U.S. Zika Pregnancy Registry and Zika-Related Birth Defects ...

U.S. Zika Pregnancy Registry and Zika-Related Birth Defects ...

The US Zika Pregnancy Registry and Zika-Related Birth Kentucky Zika Summit Defects Surveillance May 11, 2017 Judy Theriot, MD, CPE Commission for Children with Special Health Care Needs Medical Director

Objectives Describe the US Zika Pregnancy Registry (USZPR) Describe Zika-Related Birth Defects Surveillance (ZBDS) Define Zika-related birth defects Understand the similarities and differences between the USZPR and ZBDS Understand the prevalence of Zika in the US and in Kentucky Importance of Collecting Surveillance Data About Zika Virus and Its Effects Track the spread of Zika in the United States and territories

Address questions about timing, risk, and the spectrum of outcomes linked with Zika during pregnancy Update recommendations for clinical care Plan for services for pregnant women and families affected by Zika virus Connect families to local health and social services in their community Improve prevention of Zika virus infection during pregnancy US Zika Pregnancy Registry US Zika Pregnancy Registry

(USZPR) CDC established the US Zika Pregnancy Registry to: Learn more about the effects of Zika exposure during pregnancy and adverse outcomes Learn more about the growth and development of infants born to Zikapositive mothers ArboNET ArboNET is a national arboviral surveillance system managed by CDC and state health departments, it collects data only on laboratory confirmed cases USZPR gathers much more information related to Zika

It includes symptomatic and asymptomatic pregnant women with positive, equivocal, or inconclusive Zika test results It includes all infants born to these women, not only those with identified congenital infection Infants will be followed for 1 year What are the inclusion criteria for the USZPR? Pregnant women in the United States with laboratory evidence of Zika virus infection (positive or inconclusive test results, regardless of whether they have symptoms) and periconceptionally, prenatally, or perinatally exposed infants born to these women Infants with laboratory evidence of congenital Zika

virus infection (positive or inconclusive test results, regardless of whether they have symptoms) and their mothers What information is included in USZPR? Maternal Health History Demographics, Maternal Zika Virus History, Exposure History, Maternal Health History, Pregnancy Information, Prenatal Imaging and Diagnostics Neonatal Assessment DOB, Gender, Gestational age, Physical Examination, Imaging and Diagnostics such as hearing screen, retinal exam, head ultrasound,

Postnatal Infection and Cytogenetic Testing Results Infant Follow-up at 2, 6, and 12 months Demographics, Weight, Length, Head Circumference, Abnormal Clinical Findings What is the role of healthcare providers? Collect Data on Pregnant Women and Their Infants Completing the Maternal History, Neonate Assessment, and Infant Follow-up US Zika Pregnancy Surveillance forms Report Zika-related Adverse Events Such as Spontaneous Abortion or Termination By contacting the Kentucky Birth Surveillance Registrys (KBSR) Infant

Zika Nurse Coordinator at 1-800- 843-5877 Ext. 3103 Report Suspected New Zika Cases By contacting Kentucky Department for Public Healths Reportable Diseases Section at 1-502-564-3261 What is the role of Kentuckys Department for Public Health? Within the Kentucky Department for Public Health, the Division of Epidemiology & Health Planning and the Division of Maternal & Child Health are collaborating by: Coordinating Zika virus testing Ensuring data collection and reporting to CDC, KBDS, DPH Reportable Diseases

Providing guidance and support to healthcare providers and birthing hospitals Ensuring referrals to CCSHCN and early intervention services for woman has evidence of Zika virus? Before the birth, KDPH arranges a conference call with the birthing hospital to discuss clinical and laboratory evaluation of the infant KDPH provides written documentation outlining infant evaluation, including flowcharts for infants born with and without abnormalities

Laboratory testing is performed KDPH collects information about the clinical and laboratory evaluation of the infant and recommends appropriate clinical care and pediatric follow-up. Russell K, Oliver SE, Lewis L, et al. Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65:870878 Laboratory Testing: Recent Zika virus infection detected by: Zika RNA nucleic acid test (NAT) on any infant/fetal specimen (rRT-PCR) Recent Zika virus infection or recent flavivirus infection (serum or CSF):

Zika virus IgM positive or equivocal AND Zika virus plaque reduction neutralization test (PRNT) titer 10 OR Zika virus IgM negative AND dengue virus IgM positive or equivocal AND Zika virus PRNT titer 10 Russell K, Oliver SE, Lewis L, et al. Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65:870878 Initial evaluation of an infant with findings consistent with Congenital Zika Syndrome Consultation with: Neurologist for determination of appropriate neuroimaging and additional evaluation.

Infectious disease specialist for diagnostic evaluation of other congenital infections (e.g., syphilis, toxoplasmosis, rubella, cytomegalovirus infection, lymphocytic choriomeningitis virus infection, and herpes simplex virus infection). Ophthalmologist for comprehensive eye exam and evaluation for possible cortical visual impairment prior to discharge from the hospital or within 1 month of birth. Endocrinologist for evaluation for hypothalamic or pituitary dysfunction. Clinical geneticist to evaluate for other causes of microcephaly or other anomalies if present. Initial evaluation of an infant with findings consistent with Congenital Zika Syndrome Consider Consultation with: Orthopedist, physiatrist, or physical therapist for the management of hypertonia, club foot or arthrogrypotic-like conditions

Pulmonologist or otolaryngologist for concerns about aspiration Lactation specialist, nutritionist, gastroenterologist, or speech or occupational therapist for the management of feeding issues Perform auditory brainstem response to assess hearing Perform complete blood count and metabolic panel, including liver function tests Provide family and supportive services Initial evaluation of an infant with findings consistent with Congenital Zika Syndrome The evaluation is for every baby born with abnormalities consistent with congenital Zika syndrome For babies with abnormalities that test negative for the virus

Investigate other causes for the abnormalities, such as other congenital infections or genetic causes All babies born with abnormal findings consistent with congenital Zika Syndrome should be followed by Zikarelated Birth Defects Surveillance Russell K, Oliver SE, Lewis L, et al. Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65:870878 Russell K, Oliver SE, Lewis L, et al. Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65:870878 Management of Infants with laboratory evidence of Zika Virus and an abnormal exam

Monthly visits with PCP for at least the first 6 months Refer to Neurology, Ophthalmology, Endocrinology, Early Intervention Consider referral to Developmental Pediatrician Repeat comprehensive ophthalmologic exam at age 3 months Repeat ABR testing at age 46 months Repeat testing for hypothyroidism at age 2 weeks and 3 months Provide family and supportive services Russell K, Oliver SE, Lewis L, et al. Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65:870878 Russell K, Oliver SE, Lewis L, et al. Update: Interim Guidance for the Evaluation and Management of Infants with Possible Congenital Zika Virus Infection United States, August 2016. MMWR Morb Mortal Wkly Rep 2016;65:870878

Management of Infants with laboratory evidence of Zika Virus and an Normal exam PCP should: Follow growth parameters, and perform developmental screening at each well child visit Emphasize anticipatory guidance for families regarding developmental milestones, feeding and growth, sleep and irritability, and abnormal movements Use a standardized, validated developmental screening tool at 9 months Referral to ophthalmology within one month of birth. Perform vision screening and assess visual regard at every well child visit Perform auditory brainstem response within one month of birth. Consider repeat auditory brainstem response at 46 months or perform behavioral diagnostic

testing at 9 months of age Provide family and supportive services Management of Infants born to mothers enrolled in the USZPR in Kentucky? Kentucky is uniquely able to provide medical care and wrap around services for infants born to mothers in the USZPR providing comprehensive services in a multidisciplinary clinic located in their local community through the CCSHCN We follow both positive and negative infants through the first year of life Report to the KBSR and CDC

Commission Neurology Clinic Locations Lexington IM TR CARROLL Morehead LL CAMPBE

IN AT LL GA Louisville KENTON BOONE PENDLETON GRANT

BRACKEN E BL ROBERTSON OWEN Elizabethtown HARRISON

HENRY OLDHAM Owensboro FRANKLIN SHELBY ANDERSON BOURBON WOODFORD

CLARK AN H JESSAMINE C K C O LARUE

OHIO WOLFE FLOYD LEE D MARION LINCOLN

JACKSON OWSLEY CRITTENDEN S ING LIV Mc CR AC KE N

N TO BALLARD HART BUTLER MUHLENBERG CALDWELL WARREN

MARSHALL CHRISTIAN TRIGG HICKMAN LESLIE LAUREL LETCHER

Prestonsburg RUSSELL METCALFE KNOX LOGAN ALLEN MONROE CALLOWAY HARLAN

WAYNE CUMBERLAND TODD SIMPSON GRAVES PERRY CLAY PULASKI

ADAIR LYON KNOTT ROCKCASTLE GREEN EDMONSON BARREN CARLISLE

CASEY TAYLOR HOPKINS PIKE BREATHITT GRAYSON MARTIN

M AG OF FI N ESTILL AR R McLEAN

JOHNSON AR G BOYLE WEBSTER LAWRENCE MORGAN MENIFEE MADISON

HARDIN UNION ELLIOT POWELL WASHINGTON DAVIESS Paducah

FAYETTE ROWAN BATH MERCER NELSON CARTER RY

ME GO NT MO SPENCER BULLITT BRECKINRIDGE BOYD FLEMING

JEFFERSON MEADE GREENUP LEWIS NICHOLAS SCOTT HENDERSON

MASON WHITLEY CLINTON McCREARY BELL FULTON Bowling Green

OFFICE Somerset SATELLITE Barbourville Hazard Management of Infants born to mothers enrolled in the USZPR in Kentucky? Infant is referred to the KY Commission for Children with

Special Health Care Needs Cerebral Palsy or Neurology clinic Seen at 2, 6 and 12 months by Child Neurologist Hearing testing performed by Audiologist at 2 and 4-6 months Ensure Early Intervention referral Care Coordinators ensure infants are seen by pediatric Ophthalmologist and other sub-specialists as needed (ID, Genetics, Endocrinology) Seen by Family to Family representative Foreign language interpreters including ASL Kentucky EHDI program EHDI ensures all children in KY are screened at birth for hearing loss and followed-up if they do not pass the screen or if they pass with risk factors Kentucky prevalence of Childhood hearing loss is 1.6 per

1000 children screened, biggest risk factor is congenital infection Preliminary data from Brazil: Symptomatic infants with Congenital Zika Infection had 6% prevalence for sensorineural hearing loss Leal MC, Muniz LF, Ferreira TS, et al. Hearing Loss in Infants with Microcephaly and Evidence of Congenital Zika Virus Infection Brazil, November 2015May 2016. MMWR Morb Mortal Wkly Rep 2016;65:917919. Early Hearing Detection & Intervention What do we know about other congenital infections and hearing? cCMV 0.5%-0.7% of live births in the US (20,000-31,500) Hearing loss due to cCMV is substantial

20% of all hearing loss at birth and 25% of all hearing loss at 4 years of age Most other causes of PCHL are genetic . Early Hearing Detection & Intervention (EHDI) Program 1-3-6 Goals National

Hearing Loss Surveillance All infants will receive a hearing screening before 1 month of age Infants not passing the screening will receive appropriate audiologic and medical evaluation before 3 months of age All infants identified as deaf or hard of hearing will begin receiving early intervention services before 6 months of age Kentucky EHDI Data 1-3-6 Goals

2014 Kentucky CDC EHDI Data % Screened: 99.4% (n=53,822) % screened excluding deaths and refusals 99.8% % of those identified receiving Early Intervention: 66.7% (n=84) % Screened before 1 month of age: 96.9% (US 96.1%) % Diagnosed before 3 months of age: 74.1% (US 71.3%) % Receiving Intervention before 6 months of age: 66.1% (67.9%) % Loss to Follow-up or Documentation: 11.1% (US 34.4%) Closing the Gap USZPR is used to gather data on mothers and their infants diagnosed with the Zika virus If a mother is not diagnosed prenatally her infant may not be included in the registry

ZRBD surveillance is intended to close the gap in reporting pregnancy outcomes related to Zika. Zika-Related Birth Defects Surveillance Zika-Related Birth Defects Surveillance (ZBDS) CDC established Zika-related Birth Defects Surveillance to gain a better understanding of the effects of the Zika virus infection during pregnancy. CDC supports 50 states and local areas to

track and collect information about babies born with microcephaly and other birth defects that might be associated with Zika virus infection during pregnancy. CDC has asked local jurisdictions to use a standard approach for gathering information on Zika Population-based birth defects surveillance information is collected on ALL infants with birth defects that might be related to Zika (not just the infants that are positive for the virus) This helps to identify the full spectrum of outcomes associated with Zika Active case-finding utilizing direct medical record review

Consistent case definitions ensure data is collected in a consistent systematic way to ensure data collected from different regions can be compared in a meaningful way What are the inclusion criteria for ZBDS? Birth Defects possibly related to Zika Virus: Brain abnormalities with and without microcephaly Neural tube defects and other early brain malformations Structural eye abnormalities Consequences of central nervous system (CNS) dysfunction Infants with these abnormalities are tracked in ZBDS regardless of congenital zika virus exposure

Brain abnormalities Confirmed or possible congenital microcephaly Intracranial calcifications Cerebral atrophy Abnormal cortical formation Corpus callosum abnormalities Cerebellar abnormalities Porencephaly Hydranencephaly Ventriculomegaly / hydrocephaly (excluding mild ventriculomegaly without other brain abnormalities) Fetal brain disruption sequence Other major brain abnormalities, including intraventricular hemorrhage in utero (excluding postnatal IVH)

What is the case definition of microcephaly? Live Births: measured head circumference (HC) adjusted for gestational age and sex <3rd percentile at birth, or if not measured at birth, measure as soon as possible after birth Pregnancy Loss: prenatal HC* more than 3 SD below the mean based on ultrasound or postnatal HC <3rd percentile Birth measurements based on Intergrowth-21st standards Charts available at: intergrowth21.tghn.org/articles/new-intergrowth-21st-international-postnatal-growth-standards-charts-available/ Measuring Head

Circumference (WHO*) Use a measuring tape that cannot be stretched Securely wrap the tape around the widest possible circumference of the head At the most prominent part of the back of the head Take the measurement three times and select the largest measurement to the nearest 0.1 cm * World Health Organization When to measure Head Circumference

Although HC measurements may be influenced by molding and other factors related to delivery, most commonly-used HC reference charts by age and sex are based on measurements taken before 24 hours of life. If measurement within the first 24 hours of life is not done, the HC should be measured as soon as possible after birth. Measuring Head Circumference Congenital Microcephaly Congenital microcephaly is present prenatally or at the time of birth/delivery Abnormal development of the brain (often genetic)

Arrest or destruction of normally-forming brain (e.g., infection, vascular disruption) AP Photo/Felipe Dana Acquired microcephaly develops after birth due to a delivery complication or postnatal insult, trauma or infection HC is normal at birth As the baby grows in length, the head becomes comparatively smaller Brain Abnormalities That Can Occur with Congenital Microcephaly

Intracranial calcifications Hydrocephalus ex-vacuo Damaged brain matter shrinks and is surrounded by fluid Hydranencephaly Damaged brain matter replaced by pockets of Fluid Pachygyria, lissencephaly Abnormal ridges and folds (gyri) in the brain Brain abnormalities Confirmed or possible congenital microcephaly (see next slide) Intracranial calcifications Cerebral atrophy Abnormal cortical formation Corpus callosum abnormalities

Cerebellar abnormalities Porencephaly Hydranencephaly Ventriculomegaly / hydrocephaly (excluding mild ventriculomegaly without other brain abnormalities) Fetal brain disruption sequence Other major brain abnormalities, including intraventricular hemorrhage in utero (excluding postnatal IVH) Fetal Brain Disruption Sequence First described in 1984 but noted in earlier literature Brain destruction resulting in collapse of the fetal skull, microcephaly, scalp rugae and neurologic impairment Photos and x-ray from 1990 series*; phenotype appears to be present in affected babies in Brazil

*Moore, et al. J Pediatr 1990;116:383-386. Neural tube defects and other early brain malformations Anencephaly / Acrania Encephalocele Spina bifida Holoprosencephaly / Arhinencephaly Structural eye abnormalities Microphthalmia / Anophthalmia Coloboma Cataract Intraocular calcifications Chorioretinal anomalies involving the macula; excluding retinopathy of

prematurity Optic nerve atrophy, pallor, and other optic nerve abnormalities Consequence of CNS dysfunction Congenital contractures (e.g., arthrogryposis, club foot, congenital hip dysplasia) with associated brain abnormalities Congenital deafness documented by postnatal testing Neural tube defects and other early brain malformations Anencephaly / Acrania Encephalocele Spina bifida Holoprosencephaly / Arhinencephaly Other Birth Defects with Abnormal Head Size

Anencephaly Failure of the neural tube to close resulting in failure of the brain and skull to form Spina bifida Failure of neural tube closure resulting in an opening in the spine Can occur anywhere along the spine Other Birth Defects with Abnormal Head Size Encephalocele A sac-like protrusion of the brain and membranes that cover it through an opening in the skull Can have other brain and face defects

Holoprosencephaly/Arrhinencephaly Failure of the brain to fully divide into two hemispheres or other parts Hydrocephalus Accumulation of fluid in the brain Enlarged ventricles and skull Structural eye abnormalities Microphthalmia / Anophthalmia Coloboma Cataract Intraocular calcifications Chorioretinal anomalies involving the macula; excluding retinopathy of

prematurity Optic nerve atrophy, pallor, and other optic nerve abnormalities Consequence of CNS dysfunction Congenital contractures (e.g., arthrogryposis, club foot, congenital hip dysplasia) with associated brain abnormalities Congenital deafness documented by postnatal testing Structural eye abnormalities Microphthalmia / Anophthalmia Coloboma Cataract Intraocular calcifications Chorioretinal anomalies involving the macula; excluding retinopathy of prematurity

Optic nerve atrophy, pallor, and other optic nerve abnormalities Consequence of CNS dysfunction Congenital contractures (e.g., arthrogryposis, club foot, congenital hip dysplasia) with associated brain abnormalities Congenital deafness documented by postnatal testing Eye Abnormalities: Structural eye abnormalities Microphthalmia / Anophthalmia Coloboma Cataract Intraocular calcifications Chorioretinal anomalies involving the macula; excluding retinopathy of

prematurity Optic nerve atrophy, pallor, and other optic nerve abnormalities Consequence of CNS dysfunction Congenital contractures (e.g., arthrogryposis, club foot, congenital hip dysplasia) with associated brain abnormalities Congenital deafness documented by postnatal testing Structural eye abnormalities Microphthalmia / Anophthalmia Coloboma Cataract Intraocular calcifications Chorioretinal anomalies involving the macula; excluding retinopathy of prematurity

Optic nerve atrophy, pallor, and other optic nerve abnormalities Consequence of CNS dysfunction Congenital contractures (e.g., arthrogryposis, club foot, congenital hip dysplasia) with associated brain abnormalities Congenital deafness documented by postnatal testing Consequence of CNS dysfunction Club Feet Arthrogryposis Vital Signs Morbidity and Mortality Weekly Report April 4, 2017 What information is included

in ZBDS? Zika-related birth defects surveillance utilizes two primary collection tools to obtain information about maternal risk factors present and babies born with abnormalities potentially related to Zika virus infection during pregnancy: Maternal Health History Demographics, Maternal Zika Virus History, Exposure History, Maternal Health History, Pregnancy Information, Prenatal Imaging and Diagnostics Neonatal Assessment Demographics, Physical Examination, Imaging and Diagnostics, Postnatal Infection and Cytogenetic Testing Results How will ZBDS data be used? Understand disease patterns and risk factors Help identify the types of birth defects that are more common in infants who

were exposed to Zika virus and the subpopulations that are most affected by Zika-related outcomes. Understand effects on populations and communities Help identify who in a population is affected by birth defects that are potentially associated with Zika virus infection and can serve as a foundation to link with other data to better understand the effect of Zika virus on communities. How will ZBDS data be used? Inform prevention activities Help improve prevention of Zika virus infection during pregnancy and help researchers study the full range of other potential health problems.

Connect families to health and social services Birth defects surveillance systems provide one way to identify and refer infants born with birth defects, including those that may be caused by Zika virus infection, for services they need as early as possible. USZPR Compared to ZBDS Zika Virus Surveillance in the US and Kentucky Zika

Virus Disease in the U.S. Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory (as of May 3, 2017) Source: CDC. Updated 5/3/17 Zika Virus Disease Cases by Mode of Transmission United States, January 1, 2015 May 3, 2017 Total Cases: 5274

Travel-related, 4973, 94% Local Transmission, 224, 4% Other*, 77, 1.5% Other Transmission routes include: sexual (46), congenital infection (28), Laboratory (1), person-to-person, unknown (1) Pregnancy Outcomes in the United States Pregnancy Outcomes in the US (Updated 4/25/17) 1,793 pregnant women with laboratory evidence of possible

Zika virus infection in the 50 US States and District of Columbia. 1,409 completed pregnancies 58 liveborn infants with birth defects 8 pregnancy losses with birth defects CDC.gov/zika USZPR data In 2016 the USZPR reported 972 completed pregnancies 5% with possible Zika virus had birth defects 10% with laboratory confirmed Zika had birth defects 15% with laboratory confirmed Zika in the first

trimester had birth defects These data are for symptomatic and asymptomatic mothers Reynolds MR, Jones AM, Petersen EE, et al. Vital Signs: Update on Zika VirusAssociated Birth Defects and Evaluation of All U.S. Infants with Congenital Zika Virus Exposure U.S. Zika Pregnancy Registry, 2016. MMWR Morb Mortal Wkly Rep 2017;66:366-373. ZRBD data Baseline prevalence of birth defects associated with zika infection CDC case definition was retrospectively applied to the population-based birth defects data collected in 3 areas of the country in 2013-2014 Massachusetts, North Carolina, and Atlanta, Georgia All Zika-related Birth defects 2.86/1000

Brain abnormality/microcephaly 1.5/1000 Cragan JD, Mai CT, Petersen EE, et al. Baseline Prevalence of Birth Defects Associated with Congenital Zika Virus Infection Massachusetts, North Carolina, and Atlanta, Georgia, 20132014. MMWR Morb Mortal Wkly Rep 2017;66:219222. Zika-related Birth Defects January through September 2016 USZPR reported 26 infants/fetuses born to 442 mothers with the same baseline birth defects born to mothers with laboratory evidence of Zika Virus Infection These data suggest a 20 fold increase in all Zika-related birth defects 30 fold increase in brain abnormalities and microcephaly

Cragan JD, Mai CT, Petersen EE, et al. Baseline Prevalence of Birth Defects Associated with Congenital Zika Virus Infection Massachusetts, North Carolina, and Atlanta, Georgia, 20132014. MMWR Morb Mortal Wkly Rep 2017;66:219222. Vital Signs Morbidity and Mortality Weekly Report April 4, 2017 Zika Virus Infection in Kentucky Cases with evidence of Zika in Kentucky (Updated 5/03/2017) 34 cases with laboratory-confirmed Zika virus infection Adult cases have had travel exposure and/or sexual exposure to a traveler. No known local transmission. Most commonly reported symptoms in Kentucky: 97% Rash 74% Fever

71% Arthralgia 54% Conjunctivitis Following this talk . You should be familiar with the US Zika Pregnancy Registry (USZPR) and Zika-Related Birth Defects Surveillance (ZBDS) You should be able to recognize some of the Zika-related birth defects Have an understand of the similarities and differences between the USZPR and ZBDS Have an understanding of why it is important to collect surveillance data on Zika virus and its effects Be familiar with recent Zika prevalence data in the US and Kentucky Questions?

Judy Theriot, MD, CPE Medial Director Commission for Children with Special Health Care Needs [email protected]

Recently Viewed Presentations

  • Midterm 1 Name: Student ID: University of Waterloo

    Midterm 1 Name: Student ID: University of Waterloo

    An onomasiological process behind the term mouse potato, in the sense of a person who spends vast amounts of unproductive time in front of a computer, is metonymy. T F 10. Lexicalization is the process by which languages encode concepts....
  • Undergraduate Education Committee Thomas Chase William Durfee Susan

    Undergraduate Education Committee Thomas Chase William Durfee Susan

    Utilize alumni or industry presenters in seminars or lectures Establish a "Professional Development Day" to increase interactions between students, advisers and employers (students can talk with faculty, industry reps, grad students, International Programs reps, etc.) Undergraduate Education UG Ed Strategic...
  • C++ Programming: Program Design Including Data Structures ...

    C++ Programming: Program Design Including Data Structures ...

    * C++ Programming: From Problem Analysis to Program Design, Sixth Edition Choosing the Right Looping Structure All three loops have their place in C++ If you know or can determine in advance the number of repetitions needed, the for loop...
  • Chapter 1-thinking Geographically

    Chapter 1-thinking Geographically

    2. Functional Region- a nodal region, an area organized around a node or focal point. For example Atlanta is a airline trans- portation hub for the southeast. Marietta is a suburb of Atlanta. 3. Vernacular Region- a perceptual region, a...
  • Miedzyrzec Place of Interest

    Miedzyrzec Place of Interest

    Many women and infants perished in the most sadistic way here. One can well say that under every stone and tree, blood of our dear ones was spilled.In the arched lane that leads to the square, the brothers Ts'nki were...
  • Intelligent Content Authoring for Everyone Advancing the state

    Intelligent Content Authoring for Everyone Advancing the state

    Intelligent Content. Usable. Findable. Reusable. Intelligent. Content. Intelligent content is modular, making it portable across contexts, structured, so it can be processed predictably across applications; and semantic, so that content elements have meaning instead of formatting, and can be formatted...
  • Clinical Decision Support Consortium: Technical Expert Panel ...

    Clinical Decision Support Consortium: Technical Expert Panel ...

    Technical Expert Panel Meeting ... GEM Cutter EXTRACTOR Transforms SmartForm Set Design Next Steps For August/September Complete integration of asthma DS into existing systems flow, including sign-off from key Yale stakeholders and GLIDES Steering Group Complete system test planning and...
  • Watson Brake and Poverty Point: Early Moundbuilding Cultures ...

    Watson Brake and Poverty Point: Early Moundbuilding Cultures ...

    Watson Brake and Poverty Point: Early Moundbuilding Cultures of Eastern North America Poverty Point, LA 1700-1200 BC Watson Brake, LA 4000 BC Mimbres Ceramics The greatest cause of declines in Native North America (throughout the Americas) was highly contagious, fever...