but data for humans exist, animals have experienced liver, kidney, contact with liquid sulfuryl fuoride can cause pain and frost and cardiac damage. Most dichloropropene products contain bite due to cold temperatures from rapid evaporation. Apparently, risk for oral sium phosphide (Phostoxin®, PhosFume®, Fumitoxin®, and toxicity is low for humans unless large quantities of dichloro Fumi-Cel®) afect cell function in the liver and lungs. Exposures that are somewhat more Rodenticides serious will be evidenced by cough, tightness in the chest, difculty breathing, weakness, thirst, and anxiety. Signs and Pesticides designed to kill rodents pose particular risks to symptoms of severe exposure include stomach pain, loss of humans. Since they are designed to kill mammals, their mode coordination, blue skin color, pain in limbs, enlarged pupils, of action is toxic to humans as well. Severe poisonings can live near humans and other mammals, so accidental exposure lead to seizures, coma, and death. The active ingredients of rodenticides fall into Methyl bromide (Metabron, Meth-O-Gas®) afects the three categories: central nervous system, lungs, heart, and liver. People poi • First generation anticoagulants, soned by methyl bromide experience the common signs and symptoms of fumigant poisoning along with abdominal pain, • Second-generation anticoagulants, and weakness, slurred speech, mental confusion, muscle twitch • Non anticoagulants. Methyl bromide is corrosive to eyes; damage may have a delayed on Anticoagulants slow the bloods ability to clot. Bromethalin (Tomcat® Mouse Killer), doses, and death usually occurs within fve to seven days.
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Dates should not be reassigned based on subsequent sonographic biometric measures buy pioglitazone with a mastercard metabolic disease ppt. Highly accurate dating can be achieved by crown-rump lengths before the second trimester generic pioglitazone 45 mg with mastercard diabetes symptoms hair loss, and measures of biparietal 4 order pioglitazone 15mg online diabetes prevention quotes. If a biometric parameter is likely affected by underlying pathology, such as the biparietal diameter or head circumference with evidence of hydrocephaly present, that parameter should not be used for gestational age assessment. Additionally, aberrant fetal growth (either excessive or restricted growth) is more common after 20–22 weeks gestation and abdominal circumference measures are more affected by such processes than either head or long bone measures. For this reason, in the second half of pregnancy, the abdominal circumference is not ideally suited for gestational age estimations. Sonographic estimations of gestational age are accurate to ±10% of the gestational age in weeks determined, but patients with signicant size/dates discrepancy occurring after 22 or 23 weeks gestation should be carefully eval 4. For example, a fetus at 28 weeks ges tation by a purportedly accurate menstrual history and with symmetric sono graphic measurements of 24 weeks gestation will most often truly be 24 weeks gestation but on occasion may represent a symmetrically growth-restricted fetus. Further evaluation of such pregnancies, looking for other evidence of normal or abnormal fetal growth and development, will often help establish which of these two diagnoses is more appropriate. The placenta is rst visible at 8–9 weeks gestation as a thickened portion of gestationalring. These changes usually are assigned to one of four grades, 0–3: homogeneous echo pattern bounded by the smooth chorionic plate (Grade 0) are usually present until 31–33 weeks; nonhomogenous echo patterns are then observed (Grade1);increasedamountsofbasilarandintraplacentalcalcications(Grade 2); and development of diffuse calcications and indentations of the chorionic and basilar plates into the intraplacental perivillous septa (Grade 3). Because of the relatively small volume of the uterine cavity before 12 weeks, placental location is difcult to assess in the rst trimester. In the early sec ond trimester, placentas are often identied in close proximity to the cervix but usually appear more normally situated later in pregnancy. Placentas with margins in close proximity to the cervix are termed low lying, while those that abutthecervicalcanalaretermedmarginalplacentaprevias. Increasingdegrees of association with the cervical canal are termed partial or complete placenta previa. Abnormal situs may be associated with fetal growth abnormalities and abruption, and the placenta may grow into a prior cesarean scar. Lesser degrees of abnormal situs often resolve as the lower uterine segment lengthens and the placenta appears to migrate, particularly if such ndings were noted in the rst 12 weeks of pregnancy. Suspected cases of abnormal situs should be reevalu ated at 30–32 weeks gestation, or sooner if vaginal bleeding is noted. Abnormal situs persisting after 30–32 weeks gestation places the patient at signicant risk for abnormal placental situs at delivery and merits special management considerations during the last weeks of pregnancy and at delivery. Amniotic uid originates as a transudate from placental membranes, the pulmonary tree, and across the fetal skin in the rst weeks of pregnancy. After 15–17 weeks of gestation, the urinary system becomes the primary source of amniotic uid, and amniotic uid volume will drop precipitously if an abnormal genitourinary tract is present. If more accurate characterization of the uid volume is required, an amniotic uid index (the sum of the deepest vertical pocket depth in the four uterine quadrants) can be calculated. The amniotic uid index normally rises predictably over the course of pregnancy (Moore and Cayle 1990). Subjective estimates of uid volume by experienced technicians correlate well with numerical quantitations of the amniotic uid index. Commonly used criteria for oligohydramnios include the absence of any 2cm 2 cm uid pocket or four-quadrant amniotic uid indices of <5or6, while amniotic uid indices of >25 are considered polyhydramnios. Although oligohydramnios is sometimes a sporadic event, it commonly oc curs in association with another pregnancy complication, such as uteroplacen tal insufciency, ruptured amniotic membranes, a fetal genitourinary abnor mality such as renal agenesis or obstructive uropathy, or chronic abruption sequence (if found in association with persistent, irregular vaginal bleeding). If oligohydramnios occurs before approximately 24 weeks gestation, the fe tus may exhibit features of the Potters sequence (facial malformations, joint mobility limitation, and pulmonary hypoplasia), which are reminiscent of the ndings in renal agenesis (Potters syndrome). In post-term pregnancy, oligo hydramnios is strongly associated with perinatal morbidity and is considered an indication for delivery, but recent reports indicate that this association is not nearly as strong before 40 weeks of gestation and may not hold beyond 40 weeks of gestation in carefully selected, normal pregnancies (Sherer 2002; Conway et al. Prenatal Diagnostic Screening the value of ultrasound imaging for prenatal screening is quite controversial, because it has not been found to signicantly improve obstetric outcomes, and it is not considered an intrinsic component of normal obstetric care in low-risk patients (Dooley 1999). The skill and experience of the sono graphic technician performing the study and the interpreting physician (some times the same person) are also critical to optimal screening accuracy. Finally, patient historical factors that serve to increase the index of suspicion may be veryhelpfulbyfocusingattentiontodetailsthatordinarilywouldnotbeaggres sively pursued. Familial predisposition to congenital cardiac disease, suspicion of aneuploidy or a neural tube disorder after prior maternal serum screening, and suspected aberrant fetal growth are examples of clinical circumstances that often would result in a much more thorough fetal evaluation than might occur absent such a prior history. Certain epidemiologic factors also appear to inuence the utility of sono graphic screening. Detection rates are higher in referral centers and in infants with multiple anomalies. The predictive value of anomalous ndings is inu encedbypopulationprevalenceratesforthosendings. Forexample,echogenic intracardiac focus is weakly associated with aneuploidy in many populations, but it is a relatively common nding in Asian populations. In addition to ben etting from often more experienced personnel and better equipment, studies performed in referral populations tend to be more focused and extensive be cause of concern for the historical factors and prior ndings that prompted the initial referral. Major structural congenital anomalies occur in 12–18 per 1,000 live births, with published rate estimates that range from 6 to 26 per 1,000. Prenatal rates of anomalies are higher than live birth statistics because of increased rates of pregnancy loss among anomalous infants.
Simply put pioglitazone 45mg generic blood glucose units of measurement, a conflict of interest is any situation in which financial or other personal considerations have the potential to compromise or bias professional judgment and objectivity buy generic pioglitazone 15mg line metabolic disease in sheep. There are several tangible cheap pioglitazone 30 mg diabetes definition medical, financial conflicts of interest depicted in this case. The pharmaceutical reps are offering numerous items of monetary value, including lunch, medication samples, travel/accommodation expenses, and possible speaking honoraria. There is also potentially a less tangible conflict of interest in the form of prestige or name recognition associated with speaking at a medical conference. Scientific research and clinical care demand integrity, objectivity, and public trust. Researchers and clinicians with secondary interests (ie, financial gain, professional promotion), however, may be unduly influenced and biased in their professional assessments of and interactions with patients. Although physicians may not think they are personally influenced by external factors, research has shown that physicians are in fact more prone to act differently (ie, change their 2 prescribing patterns) in situations of competing interests. One large study, for example, found that physicians who occasionally accepted industry-sponsored meals were 2 to 3 times more likely to ask that the sponsors drug be placed on a hospitals formulary. The study further found that physicians who accepted a free trip to a drug-company-sponsored conference were also more likely to write prescriptions of the sponsoring companys drugs. Overall, physicians who interact more frequently with the pharmaceutical industry are more likely to prescribe higher 3 cost drugs and less likely to recommend generics or over-the-counter medications. Although the pharmaceutical and medical device industries are critical to scientific discovery and the delivery of patient care, industry representatives were historically permitted unrestricted access to academic medical centers, community hospitals, and private physician offices. It is not uncommon for such representatives to provide meals and various monetary gifts (ranging in value from pens to event tickets) in the hopes of influencing provider behavior. It has been estimated that the pharmaceutical industry spends around $15,000 per physician in direct 4 marketing. In working to create an environment based purely on evidence based care and free of undue influence or bias, however, more and more academic medical centers across the country have instituted policies either banning, limiting, or regulating industry 144 access to physicians, residents, and students. It is often best to consult with your specific institutions policies governing if and what type of industry access is permitted. Several studies have shown that physicians given “free” samples to dispense to their patients are more likely to then write prescriptions for what are often more expensive – although not necessarily more effective – drugs compared with physicians without access to free samples. It is critical that prescribing physicians rely on evidence-based medicine and safe practice rather than on what is simply available and “free. It is also important to distinguish between what may be time-limited vs ongoing receipt of such samples. Physicians employed by a practice or institution should always refer to their institutional policy before deciding whether to accept and dispense “free” samples. Gifts may include items as small as pens and pads and as large as vacations and meals at luxury venues. Per the American Medical Association, “No gifts should be accepted if there are strings attached. For example, physicians should not accept gifts if they are given in relation to the 5 physicians prescribing practices. Many academic medical centers now have policies that either limit or ban the acceptance of gifts of monetary value. It is the responsibility of each physician to comply with their institutions most updated policy and always keep in mind the mandate of the American College of Physicians “to assess any potential relationship with industry to assure that 1 it enhances patient care and medical knowledge and does not compromise clinical judgment. What if a physician is invited to speak at an industry-sponsored medical conference Expert physicians play a vital role in contributing to the education of their peers and the general public. It is, therefore, important for speakers to explicitly disclose any financial ties they may have with a company before presenting the relevant data. It is also not uncommon for industry-sponsored events to control the content of educational modules or provide invited lecturers with prescripted presentations or slides. Physicians presenting at such events ought to carefully review the prepared materials beforehand and modify them accordingly to ensure utmost objectivity. At the very least, physician presenters must disclose the source and authorship of any materials to the audience. In the current health care landscape, it is routinely becoming more common—in large part because of changing payment structures—for physicians to own or have some form of business arrangements with outpatient diagnostic or treatment centers and/or specialty hospitals to which they refer patients (eg, a gastroenterologist who owns outpatient endoscopy center, a radiologist who partners with an imaging suite). The secondary interest of physician owners (ie, increased income from increased referrals) certainly has the potential to interfere with what ought to be the primary interest of physicians (ie, patient welfare). Given the allure of increased profitability, patients may inadvertently be subject to unnecessary or extraneous procedures. Such concerns about physician self-referral have led to federal regulations (“Stark Laws”), which prohibit physicians from referring Medicare or Medicaid patients to entities for “designated health services” if the physicians or their immediate family members have ownership, investment interests, or compensation arrangements with the entities. In 2008, the Centers for Medicare and Medicaid Services issued a new rule, which requires physicians to disclose to patients any ownership of or 1 investment in hospitals they may have. As with all potential conflicts of interest, full disclosure to all parties involved is always warranted. Conclusions and Suggestions Conflict of interest is a very real and serious issue in health care. These conflicts can sometimes be subtle and affect even the most vigilant and well-intentioned physician. Every doctor in training should, therefore, be proactive in identifying potential sources of conflict interest and become adept in reducing or at least managing actual conflicts. Conflicts of interest overwhelmingly surface at the interplay between physicians and the health care industries. Although such collaboration cannot always be avoided—and may, in fact, be appropriate in particular settings—best practice always calls for clearly disclosing any possible conflicts of interest (financial and otherwise) to all parties involved. It is also essential that the clinician be aware that these relationships have the potential to alter their prescribing behavior in ways that may not be apparent to them.
No “safe” limits have weaning order pioglitazone with american express diabetes diet vitamins, make sure that your baby gets an adequate been determined order genuine pioglitazone online diabetes symptoms type 1 adults. Babies need fat for their brains to develop properly since it aids the production of myelin order pioglitazone toronto diabetes test report, Avoid stress, or try to manage it. The brain manages the sheath that surrounds nerve cells and helps them to stress through hormonal responses that ultimately reach transmit signals quickly. Hot Fact: Vitamin B Helps Prevent Brain Defects By taking supplements of the the brain fails to develop; affected women even know they are preg common B vitamin, folic acid, babies are either stillborn or die nant), and because half of all preg women can greatly reduce their shortly after birth. This amount affects about 4,000 pregnancies a of neural tube defects, though how can be found in vitamin supple year in the United States. Folic acid ments or in some very highly forti this defect occurs when the plays a key role in chemical reac fied breakfast cereals (check the neural tube, a structure in the tions throughout the body including labels). A 2001 spinal cord and back bones are Service recommends that women study published in the Journal of affected; results can include paral of childbearing age take 400 micro the American Medical Association ysis, lack of bowel and bladder grams of folic acid daily. In the neural tube closes 24-28 days decline in neural tube defects after a condition called anencephaly, after conception (before most fortification began. A newborn baby is bombarded with sights, sounds, emerges some time after six months, when the prefrontal smells and sensations; yet the cortex — which has to make cortex has begun to develop. How about the first signs of sense of all this information — has only barely begun to stranger anxiety — when the baby noticeably shows prefer function. Before two to four months of age, babies cant ence for parents and other familiar folks Can you think of times when attachment begins, and it means that the babys frontal lobes nothing you did would get a baby to stop crying Although there are slight differences in brain develop babies also crave novelty. Whats an appropriate level of ment between baby boys and girls, cues from the family envi stimulation, and how does your baby tell you, “Enough ronment that influence gender differences cant be ruled out already What early forms Does Daddy play more roughly with the boys than with the of recognition have you noticed in your child Does each of you spend more time with a child of the any reactions to music that you played or sang while preg same sex When did your baby first begin looking for dropped in emotional behavior among your children, even in the first toys To help him practice focusing, play tracking plastic kitchen food containers, pots and pans. Place several different containers (for example, a shoe may be able to follow only large objects moving slowly box, basket, plastic-ware or cardboard milk carton) and through a limited range, but soon he will be tracking even several choices of things that can rattle inside a small, speedy movements. He uses his vision (and hearing container (blocks, jar lids, tennis balls) on the floor. These images create new neural pathways in the brain, which become the him to put these together as noisemakers. Recommended: his creation, describe in words the sound hes hearing, An unbreakable mirror in the crib and mobiles with highly say “brushing,“ ”jingling,” “shuffling. Find an empty container with a lid that she can matic play with animal figures leaving and returning. She will enjoy opening the lid to see forcing the idea that objects and people continue to what is there. First they launches a child into two learn to speak and Twelve to eighteen months: vital projects — to find his place in the world and understand speech Toddlers begin to develop memo ry. As she gains experience, the earli Toddlers never seem to est circuits may be modified, tire of hearing the reversed, or even overlain by new same story or throwing ones. Repetition brain patterns receive enough use strengthens neural con to keep them ready to shape reac nections, helping chil tions to challenges or circum dren reinforce their skills, teaching the brains main job in childhood is stances that may arise even them to pay attention to what is to sort out which synapses to decades later. Six to twelve years old: Synapses that are used often As their synapses grow stronger, the urge toward independence grow stronger, while those little the neural pathways become from parents is joined by an used become candidates for elimi increasingly well trodden so they increasing need to be like nation. The wish to be like “everyone ences help determine which Eighteen to twenty-four months: synapses will be strengthened or else” represents an important I, Me, Mine. It is preparing children for a life the child develops a sense of self time of groups — family, play and, sometimes, selfishness. Three to six years old: mates, schoolmates, co-workers, Self-control comes with time as Children begin to sketch patterns neighbors — by tuning certain the frontal lobes mature. Before for future adult behavior, including neurons to patterns of speech, this happens, a toddler cant wait responsibility, self-respect, atti appearance, and general attitude. Instead, he is sitting at a table with a reading spe sound, but when we have to map that sound into print, cialist, moving tiny colored blocks into small rows to build there are actually three sounds that make up the word words. Then, it must assign sounds, then meaning, to these letters; finally, it must make sense of the combined let ters as a word. All the while, it must keep these sound-letters mentally “on-line” long enough to decode a full sentence. Children with dyslexia like Russells are otherwise quite smart, but they have a hard time joining the letter-sounds. They also have trouble holding dif ferent sounds in their short-term memories long enough to put them together as words. Each of the small, colored blocks that Russell moves on the table represents a dif ferent sound-feel in his mouth, giving each letter a specific sound, look and tactile feel. By arrang ing them, he can build words by recognizing and connect “I have this thing in my brain thats called dyslexia,” Russell ing the physically separate sound-blocks. But when they ing tantrums at home and dreading that “itd be really bor started getting bigger, figuring them out became difficult. Once I got the hang of it, it was kind of fun and it was After he was diagnosed, Russells parents — Bowdoin and pretty helpful.