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History of benign or malignant neoplasms of the brain, spinal cord, or their coverings. If their condition meets the definition of a disqualifying medical condition or physical defect as in paragraph 3?1. When meets the definition of a disqualifying medical condition or physical defect as in paragraph 3?1. Allergists will annually review the Soldier for progress to resolution or worsening of conditioning and adjust profiling action consistent with annual review. Government (for example, a carrier of communicable disease who poses a health threat to others). Additional conditions include: (1) Allergy to material(s) used in military uniformed clothing. Patient with cardiac dis Ordinary physical activ Patients can perform to Cardiac status uncompro ease but without result ity, such as walking and completion any activity mised. An bolic equivalents; for ex physical activity does gina with strenuous or ample, can carry 24 not cause undue fatigue, rapid or prolonged exer pounds up eight steps, palpitations, dyspnea, or tion at work or recrea carry objects that weigh angina pain. Patients with cardiac Slight limitations of ordi Patient can perform to Slightly compromised. Walking or completion any activity slight limitation of physi climbing stairs rapidly, requiring five or more cal activity. Or or stair climbing after but cannot and does not dinary physical activity meals, in cold, in wind, perform to completion results in fatigue, palpi or when under emo activities requiring meta tation, dyspnea, or an tional stress, or only dur bolic equivalents; for ex gina pain. Walking tercourse without stop more than two blocks on ping, garden, rake, the level and climbing weed, roller skate, more than one flight of dance fox trot, and walk ordinary stairs at a nor at 4 miles per hour on mal pace and in normal level ground. Patients with cardiac Marked limitation of ordi Patient can perform to Moderately compromised. Patient with cardiac dis Inability to carry on any Patient cannot or does Severely compromised. New York Heart Association Therapeutic Classification Revised classification Therapeutic Classification (prognosis) Class A Patients with cardiac disease whose physical activity need not be restricted. This chapter discusses medical conditions and physical defects that are causes for rejection in selection, training, and retention of Army aircrew. In this regulation, the term flying duty is synonymous with flight status and aviation service. These recommendations include qualified, qualified with waiver, or medical suspension from aviation service. Applicability and classes of medical standards for flying this chapter lists medical conditions and physical defects that are causes for rejection in selection, training, and retention of Army aircrew members. Army personnel selected for training, or as determined by Chief, Army Aviation Branch. Class 2 standards apply to: (1) Student aviators after beginning training at aircraft controls or as determined by Chief, Army Aviation Branch. Head Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in the accession standards, plus the following: a. Eyes Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in the accession standards, plus the following: a. Corneal refractive surgery is disqualifying if any of the following conditions are met: (a) Pre-surgical refractive error in either eye exceeds a spherical equivalent of -6 diopters or +4 diopters. New accessions to the military must have at least 180 days recovery period from the last refractive surgery or augmenting proceed and accession medical examination. New accessions must wait at least 90 days post procedure to complete the initial refraction. History of surgeries or procedures for the same, or peripheral retinal injury, defect, or degeneration that may cause retinal detachment. Vision Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the following: a. Any disqualifying condition must be referred to optometry or ophthalmology for verification. Rabin cone contrast test with any score of less than 55 in the red, blue, or green cones in either eye. Wagonner computerized color vision test with a score of moderate or severe deficiency for red, green, or blue. Refractive error of such magnitude that the individual cannot be fit with aviation specta cles. For new accessions to the military see the accession standards for allowable refractive error. Ears Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in the accession standards plus the following: a. Any infectious process of the ear until completely healed, except mild asymptomatic external otitis. Hearing Conditions that do not meet medical standards for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are hearing loss in decibels (dB) greater than shown in table 4?1. Nose, sinuses, mouth, and larynx Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in the accession standards plus the following: a. Any infectious lesion until recovery is complete and the part is functionally normal. This includes recurrent sinusitis or chronic sinusitis and/or surgery to treat chronic sinusitis. Any congenital or acquired lesion that interferes with the function of the mouth or throat. Any defect in speech that would prevent or interfere with clear and effective communication in the English language over a radio communication system. For initial applicants, this is determined by administration of the reading aloud test. Deviation of the nasal septum, nasal polyps, retention cysts, or septal spurs that results in symptomatic obstruction of airflow, chronic rhinitis, chronic sinusitis, or interference of sinus drainage. Dental Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in the accession standards plus the following: a. Orthodontic appliances, if they interfere with effective oral communication, or pose a hazard to personal or flight safety. Neck Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in accession standards. Lungs, chest wall, pleura, and mediastinum Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in the accession standards plus the following: a. Disqualifying unless clinical evaluation shows complete recovery with full expansion of the lung, and normal pulmonary function. To include bullae, blebs, or other congenital or structural defects posing an increased risk for pneumothorax; disqualifying regardless of surgical resection. Including asthma, reactive airway disease, and exercise-induced bronchospasm or asthmatic bronchitis, reliably diagnosed and symptomatic after the 13th birthday. Congenital or acquired defects that restrict pulmonary function, cause air-trapping, or affect ventilation-perfusion, results in recurrent infections, or exercise limitations. Heart Conditions that do not meet the standards of medical fitness for flying duty Classes 1, 2, 2F, 2P, 3, and 4 are the causes in the accession standards plus the following: a. To include pacemaker insertion, defibrillator implantation, valve re placement, bypass tract ablation by any method, coronary angioplasty (including bypass grafting and stenting). This is not disqualifying if fur ther testing is normal and there is no atherosclerotic coronary artery disease. To include left ventricular hypertrophy, as docu mented by clinical or electrocardiogram evidence. As defined by the current American College of Cardiology and American Heart Association guidelines. History of congenital anomalies of the heart or great vessels, or surgery to correct these anomalies. As indicated by an elevated cardiac risk index, elevated total cholesterol or cho lesterol/high-density lipoprotein cholesterol ratio in conjunction with an abnormal aeromedical graded exercise treadmill stress test, or abnormal electron beam coronary tomography.

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Pre and post-law observational survey data revealed a significant increase in booster seat use among 4 to 8-year olds from 29% to 39%. They require extensive time from State highway safety offices, time from law enforcement officers to conduct the enforcement, and time from media staff and often from consultants to develop, produce, and distribute publicity. Time to implement: A high-visibility enforcement program requires 4 to 6 months to plan and implement. These are: media coverage of enforcement and public information activities by the local press and radio and television stations; training of law enforcement officers in the benefits of child passenger protection and methods of effective law enforcement; information activities targeted to target audiences; information activities coinciding with community events; child restraint distribution programs; and public service announcements and other media coverage. Paid advertising brings with it the ability to control message content, timing, placement, and repetition (Milano et al. Communications and outreach can be conducted at local, State, regional, or national levels. Changes in the use of child safety seats or injury rates were the outcome measures evaluated to determine the success of each intervention. One of the four interventions found to be effective was community wide information plus enhanced enforcement campaigns. Education only programs aimed at parents, young children, healthcare personnel or law enforcement personnel did not have enough evidence for effectiveness to be proven. Time to implement: An effective media campaign requires 4 to 6 months to plan and implement. Use: Communications and outreach campaigns directed at booster seat age children are probably quite common, but no summary is available. Effectiveness: Uncertain, but as noted above, anywhere from a third to three quarters of children who should be in booster seats are not. Will, Sabo, and Porter (2009) note that parents and care givers of booster-seat-aged children are difficult reach with effective messages. They also note that many booster-seat programs are unsuccessful because they are too informational in nature, but that applying messages of high-threat consequences (without gore) to booster seat interventions is promising. Costs: As with enforcement-related communications and outreach, costs vary depending on program quality and delivery. Time to implement: A good educational campaign will require 4 to 6 months to plan and implement. Because of this, many State and local organizations initiated programs to make child restraints available at low or no cost to parents though child restraint loan or rental programs (Orr et al. Continuing educational and distribution programs, and especially the implementation and enforcement of child passenger safety laws, increased the levels of child restraint use to 80% for children up to 4 in 1987 (Partyka, 1988), to well over 90% (98% for age less than 1, 96% for ages 1 to 3) in 2007 (Ye & Pickrell, 2008). Use: There is no estimate of the number of child restraint distribution programs operating throughout the United States, but they are common components of State and local child passenger safety programs. Effectiveness: Louis and Lewis (1997) conducted a project to increase toddler car seat use in low-income minority families. Families in the program were divided into two study groups with both groups receiving free child restraints. The results of the study indicated that distributing child restraints resulted in increased long-term use among a low-use population. One of the four interventions found to be effective was child restraint distribution plus education programs. Costs: Program costs will depend on the size of the target audience and the components of the program. Time to implement: Complete programs typically require several months to plan and implement. Other issues: When implementing a program, one of the primary issues to decide is whether the child restraints are to be given away, or whether the parents/caregivers receiving the restraints will be required to purchase them (at a low cost or modest fee, depending on ability to pay). Also, program planners must decide whether parents should be required to attend a child passenger safety educational session, as is considered essential by many in the public health community to ensure proper and continuous use. A number of programs have been implemented to provide parents and other caregivers with hands-on assistance with the installation and use of child restraints in an effort to combat widespread misuse. Use: Child restraint inspection stations have become common components of State and local child passenger safety programs. Effectiveness: the only study conducted to evaluate child restraint inspection programs looked at Safe Kids events held at car dealerships, hospitals, retail outlets and other community locations (to provide as much local exposure as possible). The objective of the study was to measure parent confidence levels, skill development and safe behavior over a six-week interval using checklists and a matching behavioral survey. Results showed that within the 6-week time period, the child passenger safety checkup events successfully and positively changed parents behavior and increased their knowledge: children arriving at event 2 were restrained more safely and more appropriately than they were at event 1 (Dukehart, Walker, Lococo, Decina, & Staplin, 2007). Costs: Program costs will depend on the size of the target audience, the components of the program, and the level of services offered. Time to implement: Complete programs typically require several months to plan and implement. Selecting and Using the Most Appropriate Car Safety Seats for Growing Children: Guidelines for Counseling Parents. Local Police Enforcement, Public Information And Education Strategies To Foster More And Proper Use Of Child Safety Seats By Toddlers: Evaluation Of A Demonstration Project. The effect of changing from secondary to primary safety belt enforcement on police harassment. Effect on fatality risk of changing from secondary to primary seat belt enforcement. The North Carolina Child Passenger Protection Law: Implementation and Evaluation, July 1982 June 1985. Tween Traffic Safety: Influencing 8 to 12-year olds to Sit Safely Buckled in a Back Seat. Summary Report: Field Test of Combined Speed, Alcohol, and Safety Belt Enforcement Strategies. An Evaluation of Child Passenger Safety: the Effectiveness and Benefits of Safety Seats. The Effects of Changing to Primary Enforcement on Daytime and Nighttime Seat Belt Use. The Effect of Earned and Paid Media Strategies in High-Visibility Enforcement Campaigns. Fifth/Sixth Report to Congress: Effectiveness of Occupant Protection Systems and Their Use. Office of Impaired Driving and Occupant Protection, personal communication, July 14, 2006. Traffic Safety Facts: Seat Belt Use in 2008 Use Rates in the States and Territories. Traffic Safety Facts, Research Note: Child Restraint Use in 2008 Overall Results. Traffic Safety Facts, Research Note: Child Restraint Use in 2008 Use of Correct Restraint Types. A Review of Research-Based Findings and Recommendations for Programs to Increase Seat Belt Usage. Effectiveness of the May 2005 Rural Demonstration Program and the Click It or Ticket Mobilization in the Great Lakes Region: First Year Results. Evaluation of a Rural Demonstration Program to Increase Seat Belt Use in the Great Lakes Region. Effectiveness of Primary Enforcement Safety Belt Laws and Enhanced Enforcement of Safety Belt Laws: A Summary of the Guide to Community Preventive Services Systematic Reviews. Evaluation of the May 2005 Click It or Ticket Mobilization to Increase Seat Belt Use. Traffic Safety Facts, Research Note: Child Restraint Use in 2007, Overall Results. Reviews of Evidence Regarding Interventions to Increase Use of Child Safety Seats. Aggressive Driving and Speeding Overview Characteristics and problem size: aggressive driving. Aggressive driving is generally understood to mean driving actions that markedly exceed the norms of safe driving behavior and that directly affect other road users by placing them in unnecessary danger. It has proven challenging to arrive at a consensus for a theoretical definition of aggressive driving, and hence to come up with a working definition.

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Affects men (90%) and may be precipitated by alcohol or nitroglycerin Herpes zoster ophthalmicus Dermatome distribution, unilateral, followed by rash Tolosa?Hunt syndrome Orbital apex or superior orbital fssure or cavernous sinus syndrome with optic nerve involvement and varying degrees of ophthalmoplegia Trigeminal neuralgia Facial pain restricted in area to the distribution of the trigeminal nerve or its branches Convergence insuffciency Poor convergence fusion range Spasm of accommodation Blurred distance vision, relieved by cycloplegic therapy Anterior uveitis Acute red eye, blurred vision, small miosed pupil even cardiac ischaemic pain are described with this drug. Patients with severe or frequent attacks of two or more Other medications that can be taken after the onset of headaches per month or those with neurological changes headache are ergotamine 1 mg with 100 mg caffeine, di should be treated with prophylactic medication which hydroergotamine 4 mg as a single dose, butorphenol nasal includes propranolol (10?80 mg orally daily in divided spray one puff in each nostril, and sumatriptan 6 mg as a doses initially and slowly increased by 10?20 mg every single dose subcutaneously. The dose used if ergotamine has been given in the past 24 hours as can be increased up to a maximum of 160?240 mg/day). Sumat Amitriptyline (25?200 mg four times daily, starting at the riptan can be given orally as a single, 25 mg dose and the lower dose and increasing by 25 mg every 1?2 weeks if second dose is repeated if there is no relief after 2 hours. It is worth 300 mg in 24 hours, or sumatriptan 20 mg nasal spray can noting, however, that so far no cure has been found and be given as a single dose. In acute meningococcal (epidemic) meningitis papilli this due to a descending infective perineuritis is frequently Meningitis present; rarely papilloedema may develop. In the early Meningitis is an infection involving the pia?arachnoid stages there is often kinetic strabismus or conjugate resulting in the collection of infammatory exudate in lateral deviation of the eyes. If the widely open palpebral aperture, often associated with very brain parenchyma is also affected meningoencephalitis is infrequent blinking. It is due either to a systemic infection with unilateral, is more common than that of the third, although organisms such as meningococci, pneumococci, viruses, divergent strabismus due to the latter cause has been etc. The focus (for example, the paranasal sinuses, middle ear), or pupils vary in size, usually showing miosis in the early from a distant septic focus with haematogenous spread. The stages and mydriasis when coma sets in; loss of reaction clinical presentation can be a fulminant acute infection to light is relatively rare. Metastatic endophthalmitis in which progresses in a few hours, a subacute infection that children is an uncommon complication. The blindness may persist for many weeks is most commonly due to Streptococcus pneumoniae after the other symptoms subside, but sight may be ulti (approximately 50% of cases), Neisseria meningitides mately restored. Chronic basal meningitis sometimes (approximately 25%), group B streptococci and Listeria shows the same feature, but in these cases optic neuritis monocytogenes. The incidence of Haemophilus infuenzae and postneuritic atrophy may occur from secondary hydro induced meningitis has decreased following near universal cephalus and pressure of the distended third ventricle immunization with the H. Viruses causing oedema is usually due to complications such as sinus acute meningitis include enteroviruses (poliovirus), arbo thrombosis or cerebral abscess. Chronic meningitis can be due to partially treated is most frequently involved, the paralysis often causing suppurative meningitis, Mycobacterium tuberculosis, Lyme lagophthalmos. Conjugate deviation of the eyes is not disease among the bacterial pathogens; secondary or uncommon. A primary optic somiasis among protozoal pathogens; cysticercosis due atrophy usually develops bilaterally, with a central scotoma to cysts of Taenia solium, Gnathostoma spinigerum and and irregular contraction of the visual felds, either concen Angiostrongylus spinigerum among helminthic organisms. The differential diagnosis the classic clinical features include fever, headache and from a pituitary tumour is based on negative radiological neck stiffness, which are seen in over 90% of cases. Seizures and features In tuberculous meningitis a moderate degree of papil of raised intracranial pressure may be associated and, in litis is common (about 25%) and is generally bilateral. Neck rigid Miliary tubercles in the choroid, though reported in the ity, which is pathognomonic of meningeal irritation, is earlier literature, are only infrequently reported in several Chapter | 31 Diseases of the Nervous System with Ocular Manifestations 523 large series of tubercular meningitis from India, except early symptom and nystagmus may be present. Not infre followed by parkinsonian tremor (paralysis agitans) and, in quently there is a kinetic (not paralytic) conjugate deviation the later stages, spasmodic conjugate deviation of the eyes of the eyes and head to one side. Intracranial tuberculo occurs, usually upwards (oculogyric crises), accompanied mas manifest ocular signs like any other brain tumour. Oculogyric Antitubercular treatment must be administered with iso crises may be relieved by Benzedrine (up to 30 mg a day). The cerebrospinal fuid shows an increase Other Infections in cells with predominantly polymorphonuclear neutrophils in bacterial and lymphocytic pleocytosis in tubercular, viral A collection of pus in the subdural space (subdural empy and fungal infections. There is a decrease in glucose con ema), extradural space (epidural abscess), or in the brain tent in bacterial infections in contrast to normal glucose parenchyma with necrosis (brain abscess) can manifest concentration in viral. Other changes seen in acute bacterial as a space-occupying lesion with focal neurological signs meningitis include an increase in protein content, positive depending on the location. Another special form of intracranial infection of ophthal Treatment: the condition constitutes a medical emer mological relevance is suppurative thrombophlebitis, espe gency and as soon as samples are sent for culture, empiri cially cavernous sinus thrombosis. The latter can develop as cal therapy with intravenous antibiotics must be started. Septic cavernous sinus thrombosis cefotaxime and vancomycin provide good coverage for presents with fever, headache, retro-orbital and frontal pain, most organisms. Ampicillin should be added to cover restriction of extraocular movements, chemosis, proptosis, for Listeria monocytogenes in infants less than 3 months ptosis, absent corneal sensations and hypoesthesia of the face of age, those over 55 years of age or those with depressed along the ophthalmic and maxillary divisions of the trigemi cell-mediated immunity. Iatrogenic and nosocomial infec nal nerve, tortuous dilated retinal veins, papilloedema and tions, which could include Pseudomonas aeruginosa, loss of vision due to exposure keratopathy, or optic nerve should be treated with ceftazidime and vancomycin. It has always been of great interest to ophthalmologists as it affects the eyes in various ways. However, the ruses, arboviruses, infuenza virus, rabies virus, amoebiasis late tertiary manifestations of untreated disease such as the and toxoplasmosis can cause encephalitis. Ocular palsies previously common granulomatous lesion?the gumma, usually usher in an attack of encephalitis lethargica. Ptosis and cardiovascular syphilis due to occlusive endarteritis is the commonest feature, and other branches of the third are uncommon nowadays in communities with good access nerve are especially involved. Sporadic cases of neurosyphilis, particularly partially paralysed and generally recover. These included cranial govascular disease (usually presents 5?10 years after frst nerve palsies, Argyll Robertson pupil, chronic basal menin exposure) or parenchymatous involvement (general paresis gitis, opticochiasmatic arachnoiditis, meningovascular syn at 20 years and tabes dorsalis at 25?30 years), or a combi dromes, gumma, tabes dorsalis and general paralysis of nation of the three in different degrees. Cerebral Syphilis Congenital Syphilis Cerebral syphilis was the term usually applied to relatively this is acquired from the mother during any stage of preg early, direct syphilitic disease of the brain and meninges, nancy but the lesions are generally known to develop after which was essentially a gummatous infammation of the the fourth month of gestation when the foetal immuno meninges and the walls of the cerebral blood vessels. This is because the Basal gummatous meningitis was a common manifesta pathogenesis of congenital syphilis is more dependent on tion arising in the subarachnoid tissue in the region of the the immune response of the host than on the pathogenic chiasma and spreading thereafter over the optic nerves, effect of the organism. In such infections papillitis, papilloedema, or postneuritic atrophy is frequently found Acquired Syphilis (about 13% each), and is usually bilateral. Visual defects this sexually transmitted disease can also be acquired are very common. The stages of acquired such as tuberculosis and sarcoidosis, the third, ffth and syphilis in an untreated patient are (i) primary syphilis sixth nerves can be paralysed and, least frequently, the (chancre at the site of inoculation which usually heals fourth. Pupillary changes occur, depending upon the third within 4?6 weeks), (ii) secondary syphilis (diffuse lymph nerve lesions. A very characteristic feature of basal gum adenopathy, mucocutaneous lesions, rash and constitutional matous meningitis is the inconstancy and variability of symptoms), (iii) latent syphilis (clinically asymptomatic the symptoms, temporary and recurrent visual and ocular with positive serological evidence of infection; early latent, motor disturbances being very common. However, remain positive for evidence of infection with about 10?20% of cases of tabes dorsalis. Dark Argyll Robertson pupils are found in 70% of tabetics R Tonic pupil and are almost invariably bilateral. Unequal pupils are Light found in 30% of tabetics, but are met with still more (Adie tonic pupil) frequently in general paralysis. Paralyses of the extrinsic ocular muscles: this is com L Horner syndrome Dark mon in tabes, occurring in about 20% of cases. It is charac Light teristic of tabetic paralyses that they are partial pareses rather than paralyses, variable and transitory. The pareses of Cocaine 10% the ocular muscles nearly always occur in the pre-ataxic instilled in B/E stage; when they occur at a later stage they are more likely Argyll Robertson Dark to be permanent. The mnemonic paresis is useful in remembering the varied Multiple Sclerosis manifestations: personality change, affect, refexes, eye, sensorium, intellect and speech. The ocular symptoms are Aetiopathogenesis, Pathophysiology most common and unequivocal and have been attributed the and Clinical Overview same pathogenic mechanism as in tabes. In the early with a relapsing?remitting or progressive course, patho stages inequality is often accompanied by slight deforma logically characterized by focal infammation, demyelin tion in the shape of the pupil and irregularity of the pupillary ation and gliosis or scarring. In about 5% of cases the re the disease was also called disseminated sclerosis. Selec actions both to light and convergence are lost, a condition tive demyelination with relative sparing of the axons is which is rare in tabes and especially frequent in the juvenile the hallmark of this disease but partial or total destruction form of general paralysis. The sensory reaction is very often of axons correlating with irreversible neurological damage lost with the light reaction. Multiple greyish, sclerotic lesions scattered (spinal miosis) is commoner in tabes, unequal pupils in gen in the white matter, varying from 1 mm to several centime eral paralysis.

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The driver typically receives a temporary license that allows the driver time to make other transportation arrangements and to request and receive an administrative hearing or review. In addition, a system of administrative hearing officers must be established and maintained. Time to implement: Six to 12 months are required to design and implement the system and to recruit and train administrative hearing officers. Drivers whose licenses have been suspended or revoked administratively still may face criminal actions that also may include license suspension or revocation. Such a system will reduce the number of hearings requested, reduce the time required for each hearing, and minimize the number of licenses that are reinstated. Some States use telephonic hearings to solve these problems (Wiliszowski, Jones, & Lacey, 2003). These laws typically exempt passengers in buses, taxis, and the living quarters of mobile homes. Effectiveness: the only study of open-container law effectiveness (Stuster, Burns, & Fiorentino, 2002) examined four States that enacted laws in 1999. It found that the proportion of alcohol involved fatal crashes appeared to decline in three of the four States during the first 6 months after the laws were implemented, but the declines were not statistically significant. In general, the proportion of alcohol-involved fatal crashes was higher in States with no open-container law than in States with a law (Stuster et al. Costs: Open-container law costs depend on the number of offenders detected and the penalties applied to them. Time to implement: Open-container laws can be implemented as soon as appropriate legislation is enacted. In 2008, South Carolina passed a comprehensive impaired driving law that included stricter sanctions. They are difficult to understand, enforce, prosecute, and adjudicate, with many inconsistencies and unintended consequences. In many States, a thorough review and revision would produce a system of laws that would be far simpler and more understandable, efficient, and effective. Implementation costs of course will depend on the extent to which the laws are changed. Time to implement: It can take considerable time to identify qualified stakeholders and establish a task force to conduct the law review. If the penalties for refusal are less severe than the penalties for failing the test, many drivers will refuse (see also Simpson & Robertson, 2001). In 2007, new laws regarding testing or refusals were enacted in five States Colorado, Kansas, Maine, New Mexico, and Wyoming (Savage, Sundeen, & Teigen, 2007). No study has examined whether stronger test refusal penalties are associated with reduced alcohol-related crashes. Criminalizing test refusal decreases the likelihood that 1 14 drinking drivers can avoid penalties by refusing to be tested. It also ensures the drinking driver will be identified as a repeat offender upon subsequent arrests. Issued by a judge or magistrate, the warrant requires the driver to provide a blood sample, by force if necessary. One recent study reviewed how warrants are used in four States Arizona, Michigan, Oregon, and Utah (Hedlund & Beirness, 2007). They found that warrants successfully reduce breath test refusals and result in more pleas, fewer trials, and more convictions. They either stop every vehicle or stop vehicles at some regular interval, such as every third or tenth vehicle. The purpose of checkpoints is to deter driving after drinking by increasing the perceived risk of arrest. To do this, checkpoints should be highly visible, publicized extensively, and conducted regularly. Fell, Lacey, and Voas (2004) provide an overview of checkpoint operations, use, effectiveness, and issues. Fell, Ferguson, Williams, and Fields (2003) found that 37 States and the District of Columbia conducted checkpoints at least once in the year 2000 but only 11 States conducted them on a weekly basis. The main reasons given for not using checkpoints more frequently were lack of law enforcement personnel and lack of funding. In addition, a study examining demonstration programs in 7 States found reductions in alcohol-related fatalities between 11% and 20% in States that employed numerous checkpoints and intensive publicity of the enforcement activities, including paid advertising (Fell, Langston, Lacey, & Tippetts, 2008). States with lower levels of enforcement and publicity did not demonstrate a decrease in fatalities relative to neighboring States. A typical checkpoint requires several hours from each law enforcement officer involved. Law enforcement agencies in two rural West Virginia counties were able to sustain a year-long program of weekly low-staff checkpoints. States where checkpoints are not permitted may use saturation patrols (see Chapter 1, Section 2. Impaired drivers detected at checkpoints should be arrested and arrests should be publicized, but arrests at checkpoints should not be used as a measure of checkpoint effectiveness. The purpose of saturation patrols is to arrest impaired drivers and also to deter driving after drinking by increasing the perceived risk of arrest. To do this, saturation patrols should be publicized extensively and conducted regularly. A less-intensive strategy is the roving patrol in which individual patrol officers concentrate on detecting and arresting impaired drivers in an area where impaired driving is common or where alcohol involved crashes have occurred (Stuster, 2000). Use: the Century Council (2003) survey reported that 44 States used saturation patrols. Effectiveness: Saturation patrols can be very effective in arresting impaired drivers. Moreover, a recent demonstration program in Michigan revealed that saturation patrols can be effective in reducing alcohol-related fatal crashes when accompanied by intensive publicity (Fell et al. Saturation patrol operations are quite flexible in both the number of officers required and the time that each officer participates in the patrol. They generally are reliable and effective at detecting alcohol in the surrounding air. A third opportunity is to integrate impaired-driving enforcement into special enforcement activities directed primarily at other offenses such as speeding or seat belt nonuse, especially since impaired drivers often speed or fail to wear sear belts. Effectiveness: Jones, Joksch, Lacey, Wiliszowski, and Marchetti (1995) evaluated a three-site evaluation of integrated impaired driving, speed, and seat belt use enforcement. They found that the sites that combined high publicity with increased enforcement reduced crashes likely to involve alcohol (such as single-vehicle nighttime crashes) by 10% to 35%. The Massachusetts Saving Lives comprehensive programs in six communities used integrated enforcement methods. About half the speeding drivers detected through these enforcement activities had been drinking and about half the impaired drivers were speeding. Costs: As with other enforcement strategies, the primary costs are for law enforcement time and for publicity. Publicity: Integrated enforcement activities should be publicized extensively to be effective in deterring impaired driving and other traffic offenses. Such programs can generate support for law enforcement efforts and increase the perception in the community that drinking drivers will be caught. The Century Council (2003) documented diversion programs and plea agreement restrictions in several States. However, the effects of plea agreement restrictions by themselves cannot be determined in these studies. It found that plea agreement restrictions reduced recidivism in all three study communities. Costs: Costs for eliminating diversion programs can be determined by comparing the per offender costs of the diversion program and the non-diversion sanctions. Similarly, costs for restricting plea agreements will depend on the relative costs of sanctions with and without the plea agreement restrictions. In addition, if plea agreements are restricted, some charges may be dismissed or some offenders may request a full trial, resulting in significant costs. Once legislation is enacted, policies and practices can be changed within three months.

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Now she strives not to be an authoritarian but rather a guide, urging self exploration and discovery. The first step to gaining self knowledge is tapas, a concept coming from the 67 Iyengar, Light on Yoga, 23. In the Yoga tradition, asanas and pranayama are means of cleansing the body and mind. As the body becomes healthy and the mind learns to be still, harmful habits can be discarded, opening the way to new possibilities. Desikachar suggests that regular practice of Yoga eventually creates the ability to stay present in every moment. Only then can the achievement of an awareness of body movements allow decisions about what is enabling and what is hindering progress. Thus, it is crucial to strive to be as mindful as possible when practicing, to quiet the mind chatter and concentrate on some simple element of what we are doing. The next step towards unifying body and mind is svadhyaya, which translates to study or investigation. This is a stage of experimentation, asking questions, deciding on methods of practice, accessing what works, abandoning ineffective actions, and investigating the musical aspects, all while being mindful and free of preconceptions. The final phase is called isvarapranidhana; traditionally translated as love of God. It is in this stage that the technique and the physical motions are transcended; they were never truly the goal of our striving, even though sometimes it is easy to forget about it in the midst of the search for perfection. All of that is transcended to allow the body and mind to unify and truly express the music. Greene, who was mentioned at the beginning of this chapter, was once the sport psychologist for elite athletes of the U. When 71 dealing with performance anxiety, Greene suggests learning a skill called Centering. The Centering method aids in shifting thought processes from the left hemisphere of the brain to that of the right hemisphere. It is a plane where negative inner dialogues (of anxiety, self doubt, and 72 fear) can take place during the performance. Centering involves focusing on the breath, noticing specific areas of the body, releasing tension from different parts of the body through visualizing its release during the exhale, and focusing on the center point of the body. In the Yoga tradition, the center of the body (the center of gravity) corresponds to Svadhisthana Chakra (the energy center just below the navel) and was believed to be a location of the prana (life force). Clearly, most of the elements of the Centering technique are borrowed from meditative and relaxation Yoga techniques. Greene also mentions additional important information about the nature of our subconscious as discovered by Dr. Maxwell Maltz (directions including negation are not effective; the 71 this method was developed by Dr. My Experience When musicians are working on mastering a difficult passage or overcoming a general technical difficulty, I have observed that we tend to either feel overwhelmed by not knowing how to fix the problem, or we try to control every muscle of our bodies to correct it. The focused awareness can be a way out of such a situation: by simply observing what is going on we may realize that the source of the problem lies not where we thought it did. Another benefit of this approach is that by observing and quieting the mind, we give our body a chance to do things in the most natural way, just allowing them to happen. The movements required to perform a virtuosic passages are often too complex to be controlled at all times by the conscious mind. While the Self 1 observes what is going on, our Self 2 (our body) is freed to find the natural way to perform difficult motion. All this advice is encompassed in the teachings of Yoga; being present and paying attention, observing reality free of attachment (preconception), ahimsa (gentleness) in treating oneself during the process of learning. The lessons that prove to be invaluable in mastering an instrument are taught by Yoga. The bow hair almost always stays in contact with the string, and that constancy reminds me of the breath. The most frustrating part of this problem was that no amount of practicing seemed to help. For a little while, I decided to let go of my struggle and simply concentrated on the bow hand. I kept my attention and also felt specifically the spot where the bow touched the string. From that moment on, I was on the path of noticing small, subtle elements which my body changed unconsciously, but that made my playing more effortless. I believe this is what Gallwey means when he talks about a more natural way of learning. Also, similarly to Katie Lanzer, I realized that the answers to my questions can oftentimes (if not always) be found within my own body, if the mind is still. I also noticed that mindfulness during practicing is a way to deal with performance anxiety. If I manage to practice with great focus, completely (as much as possible) immersed in the moment and the music I am playing, when the time comes for the performance, I am much calmer. Since my mind is trained to concentrate on various aspects of playing my instrument, there is not much space left for inner dialogue, even under pressure. A growing body of scientific evidence is being gathered that shows the effectiveness of Yoga in overcoming various psychological challenges. For example, a 2004 pilot study 74 investigated the effects of Iyengar style Yoga on mood changes. The results of this study reported substantial increases in positive moods, decreases in negative moods, and general increases of energy levels among participants. In a recent Lancet article Yoga for Anxiety and Depression, the author reviews some of the most significant studies investigating Yoga and its effects on stress and 75 depression. For example, a 2008 study at the University of Utah examined response to stress and pain within three varied groups of participants. The researchers noted that persons exhibiting poorly regulated response to stress were also more sensitive to pain. The author also mentions a 2005 study undertaken on inpatients of the New Hampshire Psychiatric Hospital that reports a significant drop of 74 Shapiro and Cline, Mood Changes Associated with Iyengar Yoga Practices, 35-44. Patients underwent six weeks long treatment including breathing exercises, asanas, and guided meditation. Participants trained to meditate showed a significant reduction in post-performance anxiety, as well as a tendency towards more focus and less interference by intrusive negative thoughts during solo performance. The purpose of the 2009 study was conducted simply to further extend the 2006 preliminary findings, aiming to record more data by using a larger sample. The musicians participated in a two month Yoga and meditation program and were divided into three groups: a Yoga lifestyle intervention group that involved discussion sessions in addition to Yoga and meditation, a Yoga and meditation group only, and a control 76 Chang et al. Consistent with the results of the 2006 Khalsa study, the Yoga program showed a statistical tendency to reduce the cognitive and somatic symptoms of musical performance anxiety and improved mood in both Yoga groups. It is worth mentioning that participants found that yogic breath control techniques were particularly helpful when managing the anxiety, especially immediately before the concert. The authors of the article Yoga Therapy in Practice state: Embedded within the philosophy of Yoga, particularly in the Yoga Sutras of Patanjali, is a cognitive-behavioral manual that addresses the symptoms of anxiety and depression. As illustrated above, research reports that the practice of Yoga reduces the levels of perceived stress and anxiety. Stress, anxiety, and depression are linked to a hyperactive limbic system and hypoactive cortex. The limbic system, which is part of the autonomous (unconscious) nervous system, is mainly responsible for storing memories and triggering the fight or flight response. Since this structure is connected with memory, the perception of present experiences may be tinted with past traumas. Of course, the perception of what is frightening or stressful varies from person to person. Often, chronic overstimulation of the limbic system leads to heightened levels of anxiety and stress; after a while, the organism is unable to return to homeostasis and ultimately becomes exhausted and even more prone to stress, eventually leading to illness.

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The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. 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Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services. Note: For Medicaid members, when state Medicaid coverage provisions conflict with the coverage provisions in this clinical policy, state Medicaid coverage provisions take precedence. Please refer to the state Medicaid manual for any coverage provisions pertaining to this clinical policy. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Currently, a brief comprehensive primary care-friendly multiple-sleep-disorders screening instrument is not available. MethodsaaA cross-sectional study using nested data from two previous research studies (n = 395 sleep clinic referrals and n = 299 com munity volunteers) was used. Study subject interview data were used to assess patient-friendli ness of the instrument. ResultsaaSensitivities/specifcities for the diagnosed sleep disorders ranged from 0. Sleep Med Res 2017;8(1):17-25 Key WordsaaSleep, Sleep wake disorders, Primary health care, Preventive health services, Diagnosis. As important as this opportunity for prophylaxis may be, most medical providers do not inquire about their patients sleep quality or quantity. This may be due, in part, to a lack of training and expertise regarding the assessment and treatment Received: February 18, 2017 of sleep disorders. This may also be due to the understandable constraints on providers time Revised: April 27, 2017 Accepted: May 17, 2017 in primary care settings. Time constraints could be overcome, however, if a brief, comprehen Correspondence sive and psychometrically sound sleep disorders screening questionnaire were available. Measures To date, several attempts have been made to create a compre hensive self-report sleep disorders assessment tool. The instrument text is ation, 2) describe how these fndings led to the development of laid out as a grid on an 8. The time frame for responses is over the course of the last this cross-sectional study used nested data of samples from year and the rating scale (response options) ranges from never two previous research studies: 1) Who had been referred by pri to frequently (> 3 x/week). The symptom items and response mary care providers to a sleep clinic for confrmatory sleep dis options are arrayed so that completed questionnaires form a order diagnoses (n = 395)10 and 2) Community volunteer par grid of X mark patterns depending on the participants sleep ticipants in a study that included diagnosing for obstructive disorder diagnoses. Summing lar intake procedure for several clinical practices; data were the items per subscale adds to 18 (vs. Data for the community sample were are determined by summing responses in each subscale (Fig. The sleep clinic diagnoses were determined by a board certifed The use of these data for a validation study was approved by sleep medicine physician based on in-lab polysomnography, the Institutional Review Board at the State University of New questionnaires, and interviews. Over the past year: Seldom Sometimes Ofen Frequently Never (place an X in the box) (1? I have experienced sudden muscle weakness when laughing, joking, angry 14 or during other intense emotions. The text below shows how to score each item, and the subscale score above which a positive screen is indicated. Cut-point score determination is described in the methods and results sections, but are included here for completeness. Item choice Item score Subscale Items to sum for subscale score Subscale score range Cut-point score Never 0 Insomnia 1, 2, 3, 4 0?12 5 Seldom 0 Circadian rhythm 5, 6 0?6 Sometimes 1 Narcolepsy 7, 14 0?6 1 Ofen 2 Obstructive sleep apnea 4, 8, 9, 10 0?12 3 Frequently 3 Restless legs syndrome 11, 12, 13 0?9 3 Parasomnias 15, 16, 17 0?9 Fig. Interview notes of participants responses were ex formed by actigraphy data, diaries, and questionnaire responses. Similarly, patients referred to sleep clinics would be expected to report higher levels of daytime sleepiness, on average, in com Receiver Operator Characteristic Curve Determined parison to a sample from the community at large. Among all study participants, none were diagnosed with ei ther circadian rhythm sleep-wake disorders or parasomnias. In addition, those Second, the response time frame was altered from the past who reported the last year was difcult to remember indicated year to the last 3 months. Tree of these questions, while not specifc to any one ed that several changes were required to make the question diagnosis, provide information about sleep insufciency, night naire more comprehensive, more clinically relevant, and more to-night variability sleep timing, and whether the endorsed informative. The header captures patient data as the patient typically spends in bed each night. Below the header is a list of 25 symptom state garding shif work is to determine if the sleep complaints (as ments (at the ffh-grade Flesh-Kincaid reading level). Five re endorsed in items 1?6 and 25) may be, in part or in total, relat sponse options are laid out as columns, so that patients can ed to shif work sleep disorder. Each row contains a single identifes a potential corroborator regarding the data provided query and rows are clustered together to represent sleep disor and the possibility that a bed partner may be a contributory fac ders. This H3: presence of bed partner said, the interpretation method delineated in Table 3 represents H4: amount of sleep each night a common sense approach to determining: 1) the likelihood of H5: amount of time in bed each night an individual having one or more of the 13 assessed sleep dis Q1 Work/activity interferes w/sufcient sleep orders, 2) the severity of presenting complaint by category, and 3) a method for assessing cumulative morbidity. With respect Q2 Bed or wake time variability to the identifcation of one or more individual sleep disorders, Q3 Time to fall asleep any symptom grouping with at least one clinically relevant Q4 Time awake during sleep period symptom. With respect to Q6 Daytime sleepiness or fatigue relative severity of the individual sleep disorders, one may sim Q7 Prefers early bed & wake times ply sum the individual item scores for each category and divide Q8 Prefers late bed & wake times by the number of items to yield an average score per disorder. With respect to cumulative morbidity, one may simply sum all Q9 Inappropriately falling asleep of the endorsements across the 25 items, with a resulting range Q10 Snores of 0 to 100. It is anticipated that the ongoing validation studies Q11 Morning dry mouth will yield a similar strategy but it is likely that individual items Q12 Snoring interferes w/others sleep will not be equally weighted. Header information can also be used Q22 Wake up afraid for no reason to aid interpretation of the responses. Identifcation of in dividual sleep disorders: disorder may be deemed appropriate for follow-up if one or more endorsements within the category has response option 3 or 4 checked. Severity of the individual sleep disorders: sum the individual item scores for each category and divide by the number of items to yield an average score per disorder. Yet, there is no hard-and-fast rule about what constitutes a significant deviation. Clinical practice use of the instrument does however, is nearly impossible and usually requires polysomno not require permission. Treating in-house may depend on providers knowledge and Conficts of Interest comfort level with the individual sleep disorders.


  • Running more often, longer distances, or up hills
  • Glaucoma, or some medications used to treat it
  • Abnormal connections between the right and left side of the heart
  • Long-term pressure on the nerve
  • Presbyopia
  • Take a detailed history of your diet, bowel patterns, laxative use, medications, and medical problems
  • Do not bundle a feverish child in blankets.
  • Stomach swelling
  • Nausea and vomiting

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The effect of passive mobilisation following fractures involving the distal radius: a randomised study. The role of physiotherapy and clinical predictors of outcome after fracture of the distal radius. An advice and exercise program has some benefits over natural recovery after distal radius fracture: a randomised trial. Therapist-supervised hand therapy versus home therapy with therapist instruction following distal radius fracture. Cross-education for improving strength and mobility after distal radius fractures: a randomized controlled trial. Bipolar fixation of fractures of the distal end of the radius: a comparative study. A randomized, controlled trial of distal radius fractures with metaphyseal displacement but without joint incongruity: closed reduction and casting versus closed reduction, spanning external fixation, and optional percutaneous K-wires. Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. Plaster cast versus Clyburn external fixation for fractures of the distal radius in patients under 45 years of age. External fixation and recovery of function following fractures of the distal radius in young adults. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Cast or external fixation for fracture of the distal radius: a prospective study of 126 cases. A prospective randomized comparison between 6 and 1-week postoperative immobilization in 60 fractures. Internal fixation of distal radius fractures with dorsal dislocation: pi-plate or two 1/4 tube plates? Open reduction and internal fixation compared to closed reduction and external fixation in distal radial fractures: a randomized study of 50 patients. Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year. Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius: a randomised, prospective trial. Open reduction internal fixation versus percutaneous pinning with external fixation of distal radius fractures: a prospective, randomized clinical trial. A randomized prospective study on the treatment of intra articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation. Controlled trial of distal radial fractures treated with a resorbable bone mineral substitute. Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: a randomised, controlled trial. Intra-articular fractures of the distal radius: a prospective randomised controlled trial comparing static bridging and dynamic non-bridging external fixation. Comparison of external and percutaneous pin fixation with plate fixation for intra-articular distal radial fractures. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. The use of routine wrist radiography is not useful in the evaluation of patients with a ganglion cyst of the wrist. Diagnostic validity of ultrasound in patients with persistent wrist pain and suspected occult ganglion. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. Ganglions of the wrist and digits: results of treatment by aspiration and cyst wall puncture. Phenol cauterization for ganglions of the hand, wrist, and foot: a preliminary report. Surgical excision versus aspiration combined with intralesional triamcinolone acetonide injection plus wrist immobilization therapy in the treatment of dorsal wrist ganglion; a randomized controlled trial. Intervention randomized controlled trials involving wrist and shoulder arthroscopy: a systematic review. Arthroscopic versus open dorsal ganglion excision: a prospective, randomized comparison of rates of recurrence and of residual pain. Articular ganglia of the volar aspect of the wrist: arthroscopic resection compared with open excision. Hyaluronidase versus surgical excision of ganglia: a prospective, randomized clinical trial. Outcomes of Open Dorsal Wrist Ganglion Excision in Active-Duty Military Personnel. Different conditions of cold water immersion test for diagnosing hand-arm vibration syndrome. Finger thermometry in the assessment of subjects with vibration-induced white finger. Assessment of the hand-arm vibration syndrome: thermometry, plethysmography and the Stockholm Workshop Scale. The diagnostic value of finger systolic blood pressure and cold-provocation testing for the vascular component of hand?arm vibration syndrome in health surveillance. Cold-provocation testing for the vascular component of hand-arm vibration syndrome in health surveillance. Cold provocation testing and hand?arm vibration syndrome?an audit of the results of the Department of Trade and Industry scheme for the evaluation of miners. Cold stress dynamic thermography for evaluation of vascular disorders in hand-arm vibration syndrome. Multicenter study on finger systolic blood pressure test for diagnosis of vibration-induced white finger. A comparison between two methods of aesthesiometric assessment in patients with hand-arm vibration syndrome. The analysis of sensitivity, specificity, positive predictive value and negative predictive value of cold provocation thermography in the objective diagnosis of the hand-arm vibration syndrome. Thermal thresholds, vibrotactile thresholds and finger systolic blood pressures in dockyard workers exposed to hand-transmitted vibration. Diagnostic value of finger thermometry and photoplethysmography in the assessment of hand-arm vibration syndrome. Diagnostic value of finger systolic blood pressure in the assessment of vasospastic reactions in the finger skin of vibration-exposed subjects after finger and body cooling. A cross sectional epidemiological survey of shipyard workers exposed to hand-arm vibration. Clinical value of ultrasonography in the detection and removal of radiolucent foreign bodies. The use of ultrasonography to detect a radiolucent foreign body in the hand: a case report. Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Digital versus local anesthesia for finger lacerations: a randomized controlled trial. Suturing versus conservative management of lacerations of the hand: randomised controlled trial. Aesthetic and functional efficacy of subcuticular running epidermal closures of the trunk and extremity: a rater-blinded randomized control trial. Single-layer versus double-layer closure of facial lacerations: a randomized controlled trial.

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Note the abnormal superior limbal margin, ruptured granula iridica, abnormal pupillary margin with numerous synechiae and dense cataract. Ophthalmologic Disorders in Aged Horses 253 are 2 routes by which the aqueous humor exits the eye: the conventional and the un conventional pathways. With age, the trabecular meshwork changes histologically: the trabecular endothelial cellularity is reduced and the outflow spaces are decreased, which may account for an increase in intraocular pressure observed in older horses. An age-related decrease in intracellular pores in the scleral venous sinus has been shown, which may also result in a decrease in aqueous flow facility. Signs commonly associated with glaucoma in horses include hydrophthalmos, corneal edema, corneal striae (Haab striae), a mildly dilated pupil, lens luxation, and optic nerve cupping and degeneration (Fig. The intraocular pressure shows diurnal variation in horses, so, if glaucoma is suspected, repeat measurement may be required. It is important that, when repeat measurements are taken, these are done in identical circumstances; factors such as head positioning, placement of an auriculopalpebral nerve block, or sedation can greatly affect the measurements. Selec tive destruction of the ciliary body with laser (cyclophotoablation) transsclerally is intended to reduce aqueous humor production, whereas placement of gonioimplant shunts increase aqueous outflow. There is diffuse corneal edema and numerous striae (Haab striae) caused by thinning of the Descemet membrane. Chronically painful and blind glaucomatous eyes should undergo chemical ablation of the ciliary body by intravitreal injection of gentamicin or should be enucleated. Therefore, lens fibers have a limited capacity to restore crystal lines that may become damaged during the aging process. Once these crystallines are denatured, they condense into aggregates that induce light scatter and cause the white appearance of the lens in horses with cataracts. In older animals this progresses to more dense condensation around the poste rior suture, together with perinuclear and cortical (anterior and posterior) cata racts. However, surgery is typically reserved for those horses with a significant visual impairment. Another recent study found age not to be significantly associated with poorer outcomes following phacoemulsification, although horses older than 15 years had a lower visual outcome. Asteroid hyalosis is a rare finding and manifests as white or refractive lipoid deposits within the vitreous gel structure, approximately 1 to 2 mm in size. These asteroid bodies remain suspended in the vitreous body but on occasions they move when the globe moves. There is thickening of the internal limiting membrane and a decrease in the neural elements of the retina. Large vacuoles, caused by bullous elevation of the epithelial cell layer, were detected at the level of the pars ceca retinae. The second change, observed in almost half of the retinas stud ied, was degeneration of the pars optica retinae with complete loss of the normal structure, affecting the first 0. Studies have shown a prevalence of between 33% and 42% in the general geriatric 256 Malalana population; however, this prevalence increased to 73% when only horses older than 30 years were considered, suggesting a progressive nature. The pathogenesis of senile retinopathy is not fully understood but possible causes include oxidative damage or choroidal vasculature disease. Some investigators think that this alteration is of no clinical significance, whereas others report problems with vision in the affected an imals, particularly in poor lighting conditions. On some occasions they can cause visual deficits, but most often they represent an incidental finding. Nonneoplastic masses of the optic nerve head also seems to be more common in older horses. Proliferative optic neuropathy appears as a white or pink lobulated mass at the edge of the optic nerve (Fig. It is normally an incidental finding, although it may affect vision if it is big enough to obstruct the optic nerve head or central retina or when it results in continued movement (causing shying behavior). The owner reported no visual deficits and this was considered an incidental finding. In addition, geldings are 5 times more likely to develop ocular squamous cell carcinoma than stallions and twice more likely than mares. Treatment of these tumors is challenging and frequently involves surgical excision followed by adjunctive therapy, including radiation, chemotherapy, and/or cryotherapy. In contrast, most cases of intraocular melanoma tend to occur in younger horses between 5 and 10 years of age. Other treatment options, with variable success rates reported, include intratumoral chemotherapy, immunotherapy, and cimetidine administration53,54,56 Fig. Squamous cell carcinomas affecting the third eyelid of a 15-year-old Appaloosa gelding (left) and the nasal corneolimbal margin of a 17-year-old Haflinger mare (right). Melanoma affecting the lower eyelid of a 16-year-old mare before (left) and after (right) surgical resection. Horses with significant ocular disease frequently show no behavioral changes that indicate visual compro mise,57 especially if the vision loss has developed over a long period of time. The prevalence of owner-reported visual deficits in geriatric horses varies between 3. Note that 1 of these studies showed that, despite the owners concerns about the visual capacity of their horses, 50% were still used for ridden exercise, raising some important safety considerations. Horses are naturally grazing animals that are hunted by predators and rely on vision as their primary sense. Blind horses, or those with significantly reduced vision, can show a high level of fear and anxiety; they can become unpredictable and require cautious handling by experienced caretakers. Although these seldom cause overt visual deficits detected by their owners, they can be a source of chronic or acute discomfort so early detection, and treatment when available, is essential. Some of these abnormalities are specific to old horses, whereas others are a result of ongoing disorder or inflammation that started earlier in life but that becomes more evident when the damage sustained to the eye is advanced. If vision is significantly affected, consideration of human safety and animal welfare is paramount. Demographic and clinical characteristics of geri atric horses: 467 cases (1989-1999). Comparison of owner-reported health problems with veterinary assessment of geriatric horses in the United Kingdom. Disease prevalence in geriatric horses in the United Kingdom: veterinary clinical assessment of 200 cases. Evaluation of the effects of age and pituitary pars intermedia dysfunction on corneal sensitivity in horses. Grid keratotomy as a treatment for superficial nonhealing corneal ulcers in 10 horses. Treatment of nonhealing corneal ulcers in 60 horses with diamond burr debridement (2010-2013). Association of leptospiral seroreactivity and breed with uveitis and blindness in horses 372 cases (1986-1993). Long-term outcome after implantation of a suprachoroidal cyclosporine drug delivery device in horses with recurrent uveitis. Effect of sedation with detomidine on intraocular pressure with and without topical anesthesia in clinically normal horses. Effect of intravenous administration of romifidine on intraocular pressure in clinically normal horses. Description of ciliary body anatomy and iden tification of sites for transscleral cyclophotocoagulation in the equine eye. Semiconductor diode laser trans scleral cyclophotocoagulation for the treatment of glaucoma in horses: a retro spective study of 42 eyes. The long-term effects of semiconductor diode laser transscleral cyclophotocoagulation on the normal equine eye and intraocular pressure. The location of sites and effect of semiconductor diode trans-scleral cyclophotocoagulation on the buph thalmic equine globe. Retrospective evaluation of phacoemulsification and aspiration in 41 horses (46 eyes): visual outcomes vs. Concurrent clinical intraocular findings in horses with depigmented punctate chorioretinal foci. Mitomycin C, with or without surgery, for the treatment of ocular squamous cell carcinoma in horses.

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A novel quaternary structure of the dimeric alpha-crystallin domain with chaperone-like activity. Interactions entre proteines en solution : etude par diffusion des rayons X aux petits angles du lysozyme! The network and the remodeling theories of aging: historical background and new perspectives. Inversion and isomerization of Asp-58 residue in human alphaA-crystallin from normal aged lenses and cataractous lenses. Alpha-crystallin assists the renaturation of glyceraldehyde-3-phosphate dehydrogenase. The nucleus of the human lens: demonstration of a highly characteristic protein pattern by two-dimensional electrophoresis and introduction of a new method of lens dissection. Deamidation, isomerization, and racemization at asparaginyl and aspartyl residues in peptides. A kinetic study of the competition between renaturation and aggregation during the refolding of denatured-reduced egg white lysozyme. Lys-17 is the amine-donor substrate site for transglutaminase in betaA3-crystallin. Relation between the solubility of proteins in aqueous solutions and the second virial coef? The small heat-shock protein, alphaB-crystallin, has a variable quaternary structure. Small heat-shock protein structures reveal a continuum from symmetric to variable assemblies. The lens protein alpha A-crystallin of the blind mole rat, Spalax ehrenbergi: evolutionary change and functional constraints. Phosphorylation-induced change of the oligomerization state of alpha B-crystallin. Protein folding and association: in vitro studies for self-organization and targeting in the cell. Protein self-organization in vitro and in vivo: partitioning between physical biochemistry and cell biology. Junior chaperones: a-crystallins of the vertebrate eye lens are members of the family of small heat-shock proteins, sharing with other family members the ability to chaperone protein folding. Lens crystallins and their microbial homologs: structure, stability, and function. Glyceraldehyde 3-phosphate dehydrogenase is an enzyme-crystallin in diurnal geckos of the genus Phelsuma. Deamidation, but not truncation, decreases the urea stability of a lens structural protein, betaB1 crystallin. Incidence of age-related cataract over a 10-year interval: the Beaver Dam Eye Study. Link between a novel human gammaD-crystallin allele and a unique cataract phenotype explained by protein crystallography. Extrinsic protein stabilization by the naturally occurring osmolytes beta-hydroxyectoine and betaine. In vitro unfolding, refolding, and polymerization of human gammaD crystallin, a protein involved in cataract formation. Folding pattern of the alpha-crystallin domain in alphaA-crystallin determined by site-directed spin labeling. Homo-dimeric spherulin 3a: a single-domain member of the beta gamma-crystallin superfamily. Kinetic and thermodynamic stabilization of the betagamma crystallin homolog spherulin 3a from Physarum polycephalum by calcium binding. Refractive index distribution and spherical aberration in the crystalline lens of the African cichlid? Lens proteomics: analysis of rat crystallin sequences and two-dimensional electrophoresis map. A small heat shock protein stably binds heat-denatured model substrates and can maintain a substrate in a folding-competent state. Long-term caloric restriction delays age-related decline in proliferation capacity of murine lens epithelial cells in vitro and in vivo. Heat-induced conformational change of human lens recombinant alphaA and alphaB-crystallins. Phase separation in aqueous solutions of lens gamma-crystallins: special role of gamma s. Sorting-out of acceptor?donor relationships in the transglutaminase-catalyzed cross-linking of crystallins by the enzyme-directed labeling of potential sites. The evolution of lenticular proteins: the beta and gamma crystallin super gene family. Structure and function of small heat shock/alpha-crystallin proteins: established concepts and emerging ideas. Cell division, cell elongation and distribution of alpha-, beta and gamma-crystallins in the rat lens. Mechanism of chaperone function in small heat shock proteins?two-mode binding of the excited states of T4 lysozyme mutants by alpha A-crystallin. Structural and functional similarities of bovine alpha-crystallin and mouse small heat-shock protein. Effect of a concentrated inert macromolecular cosolute on the stability of a globular protein with respect to denaturation by heat and by chaotropes: a statistical-thermodynamic model. Stress-inducible responses and heat shock proteins: new pharmacologic targets for cytoprotection. Denaturant m values and heat capacity changes: relation to changes in accessible surface areas of protein unfolding. The X-ray structures of two mutant crystallin domains shed light on the evolution of multi-domain proteins. Towards a molecular understanding of phase separation in the lens: a comparison of the X-ray structures of two high Tc gamma-crystallins, gammaE and GammaF, with two low Tc gamma-crystallins, gammaB and gammaD. The X-ray structure of a mutant eye lens beta B2-crystallin with truncated sequence extensions. Mutational analysis of hydrophobic domain interactions in gamma B crystallin from bovine eye lens. X-ray structures of three interface mutants of gammaB-crystallin from bovine eye lens. Role of the C-terminal extensions of alpha-crystallins: swapping the C-terminal extension of alpha A-crystallin to alpha B-crystallin results in enhanced chaperone activity. Intracellular signaling from the endoplasmic reticulum to the nucleus: the unfolded protein response in yeast and mammals. Age-related telomere shortening occurs in lens epithelium from old rats and is slowed by caloric restriction. Conservation of rapid two-state folding in mesophilic, thermophilic and hyperthermophilic cold shock proteins. Transglutaminase activity in the eye: cross-linking in epithelia and connective tissue structures. The chaperone-like alpha-crystallin forms a complex only with the aggregation-prone molten globule state of alpha-lactalbumin. Interaction of human recombinant alphaA and alphaB-crystallins with early and late unfolding intermediates of citrate synthase on its thermal denaturation. Calcium binding properties of gamma-crystallin: calcium ion binds at the Greek key beta gamma-crystallin fold. Temperature-dependent chaperone activity and structural properties of human alphaA and alphaB-crystallins. Direct observation of the self-association of dilute proteins in the presence of inert macromolecules at high concentration via tracer sedimentation equilibrium: theory, experiment, and biological signi? Ca -loaded spherulin 3a from Physarum polycephalum adopts the prototype gamma-crystallin fold in aqueous solution.

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As noted from personal observation, it provides a deeply relaxing massage to the entire upper limb (shoulders, arms, and hands). Additionally, it improves flexibility, including that of the hands and 86 fingers. David Swenson provides the instruction for the execution of this asana (see Figure 4. If you are not clasping the hands then leave them on the floor or hold the left leg with both hands. Marichyasana Besides reliving fatigue, lengthening the spine and improving its alignment, Halasana, or Plow Pose, also addresses the entire upper limb area. If it is too much to take the feet all the way to the floor you may rest them on a chair behind you or lower them only half way to 61 David Swenson, Ashtanga Yoga, 90. Another useful pose addressing the arms, wrists, and hands, as well as the chest, is Adho Mukha Vrksasana (Downward Facing Tree or Handstand in English). This pose was briefly discussed in Chapter 1, as a part of Robert Boustany recommendation for working on posture in general (see p. Handstand builds strength and balance as it 63 develops the chest and strengthens the whole upper limb. Begin from the Downward Dog Pose while the hands are placed a few inches from the wall and the fingers are spread wide. The pose should be held for five deep breaths and repeated twice for a total of three repetitions. When proverbial chips are down, it doesn?t matter how fast you can trill, what conservatory you attended, or 64 what chorus you sing in: stress can make you or break you. The previous chapters have focused on various physical aspects of playing the instrument and the ways in which Yoga practice can be effective in dealing with such challenges. This chapter will explore the views of a variety of authorities on psychological components of music making and demonstrate usefulness of Yoga as illustrated by scientific research with respect to this issue. As previously mentioned, the uniqueness of Yoga lies in its inclusion of both physical and mental elements as it involves the whole person, and unifies physical, emotional, mental and spiritual planes. It is obvious that a high level of technical proficiency must be achieved in order to be able to communicate and execute musical ideas, but as Greene observes, this may be irrelevant if the performer cannot handle the stress of performing under extreme pressure. There are countless examples of talented musicians who never fulfilled their potential because of debilitating stage fright; one of 64 Greene, Performance Success, 15. Drawing from personal experience and information provided by available sources, I believe that the practice of Yoga?its meditative techniques, as well as breathing and asanas offers a set of tools that can be of great help in dealing with these problems. Although a popular prescription, pharmacological treatment of performance anxiety is not a valid option for many musicians; anti-anxiety medicines often negatively affect the fine motor control, which is critical to demanding, high-level performance. All renowned Yoga masters teach that the relation between breath and the state of mind is of great importance. Awareness and control of the breath translates into controlling and quieting the mind. Iyengar states that while asanas may appear to deal mostly with the physical body, they in fact influence chemical messages sent to and from 65 the brain, thus improving and stabilizing the mental state. The practice and philosophy of Yoga has proven to be a great inspiration for many respected teachers, authorities, and musicians. Overtly, the book addresses the challenges encountered by tennis players, but ultimately, it gives invaluable insights into the issues related to any kind of performance. Inner Game became one of the most influential texts used by music teachers throughout the world. It must be noted that his ideas and discoveries are deeply rooted in the philosophy and practice of Yoga. This is the game that takes place in the mind of the player, and it is played against such obstacles as lapses of concentration, nervousness, self-doubt and self 66 condemnation. The first step, and the fundament of mastering the inner game, involves quieting the mind and letting go of negative inner dialogue. Gallwey introduces here the concepts of Self 1 and Self 2, where Self 1 represents the conscious, ego driven mind (the part of us which tells us what to do), while Self 2 corresponds with our natural capabilities (it is the doer). A still (quiet) mind enables one to better observe reality, free of any preconceptions (for example what we are doing while playing a difficult passage). Abandoning judgments and instead noticing what is happening is the key skill of the inner game. The classic purpose of Hatha yoga was to prepare the body and mind for deep concentration and ultimately meditation in order to free it from chittavritti (modifications of the mind or, in other 66 Gallwey, Inner Game of Tennis, Introduction. Yoga develops and cultivates the ability to quiet the mind and thus assists in improving focus. In her article Yoga and Piano, Lanzer states: Through the practice of Yoga, I have found relief from the perpetual tension and pain that used to accompany my playing. After years of searching for the right way to play, I have discovered that the solution to my struggles is not in any prescribed method or well-meaning teacher. The answers lie within my own body 68 as I learn to become keenly aware of every motion I make. Yoga helped Lanzer, not only with the challenges she faced as a performer, but also changed her attitude as a teacher. The person in such condition feels constantly hyper-vigilant and forced to be continually on watch. A number of studies has shown decreases of cortisol in the blood of the participants, as well as alpha wave brain activation just after one Yoga class (alpha brain waves are associated with deep calm, and have been linked with enhanced immunity). Yoga has also shown to balance the levels of certain neurochemicals in the brain (especially of gamma-aminobutyric acid) that have been associated with anxiety 79 disorders and depression. It is a way of reinforcing positive, more effective behaviors, which ultimately leads to discarding old, ineffective habits. It is a way of gaining freedom to chose how one acts without being controlled by past conditioning. Thus the benefits of Yoga may be viewed from two different perspectives; as injury prevention and the enhancement of performance skills. The recognition of seriousness this issue presents, and the development of the field of performing arts medicine is relatively recent and still requires further advancement. The awareness of the importance and correlations 81 Rogers, Survey of Piano Instructors, 1. Three chapters of this document provide anatomical descriptions distinctively useful for violinists, an overview of a number of the most common injuries, and also specific demonstrations of the unique characteristics of various asanas and their value in both preventing and battling these conditions. As emphasized in Chapter 5, in addition to physical problems, a musician in the modern world is also confronted with extremely vital psychological challenges including performance anxiety, stress, inability to focus or negative inner dialogues during performances. The essence of this lesson is learning how to unlearn; to release harmful habits both mental and physical. Alexander came to his conclusions by applying a scientific approach to his body and its use. Through unbiased observation he realized that his perception of the body posture and his motions was different from what was happening in reality. Alexander was able to achieve the realization that the faulty position of his head, neck and back interfered with his abilities to perform, only by being fully present in the moment, 82 Oestreich, In Music as Well as Sports, Injuries can End a Career, C9; quoted in Rogers, Survey of Piano Instructors, 1. Gallwey also suggests that to find solutions to technical and mental challenges of any performance (for example to quiet negative mind chatter), one needs to put the attention into what is happening in the now. He also proposes the Centering technique, again, as a way to bring oneself into the present. I believe that practice of Yoga will make one better equipped to explore all of these methods. Furthermore, as Ted Cox, the principal tuba player with the Oklahoma City Philharmonic and Yoga instructor says, In our culture, results get all the attention and 83 the process is overlooked. I believe that with help of Yoga, we may overcome negative notions and make our music making much more enjoyable and creative. Yoga provides the means to help us free ourselves from dependence on the verdict of our judges; we come back to playing our instruments for the sake of music and our original love of it. As the authors of a recent article on Yoga therapeutics state, 84 the practice of Yoga can narrow the gap between insight and change.


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