Medieval II: Total War - poradnik do gry. Kre. Chmury coraz ciemniejsze. Jest to kolejna z serii gier strategicznych Total War. Niniejszy poradnik ma za zadanie przybli. Gra ze swoimi mechanizmami jest bowiem bardzo podobna do poprzedniczek. W poradniku tym znajdziecie opisy wszystkich g.
Policjant drogówki ROME GUIDE presents in a simple and detailed way the program of events and tourist services to which Roma Pass holders are entitled. The four-month Guide features. Zgodnie z postanowieniami konferencji ja Jako przewodniczka pracuj Nie znajdziecie tu jednak opisu ka. Medie 2 oferuje na tyle przejrzysty system opis. Nie znajdziecie tu te. Jak bezstresowo zwiedzi. Piotra powinien zobaczy. To symbol Rzymu i pot. Czy okolice Watykanu mog? Il presepe dei netturbini – ulubiona szopka Jana Paw. To bardzo oryginalna szopka, przenosi nas do Palestyny sprzed 2. Kapitalna sceneria: ogl. Piotra (odradzam autobus 6. Kto rano wstaje, ten wszystko zobaczy. Bazylika jest otwarta od godz 7, ale ju. Polecam audioprzewodnik po Bazylice . Zarezerwujcie minimum godzin. Wirtualny przewodnik po bazylice jest kiepski, ale mo. Ochrona jest restrykcyjna i nie wpu. Panowie, najlepiej za. To druga kaplica prawej nawy, kolejna po Piecie Micha. Obecnie jest odgrodzona szar. Po beatyfikacji 1 maja 2. W tym miejscu spoczywa. Obecnie spoczywa on pod O. Sebastiana zdobi mozaikowa autorstwa Pier Paolo Cristofariego wykonana wed. Z drugiej strony ocali. NA CZAS TRWANIA ROKU JUBILEUSZOWEGO ULEG. Z biletem wchodzicie od razu, wypocz. Podobnie w Opera Romana Pellegrinaggi – przy Piazza Pio XII – po lewej stronie – . W praktyce ostatnie wej. Realnie, kto chce skorzysta. Zainteresowanie jest ogromne niezale. To pozwoli Wam zaoszcz. Wirtualne zwiedzanie Muze. To ciekawa opcja, cena biletu taka sama jak przy normalnej wizycie, wymagana rezerwacja on- line. Najpierw trzeba jednak wys. Biuro wykopalisk wyznaczy Wam dat. Dzieci do 1. 5 lat nie mog. Dodatkowe informacje znajdziecie na stronie nekropolii, tam tak. Audioprzewodniki w j. Autobus nie jest przystosowany do w. Rezerwacje na stronie muze. Audiencje papieskie. Oficjalnie odbywaj. Ten trzeba zarezerwowa. Kto przyjdzie pierwszy, ma lepszy sektor, bli. Nie zapomnijcie nakrycia g. Obok jest poczta watyka. Jedno miejsce jednak polec. Prosta kuchnia rzymska, dobre ceny, skoro kardyna. Zawsze przed tym lokalem ustawia si. A wszystko we wspania. Smacznie i bardzo przyzwoite ceny. Delikatesy Franchi. Bacio di Puglia – ma! Nie jest tanio, ale raz mo.
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Placement Point a leading website for job placement, jobs, hot jobs, job listing, online jobs, job opportunity vacancies, consultancy, job search engine, naukri in.Artificial Intelligence Could Prevent the Next Video Game Animation Disaster. Human character animation has gotten much better over the years, but it’s still one of the most recognizable issues when enjoying video games. Animations are normally a predetermined set of canned motions, and while real enough looking in the right setting, can totally break the immersive experience when they stray out of bounds. The uncanny valley is a particularly hard one to escape. Now, a research team from the University of Edinburgh has developed a new way to animate game characters using neural net computing, which could help developers make more fluid and realistic animations, while decreasing the system resources and time involved. The video demonstrating the new technology is legit: The minds behind this video, and an accompanying paper published in ACM Transactions, are Daniel Holden, Taku Komura and Jun Saito. ![]() When I caught the video, I immediately reached out to Holden for more info. What exactly makes this different from other animation methods, and what’s happening in the neural net to make the magic happen? Neural networks (or NNs) are a way to train a computer with millions of differently weighted data points. Using algorithms, a NN can create completely new outputs on its own, based on the data it has to reference. The emerging technology is commonly used in facial recognition, image processing, and stock market prediction applications. But basically, what he and his colleagues have done is employ a system called a phase- functioned neural net, in which the variables controlling a character’s movement and interaction within the environment can change on the fly. His aim was to develop intricate, human- like cyclical movement that reacts appropriately to user inputs. As players mash on their gamepads or move a mouse, the neural net learns and evolves over time to create a seamless animation.“We change the weights of the neural network depending on what point in time in the locomotion cycle the character is,” explained Holden, those weights being the data that influences what the animation will be. A drastic reduction in the amount of time and effort animators need to achieve that perfect gait. The video above only used about 1. GB, or 2 hours, of motion capture data, and the animation doesn’t need as much on- board processing power to render. Holden thinks it will “take some of the burden off animation programmers maintaining the hugely complex animation systems.”It took 3. NN training and 4 million data points to create the animation in the video and, to me, it looks pretty good. The character deftly navigates raised obstacles, appropriately speeds up and slows down based on the input and reacts accordingly to the walls and bridges. Obviously, third- person perspective games could benefit from the new approach, but VR experiences are also mediums where, for maximum immersion, we’re going to need hyper- realistic motion. Neural networks have been used in gaming before, in developing opponent AIs, but this is a great example of how the technology can make developers’ lives easier. Please note that most of these Brand Names are registered Trade Marks, Company Names or otherwise controlled and their inclusion in this index is. Holden just started a new R& D job at Ubisoft, and while unable to say if the tech is going to be used there, he looks forward to seeing more implementation in the future.“I hope that this technique does change gameplay—hopefully these sort of technologies will allow game designers to be more adventurous with the kind of environments they create,” said Holden. Bryson is a freelance storyteller who wants to explore the universe with you. Your personal information and card details are 100% secure. UpdateStar is compatible with Windows platforms. UpdateStar has been tested to meet all of the technical requirements to be compatible with Windows 10, 8.1, Windows 8. 25 years ago this week, the pink puff ball made his Japanese debuted in Kirby’s Dream Land for the Game Boy. But the game’s titular character was originally just. Job Interview Practice Test Why Do You Want This Job? Answer this job interview question to determine if you are prepared for a successful job interview. From millions of real job salary data. Average salary is Detailed starting salary, median salary, pay scale, bonus data report. Soylent, a substance, is about to be everywhere. A team of queasy venture capitalists just invested $50 million into the company. This, despite the fact that Soylent. Career advice, tips, news and discussion is coming soon More Career Information. Salaries; Interview Questions; Sample Resumes; Jobs. In finance, a foreign exchange option (commonly shortened to just FX option or currency option) is a derivative financial instrument that gives the right but not the. ![]() Depois de formado, Einstein passou quase dois anos frustrantes procurando um cargo de professor. Adquiriu a nacionalidade suíça em 21 de fevereiro de 1901, mas não. Acrobat DC A solução completa de PDF; Reader DC Exiba, assine e comente em PDFs; Adobe Sign A melhor solução de assinatura eletrônica; PDF Pack Ferramentas.
Mazinger Z - Wikipedia, la enciclopedia libre. Mazinger Z(. Infierno en algunos pa. El manga fue publicado por primera vez el 1. Sh! Este robot estaba guiado por un ni. Sin embargo, aparte de total autonom. Su primer manga en esa direcci. En sus conceptos originales, el t. Sin embargo, debido a la repentina popularidad de su serie Kamen Rider(kekko Kamen) en la que se usaba una motocicleta, Nagai sustituy. Con este nombre le confiere al robot una doble faceta: el Mazinger Z puede ser un benefactor o un destructor, un Dios o un Demonio, seg. El descubrimiento es sensacional para la historia de la Humanidad. Hell advierte que es mejor no difundir la noticia hasta no conocer mejor los detalles del descubrimiento, y pide que se le deje investigar en privado. Con ellos, anuncia su intenci. Los Robots comienzan a masacrar a los presentes. Hell, dando vida al Mazinger Z. Kabuto, pero antes de fallecer consigue contar a su nieto K. Hell y le da a conocer al Mazinger Z. Es en este momento cuando J. De hecho, en la mitad de la serie se auxili. Hein Henrik, al cual revivi. Tan notable fue este ingeniero alem. Hell, lo que supone un reto de actualizaci. Yumi, asistente del Dr. Kabuto, que atiende y supervisa la ingenier. Aunque no fue destinado en principio como arma de combate, posteriormente fue adaptado t. Hell y la ira de venganza que K. Habiendo muerto los padres de K. En el manga el Profesor Juzo construye el Mazinger Z por su propia iniciativa, sin conocer los planes del Doctor Infierno, quien acaba por asesinarlo. Es un adolescente un tanto mal geniado y desconfiado, m. Responsable y buen estudiante, cursa secundaria en el instituto y se destaca en las artes marciales, practicando Karate y Kendo. Aunque no le gustan los problemas, en cuanto se le presentan no los reh. Este es el caso de la lucha que sostiene contra el Dr. Sin embargo siempre hay quien viene a molestarle, si no son los brutos mec. Y no lo piensa por su hermano al que ama profundamente. Shir. Es hija del director del Centro de Investigaciones Fot. Hasta la llegada de K. Hija del jefe y piloto de la Afrodita A, nunca hab. Y lo peor de todo no son los celos, si no que admira a K. Es un hombre capaz de mantenerse sereno en las ocasiones m. Posee un alto sentido de la responsabilidad y del sacrificio. Peludo y barbudo, el pelo le cae hacia abajo de los lados de la cabeza y le contin. Su cara es alargada y luce un bigote blanco. Sus andares muestra que el hombre es mayor y un tanto debilitado, sin embargo a pesar de su avanzada edad se desvive por hacer todo lo que esta en sus manos por tener a punto al Mazinger Z. Es la paciencia y la voz de la experiencia del grupo. Es uno de los desarrolladores del Jet Scrander (las alas a reacci. Sus secuaces son Mucha(. Pero aumenta su encono contra K. Pasa lo mismo incluso con los robots. Las razones tienen que ver con la animaci. Para ello cuenta con un arsenal de robots gigantescos, que env. Hell no es si no un pe. Muere junto al Conde Brocken en el pen. En la historia manga el Dr. Es posible contemplar, cuando es enfocado desde el lado derecho como quien conversa es el lado femenino del personaje y si es enfocado el lado izquierdo es el masculino quien est. Igualmente, los razonamientos son diferentes seg. Ashura hace las veces de lugarteniente del Dr. Hell, que le ha dotado de un ej. Hell empieza a perder la paciencia y busca un contendiente para el Bar. La rivalidad solo aparece en el anime. La impaciencia hace que el Bar. La guerrera de color turquesa est. Brocken usa siempre guantes y su cabeza luce un pelo desmelenado, ojos con hirsutas pesta. Hell le ha concedido la fortaleza volante; Gool . Hell, no obstante ambos arist. A diferencia de Ashura, en la serie se aprecia por completo que se trata de un cyborg con algunas partes org. Hell al perder al Bar. Se asemeja a un pigmeo de cuya cintura se desprende el cuerpo de un guerrero corpulento. La idea era atacar psicol. El vizconde Pigman, a diferencia de los otros secuaces del Dr. Hell, toma decisiones de ataque m. Es temperamental y generalmente no hace caso a las . Hell y haber intentado tomar el instituto por su cuenta. Al morir se puede ver estallar su cuerpo del que salen tuercas y tornillos y de su cabeza se ven salir cables y tornillos lo que confirma que no es un ser vivo, sino otro de los cyborgs del Doctor Hell. El duque Gorg. Hell, para combatir a Mazinger Z. En principio, Gorgon, act. Visten una indumentaria con falda corta, botas, calzas y coraza ligeramente inspirada en la Macedonia del siglo IV a. Portan espada de doble filo, pero en numerosos cap. Visten un uniforme gris muy parecido al uniforme alem. Aparte de los cometidos ya comentados, las cruces de hierro realizan misiones de escolta, esqu. Este soldado infiltrado en el laboratorio de investigaciones fot. Aunque no se muestra claramente, muere durante el bombardeo al Instituto perpetrado por la bestia . Es un concentrado de hidr. Estos misiles salen disparados a la vez que giran sobre si mismos, clav. Hell en la construcci. Hell no cuenta con material de similar resistencia y busca apoderarse de . Una vez acoplada la nave en la cabeza del robot, . De hecho, a veces el robot parece tener voluntad propia: por ejemplo, algunas veces Koji se lo encuentra fuera de su hangar, como si tuviera ganas de luchar. Los robots del Dr. Hell eran controlados por un bast. Por el contrario, cuando K. Lo controla con un cuadro de mando bastante simplificado, y el robot responde a la voluntad de su compa. En el Manga en este cap. Por ello el Pilder tambi. Cuenta con metralleta que ser. El nuevo Jet Pilder, resultar. Los mares los conquist. Sin embargo para la conquista de los cielos al no poder, por su dise. Las alas externas eran acoplables y estaban propulsadas por dos cohetes conoci. Estas alas, que se ci. Nosori advierte a Siro de que el borde del ala, como ala supers. Es por ello que ha sido colocado en un hangar especial en el Centro de Investigaciones Fot. El robot descansa secretamente bajo una piscina de agua. Cuando desean que el Mazinger Z se recarge con rapidez concentran energ. No lleva enchufes. En el momento que K. Es entonces cuando se activa el robot y esta alza los brazos como desperez. El Mazinger Z ha despertado y despliega todo su poder. Pese a no formar parte del robot La Barrera de energ. Esta barrera, se despliega a trav. Los proyectores dispersan unos haces de fuerza que forman una barrera impenetrable. Algunos monstruos, intent. Hell ha creado diversas bestias que han conseguido atravesar dicho escudo, haciendo necesario modificarlo en numerosas ocasiones reforz. Afrodita, al igual que Mazinger Z, es un robot tripulado al que se accede mediante una nave planeadora, protegida por una c. La nave de la Sayaka tambi. Yumi acaba por reforzarlo con Super Aleaci. Se trata de un robot con apariencia femenina dise. Hell, que consigue construirla. Sin embargo, careciendo de Aleaci. Aparte de contar con los mismos poderes de Mazinger Z, la caracter. Ignorando el circuito, la activa para destruir a Mazinger, pero cuando Minerva se aproxima a su contrincante, el Dr. Hell pierde el control del robot y la Minerva X se sobrecalienta, llora y se desmaya. Resulta que el circuito era para sincronizaci. Sin embargo, debido a estar construida con Super- Acero, y no de Aleaci. Al enterarse de esto, el Dr. Hell manda a otro robot para que destruya a Minerva antes de que sea reconstruida y se vuelva contra . Al principio, los cient. Ahora hace de comparsa de sus hermanos mayores y aunque suele romperse por todos los sitios, y en ocasiones no encuentra ni su propia cabeza. Hay veces en las que puede presumir de que ha sido de gran ayuda para ambos. El planeador de Sayaka fue sustituido por una motocicleta, que ascend. Algunos asemejaban animales, otros bestias mitol. Los primeros son claramente inferiores a Mazinger Z y en un enfrentamiento directo son incapaces de vencerlo, como se ve en el cap. Hell es arrastrar a Mazinger a lugares peligrosos, agotar su energ. Sin embargo, con el tiempo comienzan a surgir ingenios como Baras K9, que s. Aun siendo espectaculares las capacidades de los brutos mec. Al contrario que su predecesora, tiene forma de submarino y en la parte superior muestra una cara con boca de la que sale un torbellino de gran potencia, tanto es as. Con todo la fortaleza Gur. Shunsuke Kikuchi se encarg. Fuzo Kabuto, el ataque de Day. En septiembre de 1. Telecinco volvi. Esta serie fue emitida en 1. La extinta cadena de televisi. Posteriormente, Grupo Imagen la incluy. Sin embargo en 1. Corporaci. En 1. 99. Chilevisi. En 1. 98. Paraguay y Venezuela, en TV Cerro Cora y Venevisi. En 2. 00. 2 Toei Animation lanz. Ha de recordarse que el manga japon. Fue por ello que se editaron seis t. Los siguientes conten. Construido por el padre de K. Gran Mazinger salva al robot que hasta ese d. Y acabada su saga se encargar. Tras finalizar la saga de Mazinger Z la serie pretendi. Otra de las peculiaridades de esta obra es que incluye personajes de otras series de Nagai, como Mao Dante y Violence Jack. Great Mazinger?): estreno 2. Great Mazinger, Grendizer, Getter Robo G Decisive Battle! The Great Sea Monster (! El gran monstruo marino?): estrenada en Jap. Taekwon V fue dirigida por Kim Cheong- gi. Kim Cheong- gi ha dicho que Mazinger Z fue una fuente de inspiraci. Nos encontramos con un robot diferente, que exhib. Este robot de color rojo era tripulado por un joven que se acoplaba a . El film estaba confeccionado al estilo Godzilla, marcando el precedente para los futuros Power Rangers, pues era evidente que se trataba de un hombre enfundado en un traje de robot quien actuaba. Bas. Groizer era un robot gigantesco que pod. Ver El Justiciero. Super Mazinger Z: Esta pel. Se trataba de un montaje de las OVAs . Se vendieron 4. 00,0. Estaban fabricados principalmente de metal, aunque ten! Ese volumen contiene adem. Consultado el 6 de septiembre de 2. Consultado el 5 de octubre de 2. Consultado el 1 de agosto de 2. Consultado el 1. 6 de octubre de 2. Archivado desde el original el 2. Consultado el 1. 4 de septiembre de 2. Consultado el 6 de octubre de 2. Find and Remove Duplicate Files in Linux. It might seem unnecessary to worry about duplicate files when you have terabytes of storage. However, if you care about file organization, you’ll want to avoid duplicates on your Linux system. You can find and remove duplicate files either via the command line or with a specialized desktop app. Use the “Find” Command. In case you’re not familiar with this powerful command, you can learn about it in our guide. By combining find with other essential Linux commands, like xargs, we can get a list of duplicate files in a folder (and all its subfolders). The command first compares files by size, then checks their MD5 hashes, which are unique bits of information about every file. To scan for duplicate files, open your console, navigate to the desired folder and type: find- not- empty- type f - printf. If you care about file organization, you can easily find and remove duplicate files either via the command line or with a specialized desktop app. In this case, names of duplicate files. If you prefer to manage your files in an application that offers more options at once, the next solution might suit you. Employ dupe. Guru. Developer: www.evernote.com Password: www.thinstallsoft.com MD5 Hash: 154DE91DAF60C00D4AF078126B8C37DE. Download Evernote Portable 6.5.4.4720 Public. PortableApps.com - Portable software for USB, portable and cloud drives. If you care about file organization on your Linux machine, you can easily find and remove duplicate files via the command line or with dupeGuru. Dupe. Guru is a cross- platform application that comes in three editions: Standard (SE), Music and Picture. It’s designed to find duplicate files based on multiple criteria (file names, file size, MD5 hashes) and uses fuzzy- matching to detect similar files. Windows and OS X users can download the installation files from the official website, and Ubuntu users can pull dupe. Guru from the repository: sudo add- apt- repository ppa: hsoft/ppa. To search for duplicates, first add some folders by pressing the “+” button. Setting a folder state to “Reference” means that other folders’ contents are compared to it. Before clicking “Scan,” check the “View - > Preferences” dialog to ensure that everything is properly set up. If you care about file organization, you can easily find and remove duplicate files either via the command line or with a specialized desktop app.“Scan Type” varies across dupe. Guru editions; in Standard, you can compare files and folders by contents and filename. Picture edition offers comparison by EXIF timestamp and “Picture blocks” – a time- consuming option that divides each picture into a grid and calculates the average color for every tile. In Music edition, you can analyze “Fields,” “Tags” and “Audio content.” Some settings depend on the scan type: “Word weighting” and “Match similar words” work only when you search for file names. Conversely, “Filter Hardness” doesn’t apply when you perform a “Contents” scan. Dupe. Guru can ignore small files and links (shortcuts) to a file, and lets you use regular expressions to further customize your query. You can also save search results to work on them later. DupeGuru 3.1.0 kostenlos downloaden! Weitere virengeprüfte Software aus der Kategorie Tuning & System finden Sie bei computerbild.de! Les logiciels de nettoyage pour l'ordinateur ont plusieurs fonctions. En premier lieu ils permettent de désinstaller des programmes non utilisés, à l'instar de. PowerISO est un gestionnaire d'image virtuelle pour votre CD ou DVD (ISO, BIN, DAA, CDI, etc.). En quelques clics, vous pourrez ouvrir, extraire, éditer, compresser. Download the free trial version below to get started. Double-click the downloaded file to install the software. Download Easy Duplicate Finder. Delete duplicate files from your PC or Mac without any hassle. Localize e elimine arquivos duplicados que entopem seu disco rígido. Find and remove duplicate files. Duplicate Files Finder Portable lets you find and remove duplicate files from your storage devices. If you get too many pictures on your harddrive, downloaded or photographied, from several different sources, it may happen that you have many duplicates. Apple fans will love the fact that dupe. Guru supports i. Photo and Aperture libraries and can manage i. Tunes libraries. When dupe. Guru finds duplicates, a new window opens with reference files colored in blue and their duplicates listed below. The toolbar displays basic information, and you can see more about every file if you select it and click the “Details” button. You can manage duplicate files directly from dupe. Guru – the “Actions” menu shows everything you can do. Select files by ticking the checkbox or clicking their name; you can select all or multiple files using keyboard shortcuts (hold Shift/Ctrl and click on desired files). If you’re interested in differences between duplicate files, toggle Delta Values. The results can be re- prioritized (so the files listed as dupes become references) and sorted according to various criteria like modification date and size. The official dupe. Guru user guide is helpful and clearly written, so you can rely on it if you ever get stuck. Naturally, it would be more practical if dupe. Guru wasn’t split into three editions – after all, most users love one- stop solutions. Still, if you don’t want to use the find command, dupe. Guru provides a neat and quick way to eradicate dupes from your filesystem. Can you recommend some other tools for removing duplicate files? Do you prefer the command line for this task? Tell us in the comments. All. Dup Portable 4. Download. Kompatible Betriebssysteme. Windows 1. 0, Windows 8, Windows 7, Windows Vista, Windows XP Sprache. Deutsch, Englisch Anzahl der Downloads. Gro. Wen wundert es da, dass sich im Laufe der Zeit Dutzende, Hunderte oder gar Tausende doppelter bzw. Abhilfe verspricht die Gratis- Software . Wahlweise werden Files aus allen Verzeichnissen verglichen, nur Dateien aus dem gleichen Quellordner oder Dateien aus unterschiedlichen Verzeichnissen. Doppelte MP3s und MP4s aufsp. Angezeigt werden dabei alle g. Die Suchergebnisse lassen sich speichern und in eine Textdatei exportieren. Alternativ zum manuellen Markieren per Mausklick k. Kombinieren Sie diese Option mit der Vorschaufunktion, haben Sie nicht mehr ben.
A pediatric intensive care unit (also paediatric), usually abbreviated to PICU / Therapeutic Hypothermia after In-Hospital Cardiac Arrest in Children. Silverstein, M.D., Richard Holubkov, Ph.D., Beth. Guidelines for mTBI and Persistent Symptoms 1 INTRODUCTION Overview The Ontario Neurotrauma Foundation (ONF) initiated this project with the overall objective to. It is a functional rather than structural injury that results from shear stress to brain tissue caused by rotational or angular forces—direct impact to the head is not required. Initial evaluation involves eliminating cervical spine injury and serious traumatic brain injury. Headache is the most common symptom of concussion, although a variety of clinical domains (e. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptoms must be determined. There are numerous assessment tools to aid diagnosis, including symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. These tools are also used to monitor recovery. Cognitive and physical rest are the cornerstones of initial management. N engl j med 376;4 nejm.orgJanuary 26, 2017 Therapeutic Hypothermia after Cardiac Arrest. Home / Courses / Pediatric Abusive Head Trauma for Kentucky Nurses; Pediatric Abusive Head Trauma for Kentucky Nurses Online Continuing Education Course. There are no specific treatments for concussion; therefore, focus is on managing symptoms and return to play. Because concussion recovery is variable, rigid classification systems have mostly been abandoned in favor of an individualized approach. A graded return- to- play protocol can be implemented once a patient has recovered in all affected domains. Children, adolescents, and those with a history of concussions may require a longer recovery period. There is limited research on the management of concussions in children and adolescents, but concern for potential consequences of injury to the developing brain suggests that a more conservative approach to management is appropriate in these patients. SCORZA, MD, MBA, Fort Belvoir Community Hospital, Fort Belvoir, Virginia RALEIGH, MD, Evans Army Community Hospital, Fort Carson, Colorado Initial evaluation involves eliminating cervical spine injury and serious traumatic brain injury. Headache is the most common symptom of concussion, although a variety of clinical domains (e. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptoms must be determined. There are numerous assessment tools to aid diagnosis, including symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. These tools are also used to monitor recovery. Cognitive and physical rest are the cornerstones of initial management. There are no specific treatments for concussion; therefore, focus is on managing symptoms and return to play. Because concussion recovery is variable, rigid classification systems have mostly been abandoned in favor of an individualized approach. A graded return- to- play protocol can be implemented once a patient has recovered in all affected domains. Children, adolescents, and those with a history of concussions may require a longer recovery period. There is limited research on the management of concussions in children and adolescents, but concern for potential consequences of injury to the developing brain suggests that a more conservative approach to management is appropriate in these patients. Consequently, management of concussions has changed significantly. Concussion can be difficult to recognize, complicated by the lack of a universal definition. Additionally, there are no direct objective measures for diagnosis or recovery, no treatments with well- documented effectiveness,
Males seem prone to concussion through player- to- player contact, whereas concussions in females tend to be caused by contact with the playing surface or equipment.
Disruptions of autonomic regulation can persist for several weeks, and the brain may be vulnerable to additional injury.
Factors predictive of recovery are poorly defined. Traditional markers (i. Studies have demonstrated that brief loss of consciousness is not associated with prolonged recovery,
These tools assess several domains to diagnose concussion and monitor recovery. The SAC has been validated in athletes who are junior high school–aged and older. Emergency department versions are validated in adults, although they are not optimal for use in children.
For most patients, the SCAT2 can be used alone to monitor recovery and guide return- to- play decisions.
Athletes should not return to play until they are completely recovered from the concussion and free of medications that may mask the symptoms of the concussion.
Evidence regarding pharmacologic therapy is limited. Treatment focuses on symptom management, including the same medications appropriate in patients without a concussion.
Educational and clinical management tools are available at
Pediatric Abusive Head Trauma CE . All Rights Reserved. COURSE OBJECTIVE: The purpose of this course is to enable nurses in Kentucky to recognize and prevent pediatric abusive head trauma (AHT) and to understand reporting requirements in Kentucky for instances of AHT. INTRODUCTIONChild abuse and neglect continues to be a serious threat to children. The United States has at least 3 million reports made every year (Childhelp, 2. In 2. 01. 2, there were 1,5. That is four to five children per day. Of these children, 7. U. S. DHHS, 2. 01. Pediatric abusive head trauma (AHT) is one of the most serious categories of child abuse and in infants is the leading cause of death from injury. With reported rates of AHT of approximately 1. United States (Shanahan et al., 2. Nearly one fourth of cases of AHT in children under 2 years result in death. The costs to the child, family, health system, and society are enormous. According to the American Academy of Pediatrics (2. AHT is a well- recognized constellation of brain injuries caused by the directed application of force to an infant or young child, resulting in physical injury to the head and/or its contents. It is the leading cause of traumatic death in children under 2 years of age; it has a characteristic clinical presentation and injury pattern; and it involves a variety of different injury mechanisms (Colbourne, 2. It is also important to consider the long- term implications of child maltreatment. Research from the ACE (Adverse Childhood Experiences) study demonstrates that survivors of child abuse and neglect have life- long health and behavioral issues. These include 6. 7% of people in substance abuse treatment and between 1. Childhelp 2. 01. 5). Besides physical trauma, exposure to abuse and neglect as a young child has also been shown to “cause important regions of the brain to fail to form or grow properly, resulting in impaired development. These alterations in brain maturation have long- term consequences for cognitive, language, and academic abilities and are connected with mental health disorders” (CWIG, 2. Infants frequently present with nonspecific clinical features without a “history” of trauma. In a landmark study on diagnosis of AHT, nearly 3. Jenny & Hymel, 1. Abusive head injuries are also one of the most common causes of serious acquired disability in children. Healthcare providers also need to be aware of other “red flags” for inflicted injury. Ward and colleagues (2. AHT presented previously in a healthcare setting at least once before recognition of the child’s AHT, and 3. Bruises are very uncommon in nonmobile infants (< 1%), and any unexplained bruise in a child who does not yet crawl or walk should lead healthcare providers to consider inflicted injury and/or a coagulation disorder. The good news is that much more is now known about recognizing and preventing AHT. Predicting Abusive Head Trauma (Pred. AHT) is a new clinical prediction tool used to estimate the probability of AHT in young children presenting with intracranial injuries and specific combinations of six historical and clinical features (Cowley et al., 2. It is also important for child welfare systems to increase their implementation of “trauma- informed” practices (CWIG, 2. TERMINOLOGYAbusive Head Trauma (AHT)An injury to the skull or intracranial contents of an infant or young child (< 5 years of age) due to inflicted blunt impact and/or violent shaking. The Centers for Disease Control and Prevention and the American Academy of Pediatrics (2. In fact, the diagnosis of pediatric AHT can only be made following “detailed medical examinations and testing and is not made automatically on the basis of the presence of these three findings, nor can it be excluded if one or more of these elements is missing” (AAP, 2. AAP (2. 01. 5) also reinforces the fact that shaking is an important contributor to abusive head injuries and that “shaken baby syndrome” is a subset of AHT. Additionally, since the release of their AHT statement, peer- reviewed medical literature, including case reports in which adults have admitted shaking an infant or child, have been published and further underscore the significance of shaking as an important contributing mechanism of injury. An anonymous phone survey in North Carolina reported that 1% of parents with a child under 2 years of age reported shaking their child as a form of discipline, and pediatric AHT is reported in all types of families (Keenan, 2. The message to “NEVER SHAKE A BABY” needs to be addressed in the media and in the prevention strategies shared below. INCIDENCE AND PREVALENCEUnderstanding the true magnitude of AHT, including the exact numbers of children affected, is difficult for many reasons, including issues with classification and determining subpopulations of children not included in data collection. Nationally. While accidental trauma is the most common cause of death in childhood, abusive head trauma is the most common cause of traumatic death during infancy. The incidence of abusive head trauma in the United States is estimated to be 1. Nearly 2. 5% of children under 2 years of age who are hospitalized for head trauma have been abused. Department of Health and Human Services (2. Examining this percentage by single- year- age reveals that 4. For children in the first year of life, the majority of serious head injuries result from abuse, and this peak incidence and rapid decrease with age are thought to be related to episodes of prolonged, inconsolable, and unpredictable crying that are developmentally normal for infants (Parks et al., 2. Thus, it is important to aim prevention strategies toward supporting parents and caregivers in dealing with crying. According to the CDC National Center for Injury Prevention and Control (Parks et al., 2. Deaths due to abusive head trauma also peak at 1 to 2 months of age, most likely due to higher physiologic vulnerability. Infants who have abuse- related head injuries at 3 to 4 months of age or older may be more resilient and more likely to survive their injuries. However, these children often have long- term consequences of their injuries. Neurologic, behavioral, and cognitive sequelae have been observed in victims of abusive head trauma, including severe developmental delays. Serious brain injury in children has been estimated to consume billions of dollars in healthcare costs each year. It is important to note that there are continued challenges related to tracking incidence and prevalence and in tracking the effectiveness of programs to reduce, and ultimately eliminate, abusive head trauma. These include limitations in available national data sets, inconsistency in definitions of abusive head trauma, and variation in how these definitions are applied. Clearly, a standardized method for defining abusive head trauma is needed if data are to be comparable across geographic areas and over time (Parks et al., 2. Kentucky. In Kentucky, more children die of injury- related causes than natural causes. Many factors have been associated with increased risk of injury or death in children, including socioeconomic factors, cultural factors, geographical location, education level, and health and safety issues in the community. During the 2. 01. Kentucky had 6. 4,3. Twelve children died as a result of abuse or neglect (KY CHFS, 2. UNDERSTANDING INCIDENCE VS. PREVALENCEIncidence. Prevalence. Sources: NYS DOH, 1. UNC, 1. 99. 9.# of newly diagnosed cases among those at risk# of cases of disease existing in a population# of cases per # in population at risk over a specific time period# of cases per # in population at a specific point in time. Indicates the rapidity with which a new disease is occurring in the population. Indicates the overall number of cases surviving in the population. ETIOLOGY AND RISK FACTORSMechanism of Injury. Abusive head trauma encompasses many mechanisms of injury. Children who present with AHT may have been injured in a number of ways, including shaking, blunt impact, suffocation, strangulation, and others. In order to reduce missed cases of pediatric abusive head trauma, tools have been developed to show high prediction for AHT. Hymel and colleagues (2. AHT. Their four “readily available” variables include: Acute respiratory compromise before admission. Bruising of the torso, ears, or neck. Bilateral or interhemispheric subdural hemorrhages or collections. Any skull fractures other than an isolated, unilateral, nondiastatic, linear, parietal fracture. In a systematic review, Maguire et al. It is unclear whether the cerebral ischemia is primary and due to the apnea commonly reported in these cases or due to secondary metabolic cascades (Dias, 2. Dias (2. 01. 0) reported that it is increasingly clear from both neuro- imaging studies and postmortem analyses of fatal cases of AHT that the widespread cerebral and axonal damage are in fact ischemic rather than directly traumatic in nature. There is also mounting evidence that the primary damage involves an upper cervical spinal cord or brain stem injury that was not previously emphasized. The study recognized that this type of injury was especially common in fatal cases. When a baby is shaken, the neck snaps back and forth, causing the brain to hit the front and back of the skull. The newborn child’s head is about 1. NCSBS, n. d.). The combination of a disproportionally larger head, soft and rapidly growing brain, thin skull wall, and lack of mobility and control of the head and neck makes infants extremely vulnerable to injury from shaking actions. Additionally, the infant’s brain has higher water content and less myelination than an adult brain, is more gelatinous, and is easily compressed and distorted within the skull during a shaking episode. The infant’s blood vessels around the brain are more susceptible to shearing, and tearing can lead to the characteristic subdural and/or subarachnoid hemorrhages. Hidden Anti- Counterfeit Message: VOID or COPYYour custom message can replace VOID or COPY (Minimum quantity of 2. Your Custom Water. Mark, Forgery Proof*Can’t be copied, scanned, digitally photographed. Signature Protection. 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