American Journal of Gastroenterology ISSN0002-9270 C 2008by Am.Coll.of Gastroenterology doi:10.1111/j.1572-0241.2007.01748.x Published by Blackwell Publishing
Spatiotemporal Characteristics of Acid Re?uxate and Relationship to Symptoms in Premature and Term Infants with Chronic Lung Disease
Sudarshan R.Jadcherla,M.D.,1Alankar Gupta,M.D.,2Soledad Fernandez,Ph.D.,3Leif D.Nelin,M.D.,4 Robert Castile,M.D.,5Alfred L.Gest,M.D.,6and Stephen Welty,M.D.6
1Sections of Neonatology,Pediatric Gastroenterology and Nutrition,Center for Perinatal Research,Department of Pediatrics,The Ohio State University College of Medicine,The Research Institute at Nationwide Children’s Hospital,Columbus,Ohio;2Center for Perinatal Research,The Research Institute at Nationwide Children’s Hospital,Columbus,Ohio;3Center for Biostatistics,The Ohio State University,Columbus,Ohio;4Sections of Neonatology,Center for Perinatal Research,Department of Pediatrics,The Research Institute at Nationwide Children’s Hospital,Columbus,Ohio;5Sections of Pediatric Pulmonology,Center for Perinatal Research, Department of Pediatrics,The Ohio State University College of Medicine,The Research Institute at Nationwide Children’s Hospital,Columbus,Ohio;and6Sections of Neonatology,Center for Perinatal Research, Department of Pediatrics,The Ohio State University College of Medicine,The Research Institute at Nationwide Children’s Hospital,Columbus,Ohio.
BACKGROUND The prevalence of gastroesophageal re?ux(GER)is high among infants with chronic lung
AND OBJECTIVES:disease(CLD),and the associated pathogenic mechanisms are not clear.The relationship of symptoms to the extent or duration of acid re?ux events(AREs)is not well known in preterm or
term infants.Our aim was to evaluate the relationship between spatial(height)and temporal
(duration)characteristics of AREs(pH<4.0)with symptoms in CLD.We tested the hypothesis that
in infants with CLD,AREs into the pharynx are associated with increased symptom occurrence and
delayed clearance.
METHODS:Nine infants born at29.8±5.5wk gestation(mean±SD,range24.7–39.0wk)with CLD were evaluated for GER at49.7±8.0wk postmenstrual age(mean±SD,range39.9–67.4wk).
Esophageal manometry was?rst performed to determine the nares–lower esophageal sphincter
(LES)distance.A pH-impedance probe was placed at87%of the nares–LES distance,and a
recording was performed for about24h at cribside.Symptoms(respiratory,sensory,and
movement)were documented by nurses that were blinded to the pH-impedance recordings.A
symptom was considered associated with an ARE if it occurred2min before,during,or2min
after the ARE.The proximal extent and associated clearance mechanisms were correlated with
symptom sensitivity index(SSI=number of AREs with symptoms/total AREs?100).Multiple
logistic regression methods,analysis of variance(ANOVA)models,andχ2tests were performed.
Data are described as median,mean±SD,or%.
RESULTS:A total of511AREs,based on pH-Impedance methods,were analyzed from203h of recordings in the nine infants.The distal esophagus was the maximal height reached in80%of AREs(P<
0.001,compared to other esophageal segments).Overall33%of the AREs were associated with
symptoms,and an SSI of77%was noted with high AREs into the pharynx.The average acid
clearance time was prolonged with symptomatic AREs versus nonsymptomatic AREs by3.5-fold(P
<0.001).
CONCLUSIONS:The occurrence and frequency of symptoms with AREs depend on the most proximal extent of the ARE and the acid clearance time.
(Am J Gastroenterol2008;103:720–728)
INTRODUCTION
Chronic lung disease(CLD)or bronchopulmonary dysplasia in infants is a heterogeneous lung disease de?ned as the per-
sistent need for≥30%oxygen beyond36wk postmenstrual age(1,2).The pathogenesis of CLD is multifactorial and may be due to chronic alveolar atelectasis,chronic aspiration, recurrent pneumonias,ventilator-associated lung injury,or 720
Acid Re?uxate and Aerodigestive Symptoms in Chronic Lung Disease721
reactive airway disease,or a combination of them(3).Accord-ing to the American Thoracic Society review,the pathophys-iology of CLD of infancy is not clear and multiple etiologies must be considered(1).The prevalence of gastroesophageal re?ux(GER)among infants with CLD is high,and strategies to manage acid re?ux events(AREs)have emerged without rigorous scrutiny(4–7).Furthermore,in neonates,there are no de?nite standards to aid in the diagnosis of GER,symptom recognition,or with the management of AREs.
The importance of symptom association with pH-impedance studies has been demonstrated in adults(8–10), children(11,12),and neonates(13–15).Temporal associa-tion of AREs has been observed with multiple respiratory symptoms in adults and older children.On the other hand, a relationship between AREs and CLD has been implicated in the worsening of lung disease(1–4).Although the mech-anisms are not clear,acid suppressive strategies have been adopted empirically in patients with CLD;however,there are risks involved with such medications in neonates(16).
The mechanisms leading to GER have been elucidated in health and in CLD(17).Recently,we have characterized the peristaltic re?ex mechanisms evoked upon midesophageal stimulation in infants(18–20).However,the characteristics of esophageal clearance mechanisms in response to spontaneous AREs in CLD are not known.Impedance-pH catheters allow detection of the retrograde esophageal?ow due to AREs and its subsequent anterograde clearance back into the stomach. Therefore,the height,duration,and clearance of re?uxate can be reliably characterized and perhaps provide clues to identify symptoms associated with AREs(7).
Our aim was to evaluate the relationship between symp-toms and the most proximal extent and duration of AREs in premature and term infants with https://www.doczj.com/doc/be15981634.html,ing pH-impedance techniques and symptom sensitivity indices,we tested the hypothesis that the frequency of symptoms associated with AREs depends on the most proximal extent and duration of AREs.
METHODS
Subjects
Nine infants(male7,female2)with CLD,who were undergo-ing in-patient respiratory support,tube feedings,and standard respiratory management in the neonatal ICU at Nationwide Children’s Hospital,were evaluated for suspected acid GER. Infants were born at29.8±5.5wk gestation(mean±SD, range24.7–39.0wk,median27.0wk),had a birth weight of 1.4±1.4kg(mean±SD,range0.7–4.4kg,median0.8kg), were assessed at49.7±8.0wk postmenstrual age(mean±SD,range39.9–67.4wk,median49.7wk),and had a weight at study of4.3±1.5kg(mean±SD,range2.6–7.3kg,me-dian4.1kg).This study was approved by the IRB at The Na-tionwide Children’s https://www.doczj.com/doc/be15981634.html,rmed consent was obtained from the parents,and HIPAA guidelines were followed.T wo subjects underwent tracheostomy for laryngotracheomalacia.All subjects were receiving full enteral feeds at the time of assessment.None of the infants had genetic or chromoso-mal abnormalities.No infant was receiving acid suppressive medications,prokinetics,or any other agent known to affect foregut motility.
Manometric Methods
Esophageal manometry methods have been used before to characterize esophageal motility waveforms and to de?ne the distance from the nares to the lower esophageal sphinc-ter(LES)(20–23).Brie?y,infant size-speci?c manometry catheters(Dentsleeve,Mui Scienti?c,Mississauga,Ontario, Canada)were used for the station pull-through technique. The distance from the nares to the upper esophageal sphinc-ter(UES)and LES was calculated.The following anatomic zones—pharynx,UES,proximal esophagus,middle esopha-gus,distal esophagus,and LES—were determined,based on the manometric waveform characteristics(20).This step was necessary to accurately position the pH-impedance probe in the infants so that data on spatial characteristics of bolus tran-sit during impedance studies could be collected(described below).
pH-Impedance Methods
The pH-impedance probe(pH-MII,model ZIN-S61C01E, Sandhill Scienti?c Inc.,Highlands Ranch,CO)had six impedance channels(seven impedance rings)and one pH channel(Fig.1B).The probe was?rst calibrated with pH4.0 and pH7.0buffer solutions.Next,the pH-impedance probe was securely set at87%of the distance from the nares to the upper border of the LES,such that the location of the pH sen-sor was in the distal esophagus(4,24).Based on manometric de?nitions,the esophageal body length varies between7and 12cm in our study population.The pH-impedance probe (ZIN-S61CO1E,Sandhill Scienti?c Inc.)is of adequate size to use in infants with esophageal lengths up to15cm.The pH-impedance probe was taped securely and was connected to the stationary Insight Impedance system(Sandhill Scien-ti?c Inc.).The pH-impedance data were recorded from each infant over a24-h period.
Documentation of Symptoms
Because these infants were in the NICU at the time of study, a dedicated and trained nurse assistant was available at the bedside to provide care and document events(symptoms and caring events)in real time.The nurse was blinded to the impedance recordings and to their analysis.Event markers were placed directly using the touch screen interface of the recording system.The screen was kept at minimal resolu-tion so that only?at lines were visible to the person entering events.The following events of interest were documented: (a)respiratory symptoms(cough,grunting,gagging,brady-cardia,and desaturation),(b)sensory symptoms(irritability, arching,grimace,cry,or pain),and(c)physical movement (stretching of limbs).The recorded symptoms were utilized to calculate the symptom sensitivity index(SSI).
722Jadcherla et al
.
Figure 1.Manometry and pH-impedance methods.An example of manometric de ?nitions of esophageal segments based on the waveform characteristics is shown in (A ).An example of pH-impedance probe recordings of an acid re ?ux event is shown in (B );note the fall in pH in the distal esophagus,proximal extent of ARE,subsequent clearance,and the duration of acid clearance time to baseline.UES =upper esophageal sphincter;PE =proximal esophagus;ME =middle esophagus;DE =distal esophagus;LES =lower esophageal sphincter.
Data Analysis
ACID REFLUX EVENTS.The BioView impedance pH software (Version 5.2.3,Sandhill Scienti ?c Inc.)identi ?es an ARE when the pH electrode detects esophageal pH ≤4.0for ≥5s.Therefore,for the purpose of this study,AREs were de ?ned as esophageal pH ≤4.0for ≥5s.All AREs were ver-i ?ed manually for proximal extent with impedance changes and symptom association.The analytical software (BioView,Sandhill Scienti ?c Inc.)disregards the marked meal periods and highlighted nonanalyzable artifacts and normalizes (per 24-h time period)the total time spent in ARE per patient.The characteristics of AREs analyzed with the software were used in the calculation of the Boix-Ochoa score (25).
MOST PROXIMAL REFLUX EXTENT.After determining that an ARE had occurred,the most proximal extent of the ARE was de ?ned as a drop in impedance in the most proxi-mal segment by more than 50%of its baseline value (7,21).ACID CLEARANCE TIME.It was de ?ned as the time taken for the esophageal pH to normalize to pH ≥4.0for ≥5.0s.ANAL YSIS OF RECORDINGS.First,AutoSCAN analysis (BioView Analysis,Sandhill Scienti ?c Inc.)was used to ?nd all AREs.AutoSCAN software requires retrograde bo-lus motion (detected by the impedance rings)in at least 2
Acid Re ?uxate and Aerodigestive Symptoms in Chronic Lung Disease 723
distal impedance channels.The acid clearance was noted when the pH returned to above 4.0for at least 5consecutive seconds with the absence of ?uid bolus motion as de ?ned in the most distal channel (located at 87%of the nares –LES up-per border distance).The AREs were evaluated manually for the following characteristics:(a)frequency of acid pH events,(b)the most proximal extent of the re ?uxate (determined by the most proximal bolus entry point),and (c)the duration of bolus presence in the esophageal column (esophageal acid clearance time).
Relationship of Symptoms With AREs
Artifacts (meal periods,nonanalyzable recording time)were excluded.Symptom analysis was performed after auto anal-ysis of AREs.Symptoms were characterized as ARE-associated symptoms if they were present during the 2min before the onset of the ARE,during the ARE (when pH re-mains below 4.0),or 2min after the ARE (7,11,26).To overcome the overlap of the same symptom associated with consecutive ARE time windows,we scored the symptom only once following an ARE.Symptoms were scored for their as-sociation with ARE in all subjects.As de ?ned previously (8),the SSI was calculated as:(number of AREs associated with symptoms/total number of AREs in 24h)×100.
Relationship of Background Symptoms During Esophageal Quiescence
We evaluated background symptoms that may have occurred due to the chronic nature of the lung disease.The computer was instructed to randomly assign periods of esophageal qui-escence lasting 1min.Next,we veri ?ed if distal esophageal pH was normal during the periods of esophageal quiescence (sham events).Symptoms occurring during the 2min before,during,and 2min after the sham event were https://www.doczj.com/doc/be15981634.html,-parison was made between these sham events and the real AREs with respect to symptom association.
Statistical Analysis
The main outcome variables in this study are categorical (height,type of symptoms)or continuous (acid clearance
Table 1.Characteristics of Infants with Chronic Lung Disease PCA at Respiratory Support Respiratory Support Primary Other ID GA (wk)Study (Wk)at 36Wk PMA (1,2)at Evaluation Feeding Method
Diagnoses 126.045.4CPAP ,24%O 2Nasal O 2NG Grade 1IVH 226.639.9CPAP ,25%O 2
Trach,CPAP G-tube Grade 1IVH
339.049.7N/A,full-term birth Nasal O 2NG Grade 1IVH,seizures 431.044.1Trach,35%O 2Trach NG Grade 1IVH 527.067.4CP AP ,30%O 2
Nasal O 2NG Normal
627.052.4Ventilator,38%O 2Nasal O 2G-tube Posthemorrhagic
hydrocephalus,PVL 728.052.0Nasal O 2
Nasal O 2NG Normal 824.652.4Ventilator,40%O 2Nasal O 2G-tube Grade I IVH 9
39.0
44.0
N/A,full-term birth
Nasal O 2
G-tube
Normal
GA =gestational age;NG =nasogastric tube;G tube =gastrostomy;IVH =intraventricular hemorrhage;PVL =periventricular leukomalacia;Trach =tracheostomy;CP AP =continuous positive airway pressure.
time).Several observations were made within subjects.Thus,multinomial mixed models or linear mixed models were used to study the association between symptoms and ARE height and duration.In these models,a random effect was included to account for correlation among the subjects.These models were ?t using PROC GENMOD or PROC MIXED in SAS (SAS v.9.1,SAS Institute Inc.,Cary,NC).Data are shown as median,mean ±SD,or as %unless stated otherwise.A P value of <0.05was considered signi ?cant.The height of the re ?uxate was assigned one of four ordinal categories de-pending on the maximal height reached,i.e.,distal,middle,or proximal esophagus or pharynx.
RESULTS
Characteristics of Subjects
and the pH Probe-De?ned AREs
Characteristics of the individual subjects are given in Table 1.A total of 202.8h of tracings was analyzed (mean 22.53h/subject).In total,523AREs were identi ?ed based on the results from the pH probe only,and this was 12events more than the events based on the combined pH-impedance results.Based on BioView software-generated pH probe re-sults,the frequency and characteristics of the AREs and the Boix-Ochoa scores are summarized in Table 2.
Frequency and Distribution
of AREs by Most Proximal Extent
Using the pH-impedance methods,a total of 511AREs (mean 58.1AREs per day per subject)were identi ?ed and further an-alyzed manually.The individual frequency and spatial char-acteristics of the AREs are presented in Figure 2.Out of 511AREs,the most proximal site of acid contact was the dis-tal esophagus (80%),followed by the middle and proximal esophagus (7%each),and pharynx (6%).Subject 3had a frequency of 23AREs/day and a greater proportion reached the pharynx compared to the rest.The data from subject 3were veri ?ed as real;however,subject 3is clearly an outlier.Therefore,data were analyzed with and without subject 3,and the inclusion of subject 3had little impact on the data.
724Jadcherla et al .
Table 2.Characteristics of 523AREs Based on pH Probe Results Alone,With Values Normalized for 24h
Composite Index Total ARE Number of AREs >5
Longest Number of AREs
Boix-Ochoa Score ?Subject ID Time (%of 24h)
Min Duration
ARE,Min per Day
(<16.6Normal)
1 2.9
2 5.738.911210.8 4.134.443.123
3 5.37.39.423.819.848.2 2.113.535.318.158.1 4.626.832.321.56 5.3 3.98.445.319.7723.421.242.761.356.8864.738.885.2182.7170.19
7.77.113.660.520.6Average 15.210.126.658.140.1SD 19.512.225.448.350.4Median
8.1
4.6
13.6
43.1
20.6
?
Boix-Ochoa Score utilizes all of the variables measured with AREs using pH only methods.
Because data are not symmetric and not normally distributed,all patient data comparisons were made with the median pa-tient.Subject 9was identi ?ed as the median based on data originating from pH only events (Table 2)and also from pH-impedance events (Fig.2).
Relationship of Symptoms
With the Most Proximal Height of AREs
A total of 294symptoms were noted in 168AREs;343of the AREs were not associated with symptoms.Thus the SSI for composite symptoms (occurrence of any combination of symptoms per ARE)was 33%(168/511).
We analyzed the relationship between the most proximal extent of the ARE and the composite symptoms in general,and speci ?cally with respiratory symptoms,sensory symp-toms,or physical symptoms (Table 3).For this calculation,the denominator was the maximal number of AREs that reached the most proximal site,and the numerator was the
frequency
Figure 2.Frequency and distribution of the most proximal extent of the ARE.Data from all nine patients with the subject ID corresponding to that in Table 1are shown.The frequencies of AREs per day are shown in parentheses.The proportions of AREs that have reached the most proximal location are shown as percentage.For statistical analysis,reference was made with subject number 9(median).PX =pharynx;PE =proximal esophagus;ME =middle esophagus;DE =distal esophagus.
of the AREs associated with symptoms.The distribution of symptoms occurring when AREs reached the pharynx was distinctly different from the three other spatial categories (Ta-ble 3).The odds of having a maximum height of the AREs to the pharynx resulting in symptoms was four times higher than the odds of having a maximal height of the AREs to the distal esophagus resulting in symptoms.
Comparison of Symptoms During the Absence of AREs (Sham Events)With Symptoms During AREs
A total of thirty-three 1-min sham events (as de ?ned in the methods)with 2min before and 2min after (total 165min)were veri ?ed manually.During this period,there were no respiratory symptoms,three sensory symptoms (2irritability and 1arching),and two movement symptoms.The proportion of symptom occurrence during the sham period was lower compared with symptoms associated with AREs (P <0.05,Table 4).
Acid Re?uxate and Aerodigestive Symptoms in Chronic Lung Disease725
Table3.Symptom Sensitivity Index(SSI)Based on the Proximal Extent of AREs
Characterization of Speci?c Symptom Sensitivity Index(SSI) Extent of Re?uxate(#AREs)Composite SSI Respiratory Sensory Movements Pharynx(N=30)77%(23/30)47%(14/30)47%(14/30)7%(2/30) Proximal esophagus(N=36)50%(18/36)22%(8/36)22%(14/36)19%(7/36)
Middle esophagus(N=36)50%(18/36)28%(10/36)28%(10/36)31%(11/36)
Distal esophagus(N=409)27%(109/409)11%(44/409)17%(68/409)12%(48/409)
SSI value>10%was considered to be abnormal(8).
Relationship Between Symptom Frequency
and Acid Clearance Time
Overall,each patient spent3.5±4.8h or15%of the day
in acid re?ux.Symptoms were noted in168AREs(33%
of the511AREs).When symptoms occurred,53%had one
symptom per ARE(Fig.3A).The number of symptoms
per ARE was related to the duration of acid clearance time
(Fig.3B).
To further examine the relationship between symptom fre-
quency and the duration of acid clearance,each ARE was cat-
egorized based on the presence or absence of the correspond-
ing symptoms.Symptomatic AREs were associated with
longer acid clearance times(P<0.01,Table5).The duration
of acid clearance time when the most proximal extent was
in the pharynx,and proximal,middle,and distal-esophagus
were,respectively:4.95±8.3min,3.3±9.3min,2.15±
2.5min,and
3.23±8.5min.
DISCUSSION
In this study,we characterized the spatial and temporal char-
acteristics of AREs and their relationship with symptoms
in a group of premature and term infants with CLD using
pH-impedance methods.The cardinal?nding is that the fre-
quency of symptoms associated with AREs depends on the
most proximal extent of the re?uxate and the acid clearance
time.Overall,the esophageal acid exposure time lasted for ～15%of the day,and the distal esophagus was the most frequent site of proximal acid provocation in～80%of the
AREs.Additionally,symptoms were seen with33%of the
AREs,which is high considering that an SSI greater than
10%was felt to be abnormal in a previous study(8).Since
our aim was to study the relationship of symptoms to differ-
Table4.Distribution of Symptoms During Sham Events and Acid Re?ux Events,Values Shown as SSI
Symptoms Sham(N=33)ARE(N=511)P Value Composite15%(5/33)33%(168/511)?0.02 symptoms
Respiratory0%(0/33)18%(90/511)<0.0001 Sensory9%(3/33)26%(136/511)0.01 Movement6%(2/33)13%(68/511)N.S.?During67%of the AREs,there were no symptoms noted(P<0.05,vs33%). Composite symptoms:≥1symptom per ARE were considered as1composite symptom per ARE.ent heights of AREs,we chose this index as a tool to describe the frequency of symptom association with the spatial char-acteristics of AREs.
Identi?cation of the common symptoms seen in patients with CLD permitted us to classify the symptoms into spe-ci?c categories including respiratory,sensory,or physical movement.The SSI was greater than10%in each speci?c category.This index was signi?cantly higher with the AREs than with the sham events suggesting that the symptom–ARE association was signi?cant compared to the background na-ture of symptoms due to lung disease.In this study,we did not attempt to de?ne the mechanisms of ARE-induced symp-toms,or patterns of AREs across time(time-series analyses of AREs).Such a study will require accurate temporal documen-tation of symptoms closest to the retrograde acid movement. Currently,such measurements are possible only with contin-uous recordings of cardiorespiratory physiological measures. However,for some of the symptoms of interest,the skilled human eye is the best approach to document symptoms in nonverbal ill neonates.Therefore,we have carefully chosen a broad group of common neonatal symptoms.
In adults with respiratory disease,Tutuian et al.(27)eval-uated the causal relationship between re?ux and cough.To describe the causal relationship between re?ux and this single symptom,the symptom index(SI)was considered to be a bet-ter index.However,Bredenoord et al.(28)suggested that SSI is a better alternative to SI,because the SI does not take the total number of re?ux episodes into account.We chose SSI, as our aims were to clarify the nature of symptoms associated with spatial and temporal characteristics of AREs.
The association of multiple symptoms with AREs in the study of infants with CLD is intriguing.It may be that the acts of coughing,grunting,or gagging,or a combination, may provide airway protection and facilitate exhalation,thus diverting any noxious pharyngeal or esophageal bolus away from the airway.In this study,AREs extending to the phar-ynx may lead to“chemoprovocation”resulting in adaptive responses when respiratory symptoms such as cough,gag-ging,or grunting occur.Alternatively,AREs may cause nox-ious responses that are less adaptive and deleterious,such as pain,grimace,and arching,desaturations,and bradycar-dia.In contrast,AREs extending to the distal esophagus may have caused a different type of chemoprovocation resulting in sensory phenomena(pain,irritability,arching).We speculate that the reasons for the variability in these viscerosomato-sensory responses are based on the spatial characteristics of
726Jadcherla et al
.
Figure 3.Frequency of symptoms per acid re ?ux event in relation to the number of AREs is shown in (A ),and in relation to esophageal acid clearance time is shown in Fig.(B ).Please note in (A )that there are fewer AREs with greater symptoms per event,and in (B ),there is an increase in acid clearance time when the number of symptoms per occurrence was greater.
AREs,and may be due to the recruitment of glossopharyn-geal versus vagal afferents,and also may depend on the states of alertness (29–37).
In infants with CLD,the frequency of sensory symptoms was also signi ?cantly greater with AREs than with the sham events.In this study,although the stimulus studied was clas-si ?ed based on pH <4.0,the spatiotemporal characteristics of the retrograde bolus movement may have contributed to the symptoms.The observed symptoms also support the in-volvement of the pharyngeal and esophageal afferent neural pathways that may result in multiple types of efferent motor responses ranging from irritability and arching to cough and gagging (34,38).The ?nding that there were 12more AREs with pH only methods compared to pH-impedance methods was not surprising.This may have resulted from the re ?ux-Table 5.Differentiation of Acid Clearance Time Based on the Oc-currence of Symptoms
Acid Clearance Time (s)
Symptom During AREs During AREs Categories Without Symptoms With Symptoms P Value Any symptoms 118±222(343)354±778(168)0.0002Respiratory 171±440(435)336±716(76)0.007Sensory 163±448(411)329±633(100)0.0015Movement
147±304(443)
510±1063(68)
0.017
Values in parentheses are the number of AREs with corresponding symptoms.
ate touching the pH sensor and not reaching the impedance ring VI (Fig.1B)located proximal to pH sensor.Thus,only pH changes were noted but not impedance change,which re-quires completion of the circuit.Inadvertent entry of the pH probe into the stomach is unlikely because of secure taping and constant observation.
The time windows used for symptom analysis in this study,i.e.,2min before and after the ARE,have been utilized pre-viously (8,11).Therefore,the symptoms associated in this study could be the cause of GER or alternatively could be due to the effects of the GER.The absence of symptoms in 67%of the AREs may be related to the ?nding that the clearance times were shorter when symptoms were absent,supporting appropriate primary and secondary peristaltic re ?exes,upper esophageal sphincter contractile re ?ex,and lower esophageal sphincter relaxation response.All of these re ?exes facilitate esophageal clearance or protect the airway from retrograde ascent of the re ?uxate or both (18,19).Furthermore,local mucosal buffering mechanisms (39)may modify the acid contact time,and thereby prevent the onset of symptoms.The ?nding that symptoms were more likely with longer acid clearance times may suggest that the presence of the acid in the esophagus leads to symptoms.Each speci ?c symptom that occurred during a speci ?c ARE was consid-ered only once.The likely physiology behind each symptom may differ with each occurrence.For example,cough may require glottic closure,gagging may require activation of
Acid Re?uxate and Aerodigestive Symptoms in Chronic Lung Disease727
pharyngeal muscles,and arching may require contraction of neck muscles.
The potential implications of this study to the clinician are as follows:(a)the distal esophagus is the primary site for acid related pathophysiology;(b)respiratory,sensory,and movement symptoms were associated with AREs,suggest-ing that stimulation of the afferent or efferent or both nerves is involved in the pathogenesis of symptoms;(c)signi?cant dif-ferences in symptoms with pharyngeal or distal esophageal AREs were noted,which suggests different sensory-motor interactions;(d)symptoms associated with respiratory status are likely to re?ect AREs that reach the pharynx or AREs that are associated with delayed acid clearance;(e)infants with CLD merit evaluation for AREs associated with respi-ratory symptoms;and(f)?nally,the balance between adap-tive and noxious responses may determine the de?nition of GERD.
STUDY HIGHLIGHTS
What Is Current Knowledge
r The pathogenic mechanisms that add to the severity or
maintenance of chronic lung disease(CLD)of infancy
are controversial.
r The prevalence of gastroesophageal re?ux is high
among premature and term infants with CLD of in-
fancy.
r The association of symptoms with extent or with
esophageal acid clearance time is not known in CLD
of infancy.
What Is New Here
r A novel approach using esophageal manometry to de-
?ne the esophageal landmarks,followed by combined
pH-impedance methods to evaluate gastroesophageal
re?ux in premature and term infants with CLD is de-
scribed.
r Using a symptom sensitivity index,the association of
symptoms in relation to the extent or the duration of
acid re?ux events(AREs)in CLD of infancy is de?ned. r The frequency occurrence of symptoms with AREs de-
pends on the most proximal extent of the acid re?uxate
and its clearance.
Reprint requests and correspondence:Sudarshan R.Jadcherla, M.D.,Department of Pediatrics,The Ohio State University College of Medicine,Section of Neonatology,700Children’s Drive,Nation-wide Children’s Hospital,Columbus,OH43205.
Received June15,2007;accepted November13,2007. REFERENCES
1.American Thoracic Society Documents.Statement of the
care of the child with chronic lung disease of infancy and childhood.Am J Respir Crit Care Med2003;168:356–96.
2.Walsh MC,Sze?er S,Davis J,et al.Summary proceed-
ings from the bronchopulmonary dysplasia group.Pediatrics 2006;117:S52–6.
3.Jobe AH,Bancalari E.Bronchopulmonary dysplasia.Am J
Respir Crit Care Med2001;163:1723–9.
4.Rudolph CD,Mazur LJ,Liptak GS,et al.Guidelines for
evaluation and treatment of gastroesophageal re?ux in in-fants and children:Recommendations of the North Ameri-can Society for Pediatric Gastroenterology and Nutrition.J Pediatr Gastroenterol Nutr2001;32:S1–31.
5.Krishnamoorthy M,Mintz A,Liem T,et al.Diagnosis and
treatment of respiratory symptoms of initially unsuspected gastroesophageal re?ux in infants.Am Surg1994;60:783–5.
6.Jolley SG,Halpern CT,Sterling CE,et al.The relationship
of respiratory complications from gastroesophageal re?ux to prematurity in infants.J Pediatr Surg1990;25:755–7. 7.Wenzl TG,Silny J,Schenke S,et al.Gastroesophageal re?ux
and respiratory phenomena in infants:Status of the intralu-minal impedance technique.J Pediatr Gastroenterol Nutr 1999;28:423–8.
8.Breumelhof R,Smout AJ.The symptom sensitivity index:
A valuable additional parameter in24-hour esophageal pH
recording.Am J Gastroenterol1991;86:160–4.
9.Kawamura O,Aslam M,Rittmann T,et al.Physical and
pH properties of gastroesophagopharyngeal re?uxate:A24-hour simultaneous ambulatory impedance and pH monitor-ing study.Am J Gastroenterol2004;99:1000–10.
10.Sifrim D,Mittal R,Fass R,et al.Review article:Acid-
ity and volume of the re?uxate in the genesis of gastro-oesophageal re?ux disease symptoms.Aliment Pharmacol Ther2007;25:1003–17.
11.Rosen R,Nurko S.The importance of multichannel intralu-
minal impedence in the evaluation of children with persistent respiratory symptoms.Am J Gastroenterol2004;99:2452–8.
12.Condino AA,Sondheimer J,Pan Z,et al.Evaluation of gas-
troesophageal re?ux in pediatric patients with asthma using impedance-pH monitoring.J Pediatr2006;149:216–9. 13.Lopez-Alonso M,Moya MJ,Cabo JA,et al.Twenty-
four-hour esophageal impedance-pH monitoring in healthy preterm neonates:Rate and characteristics of acid,weakly acidic,and weakly alkaline gastroesophageal re?ux.Pedi-atrics2006;118:299–308.
14.Sifrim D,Castell D,Dent J,et al.Gastro-oesophageal re-
?ux monitoring:Review and consensus report on detec-tion and de?nitions of acid,non-acid,and gas re?ux.Gut 2004;53:1024–31.
15.Peter CS,Sprodowski N,Bohnhorst B,et al.Gastro-
esophageal re?ux and apnea of prematurity:No temporal relationship.Pediatrics2002;109:8–11.
16.Guillet R,Stoll BJ,Cotten CM,et al.National Institute of
Child Health and Human Development Neonatal Research Network.Association of h2-blocker therapy and higher in-cidence of necrotizing enterocolitis in very low birth weight infants.Pediatrics2006;117:137–42.
17.Omari TI,Barnett CP,Benninga MA,et al.Mechanisms of
gastro-oesophageal re?ux in preterm and term infants with re?ux disease.Gut2002;51:475–9.
18.Jadcherla SR,Hoffmann RG,Shaker R.Effect of matura-
tion of the magnitude of mechanosensitive and chemosen-sitive re?exes in the premature human esophagus.J Pediatr 2006;149:77–82.
19.Jadcherla SR,Duong HQ,Hoffmann RG,et al.Esophageal
body and upper esophageal sphincter motor responses to esophageal provocation during maturation in preterm new-borns.J Pediatr2003;143:31–8.
20.Jadcherla SR,Duong HQ,Hofmann C,et al.Characteris-
tics of upper oesophageal sphincter and oesophageal body
728Jadcherla et al.
during maturation in healthy human neonates compared with adults.Neurogastroenterol Motil2005;17:663–70.
21.Gupta A,Jadcherla SR.The relationship between somatic
growth and in vivo esophageal segmental and sphincteric growth in human neonates.J Pediatr Gastroenterol Nutr 2006;43:35–41.
22.American Gastroenterological Association Medical Posi-
tion Statement.Guidelines on the use of esophageal pH recording.Gastroenterology1996;110:1981.
23.DiLorenzo C,Hillemeier C,Hyman P,et al.Manome-
try studies in children:Minimum standards for procedures.
Neurogastroenterol Motil2002;14:411–20.
24.Jadcherla SR,Rudolph CD.Gastroesophageal re?ux in the
preterm neonate.NeoReviews2005;6:87–98.
25.Boix-Ochoa J,Lafuente JM,Gil-Vernet JM.Twenty-four
hour esophageal pH monitoring in gastroesophageal re?ux.
J Pediatr Surg1980;15:74–8.
https://www.doczj.com/doc/be15981634.html,m HG,Breumelhof R,Roelofs JM,et al.What is the
optimal time window in symptom analysis of24-hour esophageal pressure and pH data?Dig Dis Sci1994;39:402–9.
27.Tutuian R,Mainie I,Agrawal A,et al.Nonacid re?ux in
patients with chronic cough on acid-suppressive therapy.
Chest2006;130:386–91.
28.Bredenoord AJ,Weusten BL,Smout AJ.Symptom associa-
tion analysis in ambulatory gastro-oesophageal re?ux mon-itoring.Gut2005;54:1810–7.
29.Sengupta JN.An overview of esophageal sensory receptors.
Am J Med2000;108:87–9.
30.Sengupta JN,Saha JK,Goyal RK.Stimulus-response
function studies of esophageal mechanosensitive nocicep-tors in sympathetic afferents of opossum.J Neurophysiol 1990;64:796–812.
31.Goyal RK,Padmanabhan R,Sang Q.Neural circuits in
swallowing and abdominal vagal afferent-mediated lower esophageal sphincter relaxation.Am J Med2001;111:95–105.
32.Altschuler https://www.doczj.com/doc/be15981634.html,ryngeal and respiratory protective re-
?exes.Am J Med2001;111:90–4.
33.Peles S,Miranda A,Shaker R,et al.Acute nociceptive
somatic stimulus sensitizes neurones in the spinal cord to colonic distension in the rat.J Physiol2004;560:291–302.
34.Miranda A,Peles S,Rudolph C,et al.Altered visceral sensa-
tion in response to somatic pain in the rat.Gastroenterology 2004;126:1082–9.35.Darnall RA,Ariagno RL,Kinney HC.The late preterm in-
fant and the control of breathing,sleep,and brainstem de-velopment:A review.Clin Perinatol2006;33:883–914. 36.Pickens DL,Schefft GL,Thach BT.Pharyngeal?uid clear-
ance and aspiration preventive mechanisms in sleeping in-fants.J Appl Physiol1989;66:1164–71.
37.Page M,Jeffery HE.Airway protection in sleeping infants
in response to pharyngeal?uid stimulation in the supine position.Pediatr Res1988;44:691–8.
38.Sengupta JN.Electrophysiological recording from neurons
controlling sensory and motor functions of the esophagus.
Am J Med2001;111(Suppl8A):169S–73S.
39.Bouchoucha M,Callais F,Renard P,et al.Relationship bet-
ween acid neutralization capacity of saliva and gastro-oes-ophageal re?ux.Arch Physiol Biochem1997;105:19–26.
CONFLICT OF INTEREST
Guarantor of the article:Sudarshan R.Jadcherla,M.D. Speci?c author contributions:Sudarshan R.Jadcherla: principal investigator,involved with the development of methods,concept and study design,IRB process,conduct and performance of study protocol,data analysis,and in-terpretation of data and writing of the manuscript;Alankar Gupta:involved with data analysis,assistance with perfor-mance of study,and writing of this manuscript;Soledad Fer-nandez:involved with statistical design and analysis of the data,assistance with interpretation of results,and writing of this manuscript;Leif D.Nelin:involved with research consul-tation during study protocol,data interpretation,and writing of this manuscript;Robert Castile:involved with research consultation during study protocol,data interpretation,and writing of this manuscript;Alfred L.Gest:involved with re-search consultation during study protocol,data interpretation, and writing of this manuscript;Stephen Welty:involved with research consultation during study protocol,data interpreta-tion,and writing of this manuscript.
Financial support:This study was supported in part by NIH grant ROI DK068158awarded to Sudarshan Jadcherla. Potential competing interests:None.
幼儿园大班10以内加减法口算练习题班级姓名：得分 2＋6＝ 9－7＝ 3＋2＝ 3＋4＝ 5＋4＝3＋5＝ 7＋1＝ 9－3= 8－3= 5－4= 8－2＝ 0＋8＝ 3＋1＝ 6＋1＝7＋3＝10－2＝ 7－2＝ 6－4＝ 9－2＝ 10－9＝5＋5＝ 5＋2＝ 9－4＝ 8＋1＝ 2－1＝4＋6= 2＋7＝ 9－5＝ 3＋3＝ 4－2＝10－4＝ 1＋2＝ 5－3＝ 0＋1＝ 10－7＝2＋4＝ 6－5＝ 4＋4＝ 5－1＝1＋9＝8－4＝ 6＋0＝ 3－3＝ 1＋5＝ 10－5＝1＋1＝8＋1＝ 4－1＝ 9－3＝ 3＋6＝
10－2＝ 7－2＝6－4＝ 9－2＝10－9＝5＋5＝ 5＋2＝ 9－4＝ 8＋1＝ 2－1＝4＋6＝ 2＋7＝ 9－5＝ 3＋3＝ 4－2＝10－4= 1+2= 5－3= 0+8= 10－7= 2＋4＝ 6－5＝ 4＋4＝ 5－1＝ 1＋9＝8－4＝ 6＋0＝ 3－3＝ 1＋5＝ 10－5＝1＋1＝ 8＋1＝ 4－1＝ 9－3＝ 3＋6＝ 3＋6＝ 9－7＝ 3＋2＝ 3＋4＝ 5＋4＝ 3＋5＝ 7＋1＝ 9－3＝ 8－3＝ 5－4＝
10－2＝ 7－2＝ 6－4＝ 9－2＝ 10－9＝5＋5＝ 5＋2＝ 9－4＝ 8＋1＝ 2－1＝4＋6＝ 2＋7＝ 9－5＝ 3＋3＝ 4－2＝10－4＝ 1＋2＝ 5－3＝ 0＋8＝ 10－7＝2＋4＝ 6－5＝ 4＋4＝ 5－1＝ 1＋9＝8－4＝ 6＋0＝ 3－3＝ 1＋5＝ 10－5＝1＋1＝ 8＋1＝ 4－1＝ 9－3＝ 3＋6＝2＋6＝ 9－7＝ 3＋2＝ 3＋4＝ 5＋4＝3＋5＝ 7＋1＝ 9－3＝ 8－3＝ 5－4＝
教学资料参考范本 幼儿园大班数学教案设计《10以内加减法》 撰写人：__________________ 部门：__________________ 时间：__________________
10以内加减法 活动背景： 结合主题“我要上小学”中孩子们互留电话的主题背景进行活动 预设，通过活动中孩子集体编出的密码，自然地引导他们学会关注同 样答案下式题与式题间的关系，理解一个答案可以对应多个式题的道理。 活动要求： 1．熟练运用10以内的加减法，理解相同答案可以对应多个试题。 2．熟悉生活中一些重要的电话号码，愿意了解与同伴的联络方式。 活动准备： 1.10以内加减式题卡，破译电话号码练习纸，由加减法式题组成 的电话号码卡片，红旗、黄旗、蓝旗、绿旗，记分牌。 2．开展主题活动“我要上小学了”，幼儿有了解同伴联络方式的 愿望。 活动过程： 一、导人部分：复习10以内的加减法。
师：我们小朋友就要毕业了，前几天大家也讲到过分手后联系的方式，有写信、寄贺卡、串门，还有打电话……今天我们就来玩一个破译电话号码的游戏。 （一）看式题破译电话号码。 老师出示由8道加减法式题组成的号码卡，如3+3，7-4，8+1……这个环节是帮助幼儿复习10以内的加减法。 活动中： 老师从多个角度提问，如这个电话的第一个号码是几？“6”是第几位号码？最后一位是几？ 师：你们真棒！一下子就把这个电话号码破译出来了，你们是怎么破译的？ 幼：是用加减运算的方法破译的。 师：你们知道这是谁的电话吗？ 幼：幼儿园。 师：你们以后如果有事或想念老师的时候就可以打这个电话。一起告诉我’幼儿园的电话号码是几？ （二）心算破译电话号码。
猎头英语词汇大全 1)16PF 卡特尔16种人格因素测试 2)360-degree appraisal 360度评估 3)360-degree feedback 360度反馈 4)7S 7S原则/模型 5)New 7S 新7S原则/模型 6)80/20 principle 80/20 法则 7)AAR-After Action Review 行动后学习机制 8)Ability Test 能力测试 9)Ability of Manager 管理者的能力 10)A bsence Management 缺勤管理 11)A bsence rate 缺勤率 12)A bsent with leave 因故缺勤（被）许可缺勤 13)A bsent without Leave 无故缺勤擅离职守 14)A bsenteeism 缺勤 15)A ccelerating Premium 累进奖金制 16)A ccident Frequency 事故频率 17)A ccident Insurance 意外伤害保险 18)A ccident Investigation 事故调查 19)A ccident Loss 事故损失 20)A ccident Prevention 事故预防 21)A ccident Proneness 事故（频发）倾向 22)A ccident Severity 事故严重程度
23)A ccident Severity Rate 事故严重率 24)A ccident Work Injury 工伤事故 25)A chievement Need 成就需求 26)A chievement Test 成就测试 27)A ction Learning 行动（为）学习法 28)A ction Research 行动研究 29)A ctive Practice 自动实习 30)A djourning 解散期解散阶段 31)A dminister 管理者 32)A dministrative Level 管理层次 33)A dministrative Line 直线式管理 34)A DR-Alternative Dispute Resolution 建设性争议解决方法 35)A dventure learning 探险学习法 36)A dverse Impact 负面影响 37)A dvertisement Recruiting 广告招聘 38)A ffective Commitment 情感认同 39)A ffiliation Need 归属需求 40)A ffirmative Action 反优先雇佣行动 41)A ge Composition 年龄结构 42)A ge Discrimination 年龄歧视 43)A ge Retirement 因龄退休 44)A greement Content 协议内容 45)A LIEDIM 费茨帕特里克出勤管理模型 46)A llowance 津贴
10以内加减法练习题 姓名：_______ 时间：__________ （共100题）5+4= 3+6= 4+2= 9+0= 2+7= 1+7= 6+4= 7+3= 2+3= 0+10= 10-2= 9-3= 8-7= 9-5= 6-2= 5-4= 10-9= 7-3= 8-4= 7-6= 3+( )=10 0+( )=4 4+( )=9 1+( )=8 6+( )=10 4+( )=8 5+( )=7 10+( )=10 2+( )=6 3+( )=5 2+( )=9 4+( )=6 3+( )=3 7+( )=8 6+( )=9 1+( )=10 8+( )=9 5+( )=10 6+( )=7 3+( )=10 ( )+5=10 ( )+2=5 ( )+6=9 ( )+8=10 ( )+3=8 ( )+6=6 ( )+7=8 ( )+0=5 ( )+1=7 ( )+4=6 ( )+2=9 ( )+2=8 ( )+3=7 ( )+3=8 ( )+2=9 ( )+3=10 ( )+2=4 ( )+6=7 ( )+7=10 ( )+0=6 9-( )=2 6-( )=1 10-( )=8 7-( )=6 5-( )=2
7-( )=7 10-( )=5 9-( )=0 10-( )=4 3-( )=2 9-( )=5 0-( )=0 8-( )=2 10-( )=3 5-( )=1 6-( )=4 7-( )=4 9-( )=7 4-( )=4 8-( )=4 ( )-3=3 ( )-6=2 ( )-7=3 ( )-0=6 ( )-5=5 ( )-9=1 ( )-3=0 ( )-3=5 ( )-5=1 ( )-1=8 ( )-2=7 ( )-4=3 ( )-2=7 ( )-6=4 ( )-0=10 ( )-3=6 ( )-6=1 ( )-5=4 ( )-7=0 ( )-1=8 10以内加减法练习题（二） 姓名：_____ 时间：______ 做对了_____题（共100题）( )+5=10 ( )+4=7 ( )-3=3 ( )-6=2 9-( )=2 3+( )=10 6-( )=1 ( )-7=3 ( )+2=5 0+( )=4 ( )-0=6 10-( )=8 4+( )=9 7-( )=6 ( )-3=0 ( )+7=8 5-( )=2 ( )-5=5 ( )+6=9 1+( )=8 7-( )=7 6+( )=10 ( )+2=8 ( )-3=4 3+( )=4 9-( )=0 ( )+6=7 4+( )=8 ( )-9=1 ( )-3=5
幼儿园大班数学公开课教案《复习10以内 的加法》 1、复习10以内的加法算式，发展幼儿的计算能力。 2、能积极参与数学活动，大胆回答问题。 3、引发幼儿学习的兴趣。 4、喜欢数学活动，乐意参与各种操作游戏，培养思维的逆反性。 动物头饰两个，水果图片三个，星星，答题卡若干(与幼儿数量相同)学具小花若干 一、预备活动： 1、问候，组织幼儿 2、手指游戏：十个阿姨来摘梨 二、集体活动 创设情景：今天老师请来了一位好朋友，小朋友想不想看看它是谁?(出示小猫头饰)小猫说：我要去找我的好朋友小熊，我想给他带一篮水果，可是这群可爱的水果宝宝设置了迷宫，我只有回答正确它们的问题，顺利通过迷宫，才可以带走这些水果，到达小熊的家，小朋友们，你们愿意帮助我吗?(愿意)
1、小猫开始闯迷宫，首先遇到了水果菠萝：请小朋友回答出我的问题就可以带走我，(算式题2+3= 4+3=等) 2、第二个遇到了樱桃，樱桃的难题是钓鱼游戏：鱼钩上方为加法算式题，请幼儿找到身上有正确答案的小鱼 3、葡萄：智慧树。把幼儿分成男女两组进行抢答，哪组最先把五颗智慧星的加法算式题回答正确，哪组为胜利，由胜利组帮助小猫摘走水果葡萄 (此环节可使用学具小花进行算式题的验证活动) 三、幼儿操作练习 小猫在小朋友的帮助下，终于来到了小熊家，小熊见到好吃的水果说，谢谢小朋友们，为了感谢你们的帮助，我也有礼物送给你们，是爱心答题卡：请小朋友把卡纸上的加法算式题计算得数，遇到不会的.题可以使用小花学具进行边操作边计算，最后交给老师，教师有针对性的加以指导。 四、小结，收拾学具 我们常说兴趣是学生学习的法宝，如何在课堂上真正用上这个工具，是摆在我们教师面前的问题。我认为要根据智障儿童自身的特点，激发学生快乐学习就要采取多样的教学形式。在本节课《复习10以内的加法》中我采用了以下的措施： 一、设计数学游戏，使学生乐在其中。 根据低年级学生心理特点，在教学中我注意培养学生学习数学的
猎头常用的结构化面试问题清单 一、工作动机与期望 1.请谈谈你现在的工作情况，包括待遇、工作性质、工作满意度等。 2.你对现在的同事和主管怎么看?你认为他们有什么优缺点? 3.你为什么决定调换工作?你认为原单位有什么缺点，你认为什么样的工作比较适合你? 4.你为何选择来我公司工作?你对我公司了解些什么?你对我公司 提供的工作有什么希望和要求?你为什么要应聘这个职位?(追问)你认 为有哪些有利条件?还有哪些不利条件?怎么克服不利条件? 5.如果你报考公务员后，也有许多情况不如你想像的那么理想，对此，你会怎么办?根据过去的经验你为做好工作做过哪些努力?如果你被录取，你在工作上有何打算? 6.你在生活中追求什么?近来个人有什么打算?如果你被录用，由于工作需要，领导(主管)把别人不愿做又瞧不起的工作交给你，这时你怎么办?请结合这次应聘，谈谈你在选择工作时都考虑哪些因素? 7.你所要求的工作条件和待遇大致是什么?如果相差很大，你怎么办?
8.你喜欢什么样的领导与同事? 9.对你来说，赚钱和一份令人满意的工作，哪一个更重要? 10.你认为在一个理想的工作单位里，个人事业的成败是由什么决定的? 二、工作经验 1.请你谈谈毕业之后的工作经历。 2.你现在或最近所做的工作，其职责是什么?你担任什么职务? 3.请谈谈你在这家单位的工作情况和受到的奖励与惩处。 4.你认为你在工作中的成就是什么? 5.在你主管的部门中，遇到过什么困难?你是如何处理或应付过去的? 6.你认为该工作的难点或挑战性在什么地方? 7.请谈一下你在企业中职务升迁和收入变化情况。 8.你在工作中有什么收获和体会? 三、事业进取心与自信心
10以内加减法练习题（一） 姓名：_______ 时间：__________ 做对了_____题（共100题）5+4= 3+6= 4+2= 9+0= 2+7= 1+7= 6+4= 7+3= 2+3= 0+10= 10-2= 9-3= 8-7= 9-5= 6-2= 5-4= 10-9= 7-3= 8-4= 7-6= 3+( )=10 0+( )=4 4+( )=9 1+( )=8 6+( )=10 4+( )=8 5+( )=7 10+( )=10 2+( )=6 3+( )=5 2+( )=9 4+( )=6 3+( )=3 7+( )=8 6+( )=9 1+( )=10 8+( )=9 5+( )=10 6+( )=7 3+( )=10 ( )+5=10 ( )+2=5 ( )+6=9 ( )+8=10 ( )+3=8 ( )+6=6 ( )+7=8 ( )+0=5 ( )+1=7 ( )+4=6 ( )+2=9 ( )+2=8 ( )+3=7 ( )+3=8 ( )+2=9 ( )+3=10 ( )+2=4 ( )+6=7 ( )+7=10 ( )+0=6 9-( )=2 6-( )=1 10-( )=8 7-( )=6 5-( )=2
7-( )=7 10-( )=5 9-( )=0 10-( )=4 3-( )=2 9-( )=5 0-( )=0 8-( )=2 10-( )=3 5-( )=1 6-( )=4 7-( )=4 9-( )=7 4-( )=4 8-( )=4 ( )-3=3 ( )-6=2 ( )-7=3 ( )-0=6 ( )-5=5 ( )-9=1 ( )-3=0 ( )-3=5 ( )-5=1 ( )-1=8 ( )-2=7 ( )-4=3 ( )-2=7 ( )-6=4 ( )-0=10 ( )-3=6 ( )-6=1 ( )-5=4 ( )-7=0 ( )-1=8
小巨人剑桥英语预备级下册10-13单元测试卷 姓名：得分： Part IListening 1.听录音判断，相符用√ 表示，不相符则用×表示。 1）2）3）4） （）（）（）（） 2. 听句子，用√ 勾出正确答案。 1）2） （）（）（）（） 3. 听音写答案。 1). A.They’re going to Shanghai. B. They’re going to Shanghai by car. C. They’re going there by train. 2). A. Sh e’s taking a bath. B. Sh e’s having supper. C. She’s watching TV. 3). A. I like hen. B. I like rabbits. C. I like hats. 4) A. It’s an arm. B. It’s an ear. C. It’s a leg.
Part II Words and Sentences 1.写出下列单词和它的反义词。 快----伤心---- 高----老的---- 左----热---- 2、单项选择 1)．（）----What’s this？ ---- A It’s a feet. B It’s a leg. C It’s a arm. 2).（）---What’s in the pizza? --- A There is some peas. B There are some onions. C I like to eat a pizza with some onions. 3).（）当别人问你去哪里时，你应该怎么回答 A. We are going there by ship. B. I don’t like trouse rs. C We are going to Shanghai. 4).（）How are you going to the farm? A. We are going there by car. B. I don’t like trousers. C We are going to Shanghai. 5)．（）What are you doing? A.We are climbing the tree. B. He is watching TV. C.I’m play.
面试时，有几个经典问题是面试人员常常会提出的，针对这些经典问题好好准备，在面试时也就会应付自如，游刃有余了，下面就几个面试问题做出分析： —、喜欢这份工作的哪—点？ 相信其实大家心中—定都有答案了吧！每个人的价值观不同，自然评断的标准也会不同，但是，在回答面试官这个问题时可不能太直接就把自己心理的话说出来，尤其是薪资方面的问题，不过—些无伤大雅的回答是不错的考虑，如交通方便，工作性质及内容颇能符合自己的兴趣等等都是不错的答案，不过如果这时自己能仔细思考出这份工作的与众不同之处，相信在面试上会大大加分。 二、对单位的了解有多少？ 这时准备的功夫就派上用场，将你之前所吸收的信息发挥出来吧！至少也要知道公司的职能有哪些，审批哪些程序等等，不然面试官—问当场傻在那儿就糗大了，所以—定要事前准备！
三、为什么要离职？ 回答这个问题时—定要小心，就算在前—个工作受到在大的委屈，对公司有多少的怨言，都千万不要表现出来，尤其要避免对公司本身主管的批评，避免面试官的负面情绪及印象；建议此时最好的回答方式是将问题归咎在自己身上，例如觉得工作没有学习发展的空间，自己想在面试工作的相关产业中多加学习，或是前—份工作与自己的生涯规划不合等等，回答的答案最好是积极正面的。 四、你认为相关产业的发展为何？ 这也是事前准备的功夫，多阅读—些相关的报章杂志，做—些思考，表现出自己对此相关产业的的认识，如果是同业转职者，可强调以自己的经验为基础所做的个人见解，但若是初次接触此—行业，建议采取较为保守的方式，以目前资讯所提供的资料为主作答，表现出高度兴趣及诚意为最高指导原则。 五、在工作中学习到了些什么？ 这是针对转职者提出的问题，建议此时可以配合面试工作的特点作为主要依据来回答，如业务工作需要与人沟通，便可举出之前工作与人沟通的例子，经历了哪些困难，学习到哪些经验，把握这些要点做陈述，就可以轻易过关了。
大班数学：10以内的加减法 活动目标： 1、继续学习10的组成和10以内数的加减。 2、能用分合式、算式等不同的方式记录自己购物的过程。 3、能灵活、多角度地思考和解答购物活动中出现的问题。 活动准备： 1、10以内算式题，礼品商店图（见教学挂图2） 2、算式接龙卡、笔每人1份，幼儿用书第40页（看图列算式2）的操作材料。 活动过程： 一、游戏“开火车”，练习10以内数的加减。 1、教师出示算式题，幼儿快速说出火车几点开（即算式）的答案。 2、采用集体、小组、个别的形式进行练习。 二、教师出示礼品商店图，引导幼儿进行购物猜测，复习10以内的加减。 1、教师介绍购物的情况，引导幼儿猜测。如我用10元钱在礼品超市买了1件礼品，还剩下8元钱，猜猜买了什么？为什么？ 2、请幼儿列式说明理由。（10－8＝2或8＋2＝10） 教师：谁愿意把自己猜的结果告诉大家？你能把自己是怎样想的说给大家听吗？
3、请1名幼儿说出自己的购物设想，让同伴猜测。 幼儿说出自己的购物设想后，请全班幼儿猜测并列出算式，再请几名有着不同猜测结果的幼儿介绍自己的猜测过程。 三、根据所提供的购物条件，引导幼儿进行推理练习。 1、教师：买两件相同的礼物，花了6元钱，猜猜买了什么（如玩具狗）？为什么？（因为玩具狗3元钱1个，3和3合起来是6） 请幼儿列出算式进行解答。（3＋3＝6） 2、教师：买了玩具狗和另外1件礼物，用了8元钱，猜猜买了什么？为什么？（因为3和5合起来是8,8减去3等于5）请幼儿列出算式进行解答。（3＋5＝8或8－3＝5） 3、教师：买两件相同的礼物，花了8元钱，猜猜买了什么（如xx）？为什么？（因为xx4元钱1个，4和4合起来是8） 四、幼儿进行操作练习，巩固10以内的加减。 1、提供幼儿用书第40页（看图列算式2）的操作材料，指导幼儿按要求完成“看图列算式”的练习。 2.卡片归类。 请幼儿将接龙卡片按得数进行归类，分别放在分类盒里。 活动延伸：开展“礼品商店”游戏，引导幼儿在游戏活动中进行10以内的加减练习。 2017-05-05
剑桥预备级下册知识点汇总 目录 剑桥少儿英语预备级下知识点汇总 (22) Unit 1 School is fun. (22) Unit 2 Classroom Olympics (22) Unit 3 You and I (33) Unit 4 They are my friends. (33) Unit 5 I like dogs. (44) Unit 6 Do you like oranges? (44) Unit 7 What’s Bobby doing? (44) Unit 8 What’s in the pizza? (55) Unit 9 Dress for Children’s Day (55) Unit 10 What are they doing? (66) Unit 11 Where are you going? (66) Unit 12 A song of opposites (77) Unit 13 The big man and the little people (77) Unit 14 Hello! This is my friend, Linda. (88) Unit 15 He’s got three sticks. (88) Unit 16 Game time (99) 剑桥少儿英语预备级上册知识点总结 (99) 一、问候用语： (99) 二、告别用语： (99) 三、感谢： Thank you ! Thanks 谢谢！ (99) 四、书中句型： (99)
五、单词分类总结： (1111) 1. 颜色： (1111) 2. 水果： (1212) 3. 地点： (1212) 4. 衣物： (1212) 5. 动物： (1212) 6. 交通工具： (1212) 7. 文具： (1212) 8. 食物： (1212) 9. 物品： (1212) 10.表示方向和位置的词： (1313) 11. 数词： (1313) 剑桥少儿英语预备级下知识点汇总 Unit 1 School is fun. 重点词汇： 【默写】包bag,，书book，钢笔pen 【认读】铅笔pencil，文具盒pencil- case，橡皮eraser，尺ruler，黑板blackboard 【复习】操场playground，游泳池swimming pool，教室classroom，花园garden 重点句型： 你能看见什么？What can you see? 我能看见一本大书.I can see a big book. 这是我们的游泳池.This is our swimming pool. School is fun,school is fun,Drawing,singing and we are Number One. School is fun,school is fun,Reading,writing and we are Number One. Dancing,running,jumping and swimming.Dancing,running,jumping and swimming. We are Number One,We are Number One. Unit 2 Classroom Olympics 重点词汇：
猎头最常问的15个问题 由于大多数猎头顾问相信，过去行为是未来表现的最佳预测，因此他们会在面谈中着重提出有关行为的问题。 对于候选人来说，针对一些常见的问题进行准备，能够使你从容应对。猎头顾问与CEO候选人会见中，最常问的15个问题是： 1、你最喜欢目前工作的那些部分？最讨厌那些部分？ 提问目的：你目前岗位上的技能与经验将有多少可运用到新职务中，以及你想从新职务中获得那些经验、挑战或技能。 特别提醒：避免谈你不喜欢的事,批评目前或过去的雇主是很危险的行为。 2、目前你工作上最大的挑战是什么？你是如何应付的？ 提问目的：你如何把握在目前职务上的机会。 特别提醒：你应该说明为什么你的工作对公司盈利、节省成本或时间有重要意义。 3、对新的职务你最想做怎样的贡献？ 特别提醒：比较求才公司与你自己的专长、经验及兴趣。挑选有证据的一些项目来回答。 4、你为什么现在想换工作？ 特别提醒：你必须说明为什么你希望加入这个新公司，而不是为什么你要离开现在的公司。 5、你认为你凭什么会令我的客户高兴地接受你成为高级主管？ 特别提醒：事前详细研究求才企业的职务说明书，仔细准备好面谈脚本。 6、你的职责、工作成就和你的职业生涯规划有何关系？ 提问目的：你对自己目前发展状况的评估。 特别提醒：说明一下你的职业目标，分析你完成上述事业目标的方法，讨论你目前的进展，以及你目前的计划。 7、你最突出的工作成就是什么？ 特别提醒：尽可能根据求才职务说明书来举例。至少引举3项负责过的活动和计划。 8、你下一阶段的事业目标是什么？ 特别提醒：你要表明希望继续提升专业能力，扩展个人的能力，并愿意接受更多挑战。 9、描述你曾经碰过的问题或危机，并说明你是如何处理的？ 提问目的：你如何排除困难和面对挑战时的处理方式。
剑桥少儿英语预备级下Unit1-4 Name：Score： 一．选出你听到的单词。5% 1.( ) A, horse B. house C. home 2.( ) A. friend B. friends C. face 3.( ) A. grass B. glass C. glasses 4.( ) A. bike B. kite C. like 5.( ) A. sheep B. ship C. let 二．连线。20% 1.pen 黑板 2.ruler 铅笔盒 3.bag 钢笔 4.eraser 教室 5.pencil-case 橡皮擦 6.blackboard 操场 7.classroom 花园 8.playground 游泳池 9.garden 书包 10.swimming pool尺子 三.判断对错。对（√）错（×）10% 1. eight 八（） 2. hop 跑（） 3. catch 抓（） 4. draw 玩（） 5. six 六（） 6. football 篮球（） 7. hello 你好（） 8. friend 爸爸（） 9. Mum 妈妈（） 10. they 他们（） 四．选择题。10% ( )1. The children are very happy. A. It B. They C. She D. You ( )2. The girl is reading a book. A. He B. They C. She D. You ( )3. The box is very big. A. It B. They C. She D. He ( )4. Tom and I are very tall. A. We B. They C. She D. You ( )5. Mary is sleeping. A. It B. He C. She D. You ( )6. Tom is swimming. A. He B. They C. She D. You ( )7. Two boys are playing. A. We B. They C. She D. You ( )8. Two girls are eating. A. We B. They C. She D. He ( )9. A dog is sad.
猎头常用术语集锦 术语：CC--coldcall：陌生电话。在猎头公司，新入职的researcher通常需要为了某个职位打大量的coldcall，用于了解行业信息、目标公司架构、搜寻合适候选人。 C&B =Compensation&Benefit 薪酬福利 CAO=Chief Administrative Officer 首席行政官CAO=Chief Art Officer 首席艺术官CBO=Chief Business Officer 商务总监CBO= Chief Brand Officer 首席品牌官CCO=Chief Cultural Officer 首席文化官CCO=Chief Content Officer 内容总监CDO=Chief Development Officer 开发总监CDO=Chief Design Officer 首席设计官CEO=Chief Executive Officer首席执行官C FO=Chief Financial Officer 财务总监CHO=Chief HumanResource Officer人事总监 CIO=Chief Information Officer 首席信息官，技术总监 CKO=chief knowledge officer 首席知识官，知识总监 CMO=chief Marketing officer 市场总监 CPO=Chief Procurement Officer采购总监CPO=Chief PublicRelation Officer 公关总监CQO=Chief Quality Officer 质控总监CRO=Chief Research Officer研究总监CSO=ChiefSolutionOfficer首席问题官CUO=Chief User Officer 客户总监COO=Chief Operating Officer 运营总监 猎头常用英语学习 Executivesearch：猎头，指针对高端职位、收费较高的猎头服务。 headhunt：猎头，比较通俗的说法，香港和台湾公司喜欢用这种说法。 BD-businessdevelopment：业务拓展，在猎头公司通常指开发新的客户公司。Consultant：顾问，在猎头公司顾问的工作通常是：为了完成客户的新职位而做职位和行业分析、search suitable candidates：面试，写推荐报告，安排客户面试，做背景调查报告、协助候选人办理离职和入职手续、收款。 Researcher：研究员，协助顾问搜寻合适的候选人，打cold call Proposal：提议、建议，在猎头公司通常指为了BD某一个职位或者客户，为客户撰写的展现猎头公司概貌的文件，由公司简介、业绩、擅长行业和职位、为了BD某一个职位或者客户而专门提出的建议和打算采用的措施等等。 case：案例，一个案子。在猎头公司通常指客户公司提供的一个需要搜寻的职位。position：职位，客户公司给猎头的公司的一个position通常叫一个case。 close：关闭；接近……。在猎头公司closecase指完成了一个职位。 successfulcase：成功案例，成功职位，在猎头公司指推荐的候选人上班并通过试用期、收回服务费的case。 servicefee（charge）：服务费 database：数据库，在猎头公司通常指为了完成各类职位而积累的候选人简历库。candidate：候选人，为了客户的职位而搜寻的目标人选。 JD-JobDescription：职位描述 delivery：交付,交货;投递,传送，在猎头公司指为客户推荐简历的整个过程，也特指推荐简历。
幼儿园大班10以内加减法口算练习题 班级姓名：得分 2＋6＝ 9－7＝ 3＋2＝ 3＋4＝ 5＋4＝ 3＋5＝ 7＋1＝ 9－3= 8－3= 5－4= 8－2＝ 0＋8＝ 3＋1＝ 6＋1＝7＋3＝10－2＝ 7－2＝ 6－4＝ 9－2＝ 10－9＝5＋5＝ 5＋2＝ 9－4＝ 8＋1＝ 2－1＝4＋6= 2＋7＝ 9－5＝ 3＋3＝ 4－2＝10－4＝ 1＋2＝ 5－3＝ 0＋1＝ 10－7＝2＋4＝ 6－5＝ 4＋4＝ 5－1＝1＋9＝8－4＝ 6＋0＝ 3－3＝ 1＋5＝ 10－5＝1＋1＝8＋1＝ 4－1＝ 9－3＝ 3＋6＝8－2＝ 0＋8＝ 3＋1＝ 6＋1＝ 7＋3＝10－2＝ 7－2＝6－4＝ 9－2＝10－9＝5＋5＝ 5＋2＝ 9－4＝ 8＋1＝ 2－1＝4＋6＝ 2＋7＝ 9－5＝ 3＋3＝ 4－2＝10－4= 1+2= 5－3= 0+8= 10－7= 2＋4＝ 6－5＝ 4＋4＝ 5－1＝ 1＋9＝8－4＝ 6＋0＝ 3－3＝ 1＋5＝ 10－5＝1＋1＝ 8＋1＝ 4－1＝ 9－3＝ 3＋6＝
3＋6＝ 9－7＝ 3＋2＝ 3＋4＝ 5＋4＝3＋5＝ 7＋1＝ 9－3＝ 8－3＝ 5－4＝8－2＝ 0＋8＝ 3＋1＝ 6＋1＝ 7＋3＝10－2＝ 7－2＝ 6－4＝ 9－2＝ 10－9＝5＋5＝ 5＋2＝ 9－4＝ 8＋1＝ 2－1＝4＋6＝ 2＋7＝ 9－5＝ 3＋3＝ 4－2＝10－4＝ 1＋2＝ 5－3＝ 0＋8＝ 10－7＝2＋4＝ 6－5＝ 4＋4＝ 5－1＝ 1＋9＝8－4＝ 6＋0＝ 3－3＝ 1＋5＝ 10－5＝1＋1＝ 8＋1＝ 4－1＝ 9－3＝ 3＋6＝2＋6＝ 9－7＝ 3＋2＝ 3＋4＝ 5＋4＝3＋5＝ 7＋1＝ 9－3＝ 8－3＝ 5－4＝
Unit 10 What are they doing? 教学目的和要求 Teaching aims and demands 通过学习，使学生进一步复习和巩固现在进行时的用法 帮助学生学会使用相应的动词短语 使学生表达和询问单复数概念的句子 交际用语 Expressions in communication What are the pets doing in the house? I don’t know. Let’s ask our friend. Who can tell us? What are the cows doing? They are eating grass. 重点朗读词汇 Key words and expressions Cows, elephants, dogs, cats, snakes, bees, chicks, giraffes, pandas, turtles, fish, tigers, ducks, horses, sheep, lions, goats, mice, rabbits, parrots, spiders, brush teeth, read books, take a bath, play a game, have breakfast, watch TV, tell a story, play hide-and-seek, climb the tree,play football 所需教具 Materials for teaching 相关动物图片，短语卡片，做Bingo的游戏纸，奖励用的小贴纸 如何导入教学？ 教师上课时首先问大家What are you doing now?教师可以引导学生回答We are having a class.然后，教师拿出一张有关的图片问大家：What are the cows doing now?学生应该回答They are eating grass now.教师接着说 Yes, Now I have many pictures. You tell me what they are doing now. OK? 教师依次拿出图片问大家：What are they doing now? 回答：They are brushing their teeth.教师可以将问到过的动物贴在黑板上，然后将相应的动词短语也放在该图片的下面，便于学生对照着看。同时，教师也要问一些与学生有关的问题，如Do you often brush your teeth? When do you usually brush your teeth, in the morning or in the evening?教师穿插的问题不宜太多，否则所要练习的句型就要受影响，教师问完所有的与动物有关的问题后，也已经将相关动词短语放在了图片下面。教师应带领学生进行认读，然后，教师可以用这些图和短语做一个游戏。教师对学生们说Now let’s play a game. I’ll put all the pictures and the phrases on the table. I’ll mix them up together.教师边说边把图片及短语卡片取下来并混在一起。I want somebody to come to the front and quickly find three pictures together with their phrases. Put them back on the blackboard.教师找一个同学到前面来，然后对全班说Let’s count the number together.One, two, three, four, five, six最后教师看该学生在哪个数字前结束，然后教师说Who wants to be the next one?该游戏继续进行，直到所有的图片及短语都呈现在黑板上。教师再组织大家复习一遍。 单元教学活动2 Matcj amd say 与上面的活动一起进行之后，教师可以通过做游戏有来强化这些短语。比如教师说Listen very carefully. I want to choose a person to come to the front and look at
猎头最常用的十个问题 “有一家年销售额800亿美金的欧洲公司，想请您担任大中华区的行政事务总监，您看有没有兴趣？我们想跟您聊聊。”当你接到类似的电话时，恭喜你，你被猎头相中了。 相信不少高级人才都接到过这类电话，不过大部分人并没有这么好运。对于信息缺乏的中高级职业人来说，如今流行的不再是坐等机遇，而是主动找到猎头，毛遂自荐，掌握主动权。那么如何找到合适自己的猎头？如何与猎头对话？ 近半人欢迎猎头到访 随着上海外资投资企业的增多，更多研发中心的设立，猎头行业生存的土壤越来越肥沃。据女性经理人[https://www.doczj.com/doc/be15981634.html,]消息，近年来进入中国市场的外资猎头公司多达200多家，猎头成了“人见人爱”的角色：一方面是市场信息的“晴雨表”，另一方面给职业人提供了更好的职业机会。一般猎头都在职业生涯规划上有一套，他们负责“包装”个人，促成“交易”，即使不想跳槽，职业人也不会拒绝一次免费的职业咨询。一项调查显示，48%的人非常欢迎猎头的到访，另有48%的人则稳妥地表示“不排斥”，只有4%的人明言拒绝。 如何主动成为猎物 猎头的到访无疑是个人职业成功的一次证明。那么，怎样的才能主动得到猎头的垂青？ 首先，寻找合适途径靠近猎头。猎头是相对隐秘的行业，经常给人“神龙见首不见尾”的感觉。因此高级人才需要积极寻找猎头的信息，网络搜索、业内人士介绍、进入猎头论坛发言、通过猎头们的相互推荐等，都是有效的渠道。当然，猎头公司有大小数千家，还需分辨规模和专业性。
其次，寻找合适的猎头。各家猎头公司都有“特长”，比如有些公司专注于做德资企业，有些猎头则重点为日本客户挖掘人才。又比如有些公司熟悉擅长IT行业，拥有大把IT知名企业客户，有些公司则在快速消费品、汽车、金融等行业拥有良好的口碑。当然，还有一些较大规模的公司做综合行业的猎头工作，拥有来自各个行业的优秀客户。职场人应该根据自己的行业定位，寻找契合的猎头公司。 最后，致电和发送简历。找到猎头公司，可以马上致电说明来意。大多猎头都非常欢迎高级人才毛遂自荐，完全不用担 心自己的冒昧。拿到专业猎头顾问的邮箱后，发送并确认简历。一个猎头的人才库中，优秀人才成千上万，在投递简历后，最好能主动约见一次，以增加印象，事后也可经常联系，保持良好的关系。 猎头最常用的10个问题 上海伯格人力资源公司总经理陈维女士表示，专业的猎头公司拥有专业的资质和人才甄选手段。面试是企业客户筛选人才的第一关，很多企业将自己收到的简历交给猎头审阅，让猎头帮助其把关。 大多数猎头顾问相信，过去行为是未来表现的最佳预测，因此他们会在面谈中着重提出类似“行为面试”的问题。候选人在与猎头对话前，需要做些准备。以下罗列了你可能遇到的10类问题： 1、你最喜欢目前工作的那些部分？最讨厌那些部分？
剑桥少儿英语预备级知识点总结 目录 剑桥少儿英语预备级下知识点汇总 (2) Unit 1 School is fun. (2) Unit 2 Classroom Olympics (3) Unit 3 You and I (3) Unit 4 They are my friends. (3) Unit 5 I like dogs. (4) Unit 6 Do you like oranges? (4) Unit 7 What’s Bobby doing? (5) Unit 8 What’s in the pizza? (5) Unit 9 Dress for Children’s Day (6) Unit 10 What are they doing? (6) Unit 11 Where are you going? (7) Unit 12 A song of opposites (8) Unit 13 The big man and the little people (8) Unit 14 Hello! This is my friend, Linda. (9) Unit 15 He’s got three sticks. (9) Unit 16 Game time (10) 剑桥少儿英语预备级上册知识点总结 (10) 一、问候用语： (10) 二、告别用语： (11) 三、感谢：Thank you ! Thanks 谢谢！ (11) 四、书中句型： (11)
五、单词分类总结： (13) 1. 颜色： (13) 2. 水果： (13) 3. 地点： (14) 4. 衣物： (14) 5. 动物： (14) 6. 交通工具： (14) 7. 文具： (14) 8. 食物： (15) 9. 物品： (15) 10.表示方向和位置的词： (15) 11. 数词： (15) 剑桥少儿英语预备级下知识点汇总 Unit 1 School is fun. 重点词汇： 【默写】包bag,，书book，钢笔pen 【认读】铅笔pencil，文具盒pencil-case，橡皮eraser，尺ruler，黑板blackboard 【复习】操场playground，游泳池swimming pool，教室classroom，花园garden 重点句型： 你能看见什么？What can you see? 我能看见一本大书。I can see a big book. 这是我们的游泳池。This is our swimming pool. School is fun,school is fun,Drawing,singing and we are Number One.