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These residual problems may be manifested in obvious or subtle ways, and an explanation of their nature may be helpful. With route to recovery from addiction, untangle a complex out concerted and persistent effort toward recovery, per knot of problems, including the changing pretraumatic sonal, family and social dimensions of life are deeply lifestyle, while dealing with the confusion and psycholog threatened and treacherously undermined. Many of physiological organ responsible for memory, language, these regions of the brain interface to enable the perfor reasoning, judgment, and behavior (among other skills and mance of complex skills such as reading, or remembering abilities) has been compromised. For Attention situations in which it is appropriate, encourage the head this includes maintaining attention for normal periods injured person also to ask speakers to slow down, to re and the ability to shift attention to different areas after peat points, and to explain ideas in different words. Also included here are port may be required to downplay feelings of embarrass difculties screening out distractions (voices, noises, and ment to do these things. As a general rule, encourage him to take time rather than attempting longer amounts that may time to think about what he wants to say, to plan how to prove too fatiguing to the sponsoree. Gradually lengthen the time of ex pected attention and concentration as increasing abilities Basic skills such as cause-effect reasoning and/or the abil permit. Similarly, problem-solving skills are the most common type of decit resulting from brain often marred by impulsive decision making, difculty in injury is of short-term memory. This appears as difculty considering several solutions to problems and in envi holding onto several pieces of information while having sioning potential consequences of actions. Fortunately, mem which behaviors, and reecting on the propriety of what ory for pretraumatic episodes are most often unimpaired he has just said or done. If but rm advice-giving anyone working in a recovery pro such memory aids are necessary, consider this simply an gram may require. It may be helpful to point out specic other component of the program to be worked; do not incidences as examples of behaviors that need to be shy from expecting self responsibility. In both cases, a slower Executive Functions speed of processing language is at play. Also, delays in recalling the words needed to articulate a thought are Executive functions refer to those abilities to initiate, common. When speaking, the head-injured person may organize, direct, monitor, and evaluate oneself. Self ramble and talk in a disorganized, circular kind of way, insight is a crucial component. Owing to the very high often failing to come to the point or himself losing it in level nature of these skills and to the vulnerability of the the details of the conversation. As a result, even with other skills and abilities is the goal, your responsibility is as it would be with any intact, the use of these executive functions in a directed, other such partnership. Tactful but clear identication of purposeful manner may be lacking, making the overall problems, complete with acceptance of them as risks to picture of brain operations rather like a full-member, continued sobriety or clean time that will necessitate competent orchestra without a conductor to organize and work, is an appropriate attitude to adopt. Whether these lead their many mixing harmonies; or, like a ready and sorts of problems are attributable to an addictive person able work crew without a foreman to coordinate and ality, or to the head injury, or to both, open, honest ac direct their labor. The sponsor are apparent in the person you sponsor, it may well be ship concept, moreover, is a very plausible means of ad come especially important for you to assume a role of dressing those sorts of problems. For a head If the person with whom you work has received treat injured person, however, the need for such help may be ment from a rehabilitation center specializing in brain deeper and more substantial. Your skills as a conductor, trauma, do not hesitate to contact the staff for advice or foreman, may be particularly required. You deserve But be careful, of course, not to foster unnecessary de great thanks. The comments in this letter are not meant pendence; increased well-being through healthy, clear to frighten or dissuade you from sponsorship, but rather minded independence is always, as you know, the ulti to provide you with basic information with which to en mate goal. Trust yourself in your work; your status as a 12-stepper well respected for your patience, in Emotional telligence, and straightforwardness. The recovering head-injured person receiving your help is fortunate to have you in his corner. There may be tendencies toward overreaction person with whom you are beginning involvement repre to stressful situations, some paranoia, depression, with sents help for someone whose life has been shattered in a drawal, or denial of problems. No single head-injured particularly devastating way, whose detour is indeed for person evidences all of these problems, of course, and midable. May your help in teaching that person to dance most would show only subtle signals of some of these psy be gratifying, and blessed, and an occasion for joy and chosocial difculties. Suggestions: In your sponsoring of a head-injured Henry K: A letter to sponsors of chemically dependent head in person who may exhibit some of the above problems, the jured persons, in Task Force on Chemical Dependency. Made a list of all persons we had harmed and became Alcoholics Anonymous willing to make amends to them all. We admitted we were powerless over alcohol; that sible, except when to do so would injure them or our lives had become unmanageable. Sought through prayer and meditation to improve the care of God as we understood Him. Made a searching and fearless moral inventory of Him, praying only for knowledge of His will for us ourselves. Having had a spiritual awakening as the result of being the exact nature of our wrongs. Were entirely ready to have God remove all these de holics and to practice these principles in all our fects of character. Ask God for the strength to be a responsible person that have been written for the traumatic brain injury with responsible behaviors. Make a list of people your negative behaviors have af these steps can be understood by those who need con fected. Be ready to apologize or make things right crete examples for understanding and using them in the with them. Reward yourself Alcoholics Anonymous group, counselor, sponsor, when you are able to behave in a positive and respon etc. Families are systems Homeostasis and Involvement with sets of relationships and roles that develop to main tain an effective balance in the day-to-day world. This ho Because hospitals and rehabilitation programs are meostasis is broken at the moment one person in the fam under increasing pressure to become more efcient and ily sustains a brain injury.

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However, if certain criteria are used to screen out an employee or employees with disabilities as a result of such an examination or inquiry, the exclusionary criteria must be job-related and consistent with business necessity, and performance of the essential job functions cannot be accomplished with reasonable accommodation as required in this part. Whether an athletic drill could be construed as a disability-related inquiry or a medical examination would have to be evaluated on a case-by-case basis. Recall that an employer can lawfully condition an offer on passing a medical exam. Moreover, the widely publicized nature of the results calls their confdentiality into question. This ambiguity revolves around the question of whether these sensors are medical devices (or are collecting medical or health-related data) when they monitor speed, force, movement, sleep, and heart rate. Using these new technologies does not clearly meet the defnition of a medical examination. They do not require the expertise of a healthcare professional and do not need to be employed in a medical setting. With some exceptions (such as the pill described earlier221), many of the technologies are not invasive, nor are they obviously medical equipment. While some wearable technologies could reveal an impairment, devices that measure speed or heart rate are not designed for this purpose. In theory, assessing performance could detect the presence of an impairment, even if the technique being used is not considered medical. For example, having a player wear a monitor while sleeping could detect signs of previously undiagnosed sleep apnea. Additionally, collecting performance-related data over time could also lead to the discovery of an impairment if the player experiences subtle declines in ability that would have otherwise gone unnoticed. Thus, a club that administers a pre-offer genetic test for the sickle cell disease or trait violates the law. To illustrate, let us return to our hypothetical player, James, introduced at the beginning of this Article. Recall, however, that this exception is for job-related inquiries, not medical exams. Because health and athletic performance are linked, those entities could easily argue that medical examinations of the players serve the legitimate business purpose of ensuring safe and efective play. However, it is worth noting that a player could voluntarily ofer medical information, for example to assuage the concerns of a club. Player will undergo a complete physical examination by the Club physician upon Club request, during which physical examination Player agrees to make full and complete disclosure of any physical or mental condition known to him which might impair his performance under this contract and to respond fully and in good faith when questioned by the Club physician about such condition. If Player fails to establish or maintain his excellent physical condition to the satisfaction of the Club physician, or make the required full and complete disclosure and good faith responses to the Club physician, then Club may terminate this contract. You have failed to make full and complete disclosure of your physical or mental condition during a physical examination. But avoiding diagnostic tests and medical exams could delay treatment and lead to further harm as the illness or injury worsens over time. Additionally, the collectively bargained nature of these disclosures and releases creates additional pressure on the players, further undermining their purported voluntariness. Claims Title I contains a rather lengthy description of what constitutes discrimination. Section 12112(b) explains that discrimination against a qualified individual with a disability covers a wide range of employer actions that both intentionally and unintentionally have an adverse effect on people with disabilities, including classifying individuals on the basis of disability; participating in discriminatory contracts or other agreements with employment-related entities; and adopting qualification standards that tend to screen out individuals with disabilities, unless those standards are job-related and consistent with business necessity. At present, courts are split on the question of whether claimants must establish that the disability was simply a motivating factor or whether it must be a but-for cause of the discrimination. Impairments cover a wide range of both physical and mental conditions,243 including addiction. As a result, a player does not have to be experiencing an actual impairment to be considered an individual with a disability. A player who experiences a limitation in a major bodily function that might not directly afect his current ability to play, such as a congenital heart problem, diabetes, or cancer, could also qualify as an individual with a disability. The regarded as prong may also be the most comfortable ft, as the players themselves loathe portraying themselves as impaired. The applicable regulations allow courts to look to written job descriptions and collective bargaining agreements when assessing which job functions are essential. Thus, the qualifed individual inquiry likely is more of a moving target in the case of an elite athlete than it is in the case of an administrative assistant. In terms of relevant case law, two cases potentially address how to determine essential job functions of professional athletes. To be sure, the qualifed inquiry for professional athletes is more complex than for traditional jobs. If that were true, the qualifcation standard would be meaningless given that every employer seeks the best available candidate. For example, an individual whose level of skill and performance might have been elite in the past may no longer be qualifed relative to the current group of players. The Court ultimately explained that the use of carts to play golf is not inconsistent with the fundamental characteristic of the game and that the essence of golf is shotmaking. For example, imagine that our hypothetical player, James, has diabetes but can still play at an elite level. The same would be true for a player with a congenital heart defect, a player with a record of a severely limiting injuries, or a player, like Star Lotulelei,277 who had been perceived as having an impairment. Since Sasser had not been invited to the Combine, his condition was not discovered until after he was drafted. The Rams still signed Sasser to a contract commensurate with his draft position (including a $113,737 signing bonus) even though they were under no such obligation. An adverse employment action based on performance data alone would not constitute discrimination on the basis of disability. Courts will likely struggle to distinguish the two should these issues be litigated.

Syndromes

  • Rapid hair loss
  • Visiting nurses or aides
  • Falling from a height greater than 20 feet
  • Unusual behaviors during sleep (sleep-disruptive behaviors)
  • You have anemia (low blood count)
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Part 1: Players Chapter 1 Players the heart of this Report is about protecting and promoting player health. That said, as we emphasized in the Introduction, players are making choices against a constrained set of background conditions, pressures, and infuences, and sometimes with limited expertise and information, all of which can affect their capacity to optimally protect their own health, especially given potentially competing interests. Thus, while they are competent adults with a bevy of responsibilities to protect themselves, they cannot do it alone. Players must be treated as partners in advancing their own health by offering them a variety of support systems to do so, recommendations for which will be accompanied by others geared toward other stakeholders. In addition, we interviewed players from multiple 94-year history, only 56 players have ever played after the age of 40. Finally, the players also represented a were African American, 813 were white (28. We also invited all 13 players that we interviewed to by Sporting News, the states that have produced the most review a draft of this chapter prior to publication. While players are among the largest and with the highest popu seven of the players agreed to review a draft, only three lations: (1) California (225 players in 2013); (2) Florida provided comments. However, many take online classes or return in the offseason to try and complete their degree. While the different career lengths also lead to different estimates the racial demographics of former players is likely closer to of mean career earnings. Weir also believes that the racial shrinking-shelf-life-of-nf-players-1456694959, archived at perma. However, we have several questions about the methodology used to generate demographics of former players is substantially similar this statistic, including: (1) the analysis does not describe its inclusion criteria, i. Consequently, the different reporting structures with any time lost from practice or games, football-related over time almost certainly contributed to fuctuations in the or not, or specifc conditions regardless of time lost, includ injury rates identifed below. Therefore, it is not possible ing but not limited to concussions, fractures, dental injuries to be certain whether injury rates have increased in recent requiring treatment, health-related illness requiring intrave years, or if, instead, the increases are due to improved nous fuid administration, and injuries or illness requiring injury reporting. Beginning with the injuries in recent years, concussions in particular, might also 2015 season, all injuries, regardless of whether or not they lead to higher reported injury totals. Thus, while there is a mean season, it is important to point out that the number of play of 0. Table 1-H: Concussion Incidence by Player Position in the Regular Season (2013) Position 2013 Offensive Line 19 Running Back 15 Tight End 16 Quarterback 6 Wide Receiver 17 Offense Total 73 (49. To be clear, these statistics only include players who played in a regular season game and thus does not include players who only played in the preseason. The data we requested is de-identifed year, and years of data, we can calculate the overall rate aggregate data that does not implicate the personal medical of concussion per player-game as 0. Finally, the above tables incorporate data from players, may be surprised that this rate is not higher. The 164,864 value is calculated by multiplying 7 seasons by 256 regular season games per season by 92 players per game. One useful question concerns ascertaining the mean num If a player fails the preseason physical, i. We tor determines the player is not physically ready to play calculated above that the rate of injuries per regular season football, and is unable to participate in training camp game per player was 0. Thus, we can calculate that but is expected to be able to play later in the season, the players play a mean of 15. We can also calculate the mean number List cannot practice or play until after the sixth game of of games a player plays before suffering a concussion. With 16 regular season games, season and are unable to return that season are placed players theoretically play a mean of 9. For context, although there is a debate practicing or playing further that season. Players with a lot of game time and players at certain positions Finally, the less severely injured players are only given a are likely to suffer concussions at rates higher than those different status on the day of the game. This is the universe of players Finally, we can calculate what percentage of player injuries from which clubs have to choose each week. Between 2009 and 2015 there were a total the game, the number of players that are permitted to play, i. During this same time period, there were 1,112 regular season con players are declared Inactive and cannot play. A player is Inactive for that particular game, but can Finally, below is some additional information from be Active for the next game. If the player is still physically unable to play two seasons after the injury, he is entitled to 30 percent of his salary up to a maximum for $525,000 o Statistics for injuries other than concussions are only available in bar graph form. See 2011 Consequently, we estimate the injury statistic based on the graph available. Nevertheless, we provide the reader with the best rates of depression substantially lower than that found by existing data. But in the meantime, extrapolating from the above episodes); Ronald Kessler, et al. Recurrent Concussion and Risk of Depression in Retired suffering from some form of mental illness. Also of note, the study found that retired players reporting a history of three Michigan Studyq found that 25. Aside from the resources that do exist, players are a) Current Legal Obligations likely concerned about clubs knowing whether they have sought mental healthcare. The chaplains often hold small studies or sermons but avoid overly religious messaging, instead focusing on themes relevant to football and the players or other themes as directed by the coaching staff. The Standard important words of encouragement and positive feedback Player Contract is 9 pages in length and contains the most basic and important pro in an environment that is often lacking both. Most player contracts include multi-page addendums addressing more specifc compensation or contractual issues. Professional athletes have had their contracts stances under which these waivers are executed is an area worthy of additional terminated after being injured in motorcycle accidents or playing pickup basketball. For example, questions might be raised as to whether the players are See Herzog, Bob. Basketball Injury Might Cost Boone Big Part of Contract, Newsday, providing meaningful informed consent in their execution. These grievance mechanisms will bez report injuries to their club, outside of the physical exam. However, While we recognize that players currently lack suffcient if a player is not undergoing a physical and has not recently information to be fully empowered, assuming that players suffered an injury, he does not have to tell the club about are concerned with maximizing their health, they do have his medical needs. Thus, it does not appear that the player some obligations to help support that goal.

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It divides into anterior and and leg below the knee but excludes the medial aspect of the page 106 Update in Anaesthesia | Indications: All surgical procedures involving the posterior Landmarks: Greater trochanter, ischial tuberosity, gluteal aspect of the leg especially below the knee, for example crease, biceps femoris muscle. The nerve posterior approach to the sciatic nerve is often palpable in the groove lateral to biceps femoris in Position: Lateral recumbent, hip fexed, knee fexed, the side to young children. Insert a needle at the Landmarks: pubic tubercle, anterior superior iliac spine, midpoint of this line and direct towards the ischial tuberosity. A line drawn from the pubic tubercle to the anterior superior iliac spine (inguinal ligament) is divided L5 into thirds. A perpendicular is then dropped from the junction of the inner and middle thirds onto a line drawn parallel to the inguinal ligament through the greater trochanter. Technique: Insert a needle perpendicular to the midpoint of a line drawn from the head of fbula to the ischial tuberosity in 2 the posterior thigh. Nerve blocks for anaesthesia and analgesia of the Position: Prone, lateral or supine. The exact location of this division is variable but in the majority of children it is within the popliteal fossa. The The nerve to vastus medialis can be located using a nerve posterior tibial nerve courses down the midline of the lower leg stimulator. Insert an insulated needle perpendicular to the skin posteriorly in close proximity, but superfcial to the popliteal 0. Although the nerves branch, there is a common epineural Muscle twitches in the sartorius muscle confrm the close sheath that envelops both the posterior tibial and the common proximity to the saphenous nerve at this level. Stimulation of the common peroneal will cause An advantage of this block over a femoral block is that motor dorsifexion and eversion of the foot while stimulation of the activity in the remainder of the quadriceps is spared. Various landmarks have been described for the insertion of Make a deep linear subcutaneous infltration below and the needle. For each 10kg body weight the needle insertion behind the insertion of the sartorius tendon (medial surface of moves 1cm further above the popliteal crease just lateral to 32 tibia) where the nerve lies in a shallow gutter immediately in the midline. Alternatively, insert a needle at the apex of the front of the upper part of the medial head of gastrocnemius. Landmarks: Medial and lateral malleolus, extensor hallucis longus tendon, Achilles tendon, dorsalis pedis pulse. Ankle blocks are used for procedures confned to the foot A lateral approach to the popliteal fossa has recently been 40 including distal phalangeal amputations, foreign body removal described in children. The fve peripheral nerves the postero-lateral aspect of the knee approximately 4-6 cm blocked at this level are the terminal branches of the sciatic above the popliteal crease. Insert a needle anterior to the biceps (posterior tibial, superfcial peroneal, deep peroneal and sural femoris tendon until the needle contacts the shaft of the femur. At this point gently walk the needle of the femur posteriorly and advance until foot dorsifexion or plantar fexion along An ankle block is relatively easy to perform by injecting with eversion is elicited. Avoid local anaesthetics containing adrenaline since it may compromise end-arteries Saphenous nerve block in the foot. Block each nerve separately for best results (see Indication: The main indication for blocking this nerve is to Figure 7). It is located on the medial side of the dorsum of the foot anterior to the medial malleolus. A subcutaneous injection from the medial malleolus along the anterior i aspect of the ankle towards the saphenous vein will block the nerve. Resuscitation equipment (oxygen, anticonvulsants, Ambu bag and Intralipid) should be available in the event of local anaesthetic toxicity or anaphylaxis. Local Expertly performed, peripheral nerve blocks can provide long anaesthetic injected through a needle inserted postero lasting anaesthesia and analgesia for surgery or after injury medially to the Achilles tendon and directed towards the to the upper or lower limbs in children. Accuracy is improved if a nerve (b) The superfcial peroneal nerve supplies the dorsum of the stimulator or ultrasound guidance is used. A safe dose of foot and is blocked by a subcutaneous injection across the local anaesthetic must be used at all times, and care taken to dorsum of the foot between the lateral malleolus and the avoid inadvertent intravascular injection of local anaesthetic. Additional information and video descriptions of peripheral (c) The deep peroneal nerve innervates the frst web space nerve blocks can be obtained from the Internet, for instance between the 1st and 2nd toe. Insert a needle medial to extensor from the New York School of Anaesthesia website: hallucis longus tendon along anterior tibial arterial Pediatric regional anesthesia: between the lateral malleolus and the calcaneum until beyond the caudal. Pediatr Anesth approach to the brachial plexus in children: comparison with 2010; 20: 1061-9. Chan V: Advances in regional anaesthesia and pain analgesia after foot surgery in infants and children. Ultrasound-guided upper extremity blocks-tips and tricks to improve the clinical practice. The American Society of Regional Anaesthesia and Pain Medicine and the European 29. Axillary block in children: single or iliaca compartment block with the 3-in-1 block in children. Blockade of the sciatic nerve in the popliteal forearm fractures in children using axillary block anesthesia. Paediatr Anaesth in children: comparison of the posterior, anterior, and lateral 1999; 9: 435-8. An anatomical and clinical study Anaesthesist 1995; sciatic nerve block: an evaluation of a novel approach using a 44: 339-44. A new single-position supine Continuous infraclavicular brachial plexus block for acute pain approach to sciatic-femoral nerve block. Popliteal fossa block for postoperative analgesia after foot surgery in infants and children. Rachel Troncin* and Christophe Dadure *Correspondence Email: racheltroncin@hotmail. General anaesthesia increases this article correctly suggests that the resurgence the risk of apnoea and bradycardia, and ex-premature of interest in spinal anaesthetic techniques in infants remain at risk until after 60 weeks post neonates and young infants was driven by the conception. Although provides a good may be of particular use in developing countries as an the current human evidence is not conclusive, a alternative to general alternative to general anaesthesia. Spinal extremity surgery during anaesthesia is currently the mainstay of practice for the frst 6 months of life. The incidence of postoperative Montpellier apnoeas correlates with gestational age at birth, the anatomical conSiderationS France post-conceptional age at surgery, weight, anaemia and A line connecting the top of the iliac crests crosses the page 112 Update in Anaesthesia | Informed The distance between the skin and the subarachnoid space is consent should be obtained. Blood tests are not usually required for a routine herniotomy, the Distance from skin to subarachnoid space (cm) = 0. Premedication with oral or rectal atropine Cerebrospinal fuid is a clear body fuid that occupies the -1 (20mcg. Some anaesthesiologists have suggested placing cerebrospinal fuid the intravenous cannula in an anaesthetized lower extremity after volume (ml. All drugs and equipment should be The volume of distribution of drugs injected into the subarachnoid prepared and checked prior to starting. Full barrier aseptic technique space is higher in infants and neonates than in adults and consequently the injected dose is relatively greater in infants and neonates. Cardiovascular changes due to spinal block are generally short lasting and respond to a bolus of intravenous fuid (10ml. All doses for awake neonates or infants but careful attention must be directed at should be calculated carefully and checked with another maintaining patency of the airway which may be compromised with practitioner. This has been reported in children >8 sedation with a benzodiazepine such as midazolam may be indicated.

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The discovery of adrenoceptors led to the development of novel, highly successful drugs to treat many common and important disorders, such as hypertension, abnormal heart rhythms, coronary artery disease, and heart failure. For the development of beta-adrenoceptor blockers, which remain key agents in the treatment of hypertension, angina pectoris, and abnormal heart rhythms, Sir James Black shared the Nobel Prize for Physiology or Medicine in 1988. The G proteins are located near the receptors on the inner portion of the cell membrane. For the discovery of G-proteins and their significance in cellular activation by adrenaline, Alfred G. Gilman and Martin Rodbell shared the Nobel Prize in Physiology or Medicine in 1994. The release of glucose by adrenaline takes place partly by stimulating the breakdown of glycogen to form glucose in the liver. The breakdown of glycogen, in turn, involves a rather involved cascade of biochemical events. A family of chemicals called arrestins help turn off the intra cellular cascade that activates cells when G-protein-coupled receptors such as beta-adrenoceptors are occupied. The arrestin binding to the receptor then blocks further G-protein-mediated signaling and also targets the receptors for displacement from the cell membrane into the cytoplasm. For the discovery of beta-arrestin, Robert Lefkowitz shared a Nobel Prize in 2012. The remarkable array of receptors contrasts starkly with the small family of chemicals that reach those receptors. The multiplicity of receptors for Intracellular events afteroccupation of dopamine receptors. The drug, clonidine, which has an imidazoline chemical structure, constricted blood vessels in a manner similar to phenylephrine, the alpha-1 adrenoceptor agonist sold as 168 Principles of Autonomic Medicine v. In 1962, the secretary to the medical director, a Frau Schwandt, came down with a bad cold, and the medical director applied a dilute solution of clonidine to the mucus membranes of her nose. It was soon realized that clonidine enters the central nervous system, producing sedation and dropping sympathetic noradrenergic system outflows to the blood vessels and heart. The drug has also been used successfully to treat conditions as diverse as alcohol and opiate withdrawal, baroreflex failure, and attention deficit hyperactivity disorder. It is thought that in humans clonidine works in humans by stimulating both alpha-2 adrenoceptors and imidazoline receptors. Near the end of his life, in about 1876, he postulated that the body maintains 170 Principles of Autonomic Medicine v. These compensatory reactions tend to restore a state of equilibrium in response to any outside changes. Claude Bernard taught that compensatory actions help maintain the internal environment. Bernard therefore not only introduced the notion of an apparently constant inner world but also a purpose for body processes. These threats to homeostasis, by causing sensed deviations from the goal values, arouse internal nervous and hormonal systems, induce reflexive physiological changes, produce externally observable behaviors, and prompt internal emotional and motivational states, all of which serve to preserve homeostasis. Interestingly, Cannon never referred to homeostasis of blood pressure, even though this has become a focus of research and practice in autonomic medicine. Cannon taught that the body responds to all emergencies in the same way, by evoking increased secretion of adrenaline. In higher organisms, maintaining homeostasis depends on complex coordination by the brain. Just as the brain receives information from sense organs about and determines our interactions with the outside world, the brain also receives information from internal sensors and acts on that information to regulate the inner world. For most of our lives the brain tracks many monitored variables by way of internal sensory information and acts on that information to maintain levels of monitored variables by modulating numerous effectors that work in parallel. Later you will learn much more about how hierarchies of nerve networks in the central nervous system mediate this regulation. The noteworthy features of the total arrangement, apart from its efficiency, are the varieties of the devices for homeostasis, their appearance in a sequence of defences against change, and the close involvement of the sympathetic system in the conservation, production and dissipation of heat. The second is feed-forward regulation, which is the most challenging from a theoretical point of view. The third, which seems not to have been incorporated explicitly previously in concepts of homeostasis, is buffering. The Figure above shows the relationships of reflexive error control via negative feedback (red), buffering (tan), and anticipatory regulation (blue). The anticipatory control mechanisms can be instinctive (solid lines) or conditioned 175 Principles of Autonomic Medicine v. A disturbance can arouse anticipatory instinctive responses by pathways involving awareness (conscious or unconscious); and an associated conditioned stimulus can arouse anticipatory responses by pathways involving awareness and conditioned learning. Behavioral responses to buffer the cold include huddling, seeking shelter, hibernation, and bird migration. In the Figure, the + or 0 refers to buffering dependent on or independent of effector activation. Propped in bed, she would cheer on her hero, Antonino Rocca, the barefoot master of the flying dropkick, and scold Skull Murphy, who was notorious for butting opponents senseless with his shaved, vaselined head. In professional wrestling you can win by three smacks by the referee on the tarp, by disqualification, or by submission. Over the years I came to question the veracity of professional wrestling, but I do think there is a kernel of truth to the sleeper hold. When the blood pressure increases, the wall of the carotid sinus on each side of the neck expands, and this stimulates the baroreceptors in the artery walls. The blood pressure and consequently the blood flow to the brainstem decreases, and the victim loses consciousness. The story of the sleeper hold teaches that one of the most important examples of negative feedback regulation mediated by the autonomic nervous system is the arterial baroreflex. A rterial baroreceptor activation produces opposite effects on sympathetic noradrenergic system and vagal outflows.

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Collie A, Maruff P, Makdissi M, McCrory P, should conduct and interpret the neuro trauma: who needs what A comparison and return to play in high school football ences in neuropsychological testing of high school and collegiate athletes. Paediatric sport re on clinical outcome and risk of reinjury crossover study [published correction ap lated concussion pilot study. When to retire after concus Centers for Disease Control and Prevention; school athletes. Recurrent athletic head injury: Centers for Disease Control and Preven drome exist Summary and agreement statement of the first international symposium on concussion in sport, Vienna 2001. It outlines how the concussion care team prepares for and responds to this injury. However, trained healthcare providers know that a concussion requires an individualized care approach. A concussion protocol (policy) is used to ensure everyone involved knows what to do when a concussion happens. An organization needs a concussion protocol when they have children or adults who may be at risk for a concussion. Ontario, Canada has also passed legislation requiring removal from sport and return to activity protocols for youth athletes. These laws are a step in the right direction to ensuring proper care after a concussion. However, there are still many countries and communities that lack written concussion protocols. Team Physicians, Athletic Trainers, Healthcare Providers, and Rehab Professionals can fill an important gap by creating their own concussion protocols based on current evidence. The person responsible for creating a concussion protocol depends entirely on the individual setting. In g e n e r a l, a h e a l t h c a r e p r o v i d e r f a m i l i a r w i t h concussions should be the one to create the protocol. The best concussion protocols involve a variety of teammates and care stakeholders. This person should always be a trained healthcare provider who is very familiar with concussion care. They work with school staff to make sure academic adjustments are implemented as the student returns to school after a concussion. They can coordinate with athletic trainers and school nurses to make sure students get the right academic adjustments after a concussion. While concussion protocols differ by setting, most healthcare providers agree on the key elements that should be included in a concussion protocol. Concussion protocol requirements can also differ depending on country, state, or local laws. Sideline evaluations are a critical early measure in checking for a concussion and determining next steps in the concussion care process. After a bump, blow, or jolt to the head, a healthcare provider trained to recognize concussions should follow a well-defined sideline process. Because a concussion often happens without an individual losing consciousness, a healthcare provider must use screening for head injury in other ways. Without a full sideline assessment, athletes may return to play prematurely and be at risk for negative consequences. A concussion screen is a brief evaluation conducted by a trained healthcare provider. A trained healthcare provider will document whether or not there was a hit to the head and the location of impact. The healthcare provider will continue monitoring for any new symptoms that might appear after the head injury. If a patient gets a head injury, healthcare providers can use a post-injury test to help determine if they have a concussion. It measures reaction time, memory capacity, speed of mental processing, and executive functioning of the brain. This is thanks to normative data, which provides average scores within an age range. Post-injury testing is done by trained healthcare providers who use the test and other data to help evaluate a concussion. Educating athletes and patients on concussions can seem like an overwhelming process, but there are plenty of resources available to help. This include patients, students, athletes, coaches, parents, school staff, and sports officials. Education should take place prior to an athletic season, or at the beginning of each year for students. At any rate, providing concussion education and being available to answer any questions is a good start. A healthcare provider trained in concussion care should always be the one to diagnose a concussion. Concussion diagnosis should not be done by coaches, parents, or the patients themselves.

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No effects of zinc on serum copper or cholesterol concentrations or other adverse effects were found. In 1986, approximately 17 percent of women and 15 percent of men consumed supplements that contained zinc (Moss et al. The ninety-fifth percentile intake of zinc coming from food and supplements for adult men and nonpregnant women was approximately 25 to 32 mg/day (Appendix Table C-26). For pregnant and lactating women, the zinc intake from food and sup plements was approximately 40 and 47 mg/day, respectively, at the ninety-fifth percentile. Risk Characterization the risk of adverse effects resulting from excess zinc intake from food and supplements appears to be low at the highest intakes noted above. High intakes of zinc are due to the use of supplements, espe cially during lactation and pregnancy. Mineral and trace-metal balances in children receiving normal and synthetic diets. Longitudinal changes of trace elements in human milk dur ing the first 5 months of lactation. Serum concen tration and dietary intake of Zn in healthy institutionalized elderly subjects. Determination of zinc and copper absorption at three dietary Zn-Cu ratios by using stable isotope methods in young adult and elderly subjects. Tissue zinc levels and zinc excretion during experimental zinc depletion in young men. Marginal zinc deficiency in older adults: Responsiveness of zinc status indicators. Changes in cytokine production and T cell subpopulations in experimentally induced zinc-deficient humans. Intestinal absorption of dietary cadmium in women depends on body iron stores and fiber intake. Zinc supplementation in malnourished chil dren with persistent diarrhea in Pakistan. Zinc and immunocompetence in the elderly: Baseline data on zinc nutriture and immunity in supplemented sub jects. Boukaiba N, Flament C, Acher S, Chappuis P, Piau A, Fusselier M, Dardenne M, Lemonnier D. A physiological amount of zinc supplementation: Effects on nutritional, lipid, and thymic status in an elderly population. Zinc supplementation reconstitutes the pro duction of interferon by leukocytes from elderly persons. Adding zinc to prenatal iron and folate supplements improves maternal and neonatal zinc status in a Peruvian population. Maternal zinc supplementa tion does not affect size at birth or pregnancy duration in Peru. Elimination of zinc from synaptic vesicles in the intact mouse brain by disruption of the ZnT3 gene. Effect of dietary zinc and protein levels on the utilization of zinc and copper by adult females. Absorption, transport, and hepatic metabolism of copper and zinc: Special reference to metallothionein and ceruloplasmin. Zinc and calcium apparent absorption from an infant cereal: A stable isotope study in healthy infants. Changes in dietary zinc and copper affect zinc-status indicators of postmenopausal women, notably extracellular super oxide dismutase and amyloid precursor proteins. Effects of zinc and other nutritional factors on insulin-like growth factor I and insulin-like growth fac tor binding proteins in postmenopausal women. Age of introduction of comple mentary foods and growth of term, low-birth-weight, breast-fed infants: A ran domized intervention study in Honduras. Iron and zinc status of young women aged 14 to 19 years consuming vegetarian and omnivorous diets. Dietary intakes of adolescent females consuming vegetarian, semi-vegetarian, and omnivorous diets. Beneficial effects of oral zinc supplementation on the immune response of old people. Phytate:zinc and phytate x calcium:zinc millimolar ratios in self-selected diets of Americans, Asian Indians, and Nepalese. Anthropometric measurements, dietary intake and biochemical data of South African lacto ovovegetarians. The effect of zinc and vitamin A supplementation on immune response in an older popula tion. Alterations in zinc absorp tion and salivary sediment zinc after a lacto-ovo-vegetarian diet. Effect of zinc supplementation on plasma high-density lipoprotein cholesterol and zinc. A growth-limiting, mild zinc-deficiency syndrome in some southern Ontario boys with low height percentiles. Dietary strategies to improve the iron and zinc nutriture of young women following a vegetarian diet. Effect of dietary protein and phosphorus levels on the utilization of zinc, copper and manganese by adult males. Calcium, mag nesium, phosphorus, copper, and manganese balance in adolescent females. Gunes C, Heuchel R, Georgiev O, Muller K-H, Lichtlen P, Bluthmann H, Marino S, Aguzzi A, Schaffner W. Zinc nutritional status of young middle-income children and effects of consuming zinc-fortified breakfast cereals. Inositol phosphates inhibit uptake and transport of iron and zinc by a human intestinal cell line. Nutritional status and phytate:zinc and phytate x calcium:zinc dietary molar ratios of lacto-ovo vegetarian Trappist monks: 10 years later. Effects of dietary zinc depletion on seminal volume and zinc loss, serum testosterone concentrations, and sperm morphology in young men. Bioavailability algorithms in setting recommended dietary allow ances: Lessons from iron, applications to zinc. High versus low-meat diets: Effects on zinc absorption, iron status, and calcium, copper, iron, magnesium, manganese, nitrogen, phosphorus, and zinc balance in postmenopausal women. Zinc absorption, mineral balance, and blood lipids in women consuming controlled lactoovovegetarian and omnivo rous diets for 8 weeks. Nutrient intakes and eating behavior scores of vegetarian and nonvegetarian women. Change from mixed diet to lactovegetarian diet: Influence on IgA levels in blood and saliva. Homeostatic control of zinc metabolism in men: Zinc excretion and balance in men fed diets low in zinc. Studies to determine the usefulness of the zinc clearance test to diagnose marginal zinc deficiency and the effects of oral zinc supplementation for short children. Dietary intakes and plasma con centrations of zinc, copper, iron, magnesium, and selenium of young, middle aged, and older men. Zinc status is not adversely affected by folic acid supplementation and zinc intake does not impair folate utilization in human subjects.

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However, presence of fat in the nodule/mass as in our case suggests an alternative diagnosis. The disease occurs in elderly individuals who frequently use oil for constipation. The radiographic features include air space consolidation with spiculation or linear opacities. These changes are the result of interlobular septal thickening caused by infiltration of lipid laden macrophages and chronic inflammation. Cryptogenic organizing pneumonia is characterized pathologically as an organizing pneumonia in the alveoli. Radiographically it can manifest as patchy air space opacities, focal consolidation or multiple nodules. Streptococcus pneumonia can appear as nodule, opacity and or consolidation, however, it will not contain fat within it. Centrilobular nodules occur in the center of the secondary lobules, are usually ground glass in nature and are equidistance from each other. Miliary nodules are usually few mms in size, solid in nature and are randomly distributed in the lungs. Perilymphatic nodules are present in the subpleural location, on the interlobular septa and along the peribronchovascular bundle. You are shown a coronal reformatted image of a 67-year-old woman with collagen vascular disease. Interstitial Lung Diseases Associated with Collagen Vascular Diseases: Radiologic and Histopathologic Findings. Lymphangitic carcinomatosis appears as thickening of the interlobular septa and peribronchovascular bundle, often with a nodular appearance. Pulmonary veno occlusive disease demonstrates enlarged pulmonary arteries and thickening of interlobular septa. Pulmonary edema appears as thickening of the interlobular septa which are present in the provided image and thus is the correct answer. Solitary fibrous tumor Key: D References: Ana Gimenez, Tomas Franquet, Rosa Prats, Pilar Estrada, Jordi Villalba, Silvia Bague. Bronchogenic carcinoma appears as nodule/mass within the lung parenchyma and is often spiculated. Solitary fibrous tumor occurs in the pleural space and appears as a mass with smooth borders and incomplete sign which suggests that the finding is extraparenchymal in nature. Tuberous sclerosis can present as a cystic lung disease and typically involves the lung bases (not seen in this case). The cysts in this case have well-defined walls, unlike lucent lesions caused by destruction of the alveoli in emphysema. Hypersensitivity pneumonitis Key: C References: Semin Chong, Kyung Soo Lee, Myung Jin Chung, Joungho Han, O Jung Kwon, Tae Sung Kim. Pulmonary metastasis is commonly seen diffusely throughout the lungs, not confined to the upper lobes as was the case in this patient. They are found most commonly in the mediastinum, more so in the subcarinal location. Spectrum of Pulmonary Aspergillosis: Histologic, Clinical, and Radiologic Findings. Aspergillomas or Mycetomas or fungus balls is a saprophytic infection which occurs in individuals with a pre-existing cyst or cavity. Common causes of pre-existing cavity include Tuberculosis or Sarcoidosis within which mycetomas may occur. Which of the following structures is a core component of the secondary pulmonary lobule The bronchiole forms the center of the lobule with its accompanying pulmonary artery. The pulmonary vein is located at the peripheral portion of the secondary lobule within the interlobular septum. The interlobular septum is a band of fibrous tissue which surrounds the periphery of the secondary lobule. Per the above guidelines, physicians not board certified in radiology or not trained in a diagnostic radiology residency programs can perform/interpret diagnostic ultrasound if they complete the above mentioned criteria. In addition, physicians performing and/or interpreting diagnostic ultrasound examinations must be eligible for certification in Diagnostic Radiology by the American Board of Radiology and involvement with supervision and/or performance, interpretation and reporting of 300 not 500 ultrasound examinations within the last 36 months. It states Physicians must be board certified in Diagnostic Radiology by the American Board of Radiology or have involvement with the supervision and/or performance, interpretation and reporting of 700 ultrasound examinations within the last 36 months. However, the guidelines state that physician do not have to be board certified in radiology. The referring physician requests it but provides no specific history or other documentation Key: A References. Indications do not include referring physician request without specific history or documentation. Retropulsion of a fracture fragment causing severe spinal canal compromise is a relative contraindication for vertebroplasty. Epidurlal tumor extension with significant encroachment on the spinal canal is a relative contraindication. Autonomy, beneficence, nonmaleficence and justice are considered to be principles of which of the following parameters of medical practice The core principles of medical ethics are autonomy, nonmaleficence, beneficence and justice. The three fundamental principles of professionalism are: primary of patient welfare, patient autonomy and social justice. Anachronism is defined as chronological misplacing of persons, events, objects or customs in regard to each other. The parameter states that timely receipt of the report is more important than the method of delivery. The components of the report and format are describes including: demographics, relevant clinical information, body or report and impression. Therefore, a variety of sizes of coils is necessary to accommodate the needs of all pediatric patients. Adult size coils would not be the correct size for many pediatric patients and thus not meet the needs of the patient population. Coils for small children and adults would not address the needs of patients, who are larger than a small child, but not the size of an adult. The needs of larger children, infants and newborns would not be met by the purchase of coils for small children only. The American College of Radiology practice guideline for skeletal survey in children states: A. The only clinical indications for performing skeletal survey are suspected physical abuse in infants and young children and suspected skeletal dysplasias. The imaging protocol for skeletal survey is always the same, regardless of the indication for the examination. A physician diagnosing suspected child abuse is often legally required to notify local child protection authorities. The interpreting radiologist may be required to do so, if not done by the attending physician/clinician.

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Those soldiers being deployed or redeployed can also learn special coping tactics. Strong Bonds empowers soldiers and their loved ones with relationship-building skills, and connects them to community health and support resources. It is a holistic, preventative program committed to the restoration and preservation of Army families, even those near crisis. Family Caregiver Alliance Family Caregiver Alliance offers a caregiver support group at The Alliance can also be reached at 415-434-3388 or 800-445-8106, or e-mail info@caregiver. National Association of Child Care Resource and Referral Agencies this site will help you cut the cost of child care if you are the spouse of a service member who is severely injured. Transportation Services To learn about paratransit near you, call Project Action which maintains a national paratransit database, at 800-659-6428 or 202-347-3066. National Family Caregivers Support Program the number is 800-896-3650 and the Web site is. This should include new information on his or her condition and its effects on duty performance. Because your service member was found unft, he or she also has the right to a formal hearing. If some members of the board disagree with the majority, they must write a minority opinion. The board will bring your service member and his or her counsel back into the room and disclose its decision. Your service member will have 10 calendar days after the board ends to decide if he or she agrees or disagrees with its fndings. If that requires separation or retirement, then he or she will be separated or retired. Your service member can fnd out more about appeal rights by reviewing the Army Physical Disabilities Evaluation System Handbook, dated March 16, 2007. Your service member can fnd a copy of that handbook by visiting the Web site. If the board fnds your service member ft for duty, he or she will have a chance to agree or disagree with that decision. Your service member can ask the board to reconsider the case based on new information on his or her medical condition and other information the board did not have before. After your service member has answered the questions, he or she will have a chance to make a fnal statement. After discussing the case, the board will tell your service member what it decided. Your service member will have a day to respond if he or she agrees or disagrees with its fndings. For information on the mission of the military medical departments, their leadership, and links to their policies and regulations: Army. The American Red Cross the American Red Cross offers confdential services to all military personnel and their families. Counseling, guidance, information, referrals, and other social services are available through the Red Cross worldwide network of chapters and offces on military installations. To locate a Polytrauma center near you and to learn more about the Polytrauma centers, visit. National Suicide Prevention Lifeline the Preventing Suicide Network has a crisis phone line at 1-800-273-8255. Mental Health Self-Assessment Program this program allows you to take anonymous mental health and alcohol use self-assessments online, via the phone, and through special events held at military installations. Department of Labor Disability Resources the Department of Labor provides a Web site. We have found that through the doctors, through case managers, and through our family and friends who have supported us. There has always been that sense of hope, and even at the bleakest moment, there was always something that you could look back on or look forward to that could give you that hope. I think most caregivers are just amazingly resilient people themselves, and they thrive off the strength of their wounded warrior. The master forms include: contact information for members of the health care team medication log to keep track of medications, dosage, timing, and side effects home care team volunteer form to keep track of those who volunteer to help caregiver support worksheet, to help you list the members of your home care team the people who can help you take care of all the responsibilities you may not have time for. These seizures may last for seconds, or even tens of seconds, with full recovery of consciousness and no confusion. People experiencing absence seizures sometimes move from one location to another without any purpose. Amnesia can be caused by brain injury, shock, fatigue, repression, illness, and sometimes anesthesia. Special x-ray pictures are taken, allowing your health care provider to view the blood vessels of the brain, heart, or other part of the body. This usually happens when blood is unable to fow to the brain due to certain injuries, bleeding, or cardiac arrest.

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All of this may change when a family coping with the shifts in roles: openly express member acquires a serious disability, particu ing feelings and enlisting support. Family members need to your injured family member as simply as assemble a support system of friends and possible. Use straightforward language and relatives that will help relieve the tension that direct, uncomplicated gestures and naturally builds. The only way encouraged to use your intuition, participate to know how they feel is to ask them. This is the the hope is that individuals who have time when he or she will most need your experienced a brain injury or stroke will return support and the help of the team. Be aware compiled the following list of suggestions for that your family member may not seem as you to consider. Patients often deny pany a brain injury or stroke may be more their disabilities and try to influence your difficult to cope with than any physical point of view about them. If your family member behaves your assessments based on the information inappropriately, or in an unfamiliar way, it that you have. Speak in a comforting, positive and the responses may range from turning toward familiar way. The person with a brain injury and his or her family should always be the most important members of the treatment team. There is much that is still unknown about the brain and brain injury reha bilitation. Range of motion, with brain injury were largely provided in a bowel and bladder hygiene. There, he or she will spend several hours a day in a structured rehabilitation program. Often, this treatment can also be often have limited attention and stamina, provided in the home by a home-health and need a less intensive level of rehabilita agency. It is impor providing acute rehabilitation within the tant to note that the services provided by home, or community setting. Sub higher level motor and cognitive skills in acute rehabilitation programs require the order to prepare the person with a brain same appropriately trained professionals as injury to return to independent living and acute rehabilitation programs do. Health insurance can pay for a few days in the hospital but funding needs to be identified for services after discharge. The lines are busiest early kidney failure and disabled people under age in the week and early in the month. Most requests hospitals receive construction funds from the will need to be made in writing and you may federal government. Hospitals that receive have to schedule an appointment to speak to Hill-Burton funds are required by law to the funding source. This checklist is designed to help you evaluate and compare the nursing homes that you visit. It would be a good idea to make several copies of this checklist, so that you will have a new checklist for each home you visit. After you have completed checklists on all the nursing homes you plan on visiting, compare your checklists. Comparisons will be helpful in selecting the nursing homes that might be the best choice for you. Patients may also be response to the internal environment, other placed on antibiotics to help prevent possible than reflexively, to a state of wakefulness but infections. Used in accompanied by anxiety, personality change, reading, driving, and other daily activities. These drugs relax the muscles for greater comfort, to ease therapy, and to prevent spasticity. If you need any further information, you can contact the Division of Services for Aging and Adults with Physical Disabilities at 1-(800) 223-9074. No intracranial intracranial air, is an uncommon complication in head injury bleed was noted. It can present immediately following head trauma clinical symptom of increased intracranial pressure or or be delayed for many days before clinical symptoms occur. There Pneumocephalus, Traumatic brain injury, Basal skull fracture was watery blood stained discharge from the right nostril upon leaning forward or during straining. Small Pneumocephalus, also known as (intra) cranial aerocele may bony defects were seen in the lateral wall of the right exist in a variety of intracranial spaces, depending upon the sphenoid sinus and left anterior cranial fossa. Gas collection can occur in several conservatively with bed rest and laxatives to prevent further compartments: extradural, subdural, subcrachnoid, straining leading to increased intracranial pressure. It may be caused by head trauma, infection, barotrauma following scuba diving and surgery involving the sinuses, orbit, nasal passages or intracranial space1,2. The majority of A 42-year-old man was admitted after he sustained injuries in cases are due to either trauma (75-90%) or surgery. He was under the influence of to 1% of all episodes of head trauma result in alcohol during the accident and had a short duration of loss pneumocephalus. There was no bleeding from the ear or patient with recent head trauma is a sign suggestive of basal nose. Skull and Trauma is the most common cause of epidural air collection cervical radiographs were normal on admission. His condition remained unchanged will reach the subdural space; this occurs in about 28% of for the next nine days. Distinction of subdural showed extensive multifocal air collection in the basal and subarachnoid air can be difficult if the two coexist. This article was accepted: 27 May 2008 Corresponding Author: Sia Sheau Fung, Division og Neurosurgery, Faculty of Medicine, University Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia Email: sfsia02@um.

References:

  • https://www.onlinejacc.org/content/accj/69/11/1465.full.pdf?download=true
  • http://www.acoog.org/web/online/PDF/AN19/Fri/02-Yoder.pdf
  • https://books.google.com/books?id=BlQQDgAAQBAJ&pg=PA332&lpg=PA332&dq=Leigh's+Syndrome+.pdf&source=bl&ots=zPMuMek2sY&sig=ACfU3U2QnSH9fzXRAxOdJLbjr4chY9DAsA&hl=en

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