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The Sieve of Eratosthenes
To generate all prime numbers, i.e. primes, in a given range, the sieve of Eratosthenes is an old,
but nevertheless still the most efficiently known algorithm. It works as follows:
Put into an array all natural numbers up to a given limit size. Set
the first sieve prime = 2. Then cross out all multiples of the current sieve prime. Next,
look for the next larger, not crossed-out number. It will become the new sieve
prime. Repeat this process with the next not crossed out number until all
numbers are worked off. Here this process is illustrated for the odd numbers < 360:
Obviously, crossing out of multiples need to start firstly at the square
of the new chosen sieve prime. So the total effort is about size SUMp
1/p where the sum is taken over all primes less than sqrt(size).
The sum can be estimated rather well to be about ln(ln(size)/2)+0.261497. Hence, for large sieve sizes, the time of the algorithm should be roughly
proportional to the sieve size, because the function ln(ln(x)) increases so slowly.
After seen some "fast" implementations of this algorithm by other people,
I decided to
write my own, really fast and less memory consuming computer program.
There are four main improvement points for
The Art of Prime Sieving
With these tricks in mind (and a lot of optimization), I wrote a C-program
which was the fastest sieve-of-Eratosthenes implementation, I ever became aware of. In May 1998, I have further refined the algorithm with an even denser sieve, resulting in access to fixed bit-positions, and a quicker presieving. These improvements gain at least 15% speed-up over the old version.
To give you a feeling of its speed: it generates all primes
less than 1 milliard in less than 1 minute and all primes up to 2^32 in less
than 3.5 minutes on a 133 MHz Pentium CPU (I used sieve size = 8000 Bytes (processor has 8 KB Data-Cache), smallest primes = 2,3,5 and gcc-2.7.2!).
- Dense bit packing for the crossing-out flags
- To use the memory efficiently, it is necessary to mark the numbers not in
a byte or even a word of the computer, but in a bit only. This must be done
very clever, because bit-access is much more expensive in cpu-time than
byte-access or the CPU-prefered word-access!
- Only presieved numbers in the sieve
- With exception of 2, all other primes are odd, so we need only to store the flags for
the odd numbers in the sieve. But furthermore, only the numbers 6k+1
and 6k+5 can be primes (except 2 and 3). So, we can reduce the total amount
of sieve memory by a factor of 3 storing only the flags for these numbers. If we even exclude all multiples of 5, resulting in a factor of 3.75, we need only 8 flags each 30 numbers. This is
really nice, because 1 byte has 8 bits!
- Don't bother with multiples of the smallest primes
- We know, that the primes, except 2 and 3,
can occur only for those numbers which have modulo 6 a remainder 1 or 5.
So we can avoid to cross out all multiples of 2 and 3, saving a
factor of 3 in sieving speed. What is more, this list of smallest primes can
be extended, e.g. including 5 and 7, and we need only to consider 48 numbers out
of 210, achieving a speed-up factor of even 4.375. Each further small prime p will decrease the run time by a factor 1-1/p, but increase the code of
the program by a factor p-1.
- Choose an appropriate sieve size
- Typically, the sieve should fit into the computers main memory and even
better into its cache in modern high speed computers. Therefore, one can't use
a sieve of the size of the sieve limit, but must use far smaller sieve sizes normally. So, one has to choose an appropriate fixed sieve size and sieve the total
range in many parts sequentially. And hence, the dense bit packing in the sieve
pays very well!
Thanks to Thomas Fiedler, University of Jena, who discovered in May 2003 an important bug (a 1 not a 0 should have been there) when segmentating sieving, I polished the source a bit
and thus you can fetch the latest prime_sieve.c version 2.0c. And here is the corresponding README.
- source code availible
- very fast
- interval sieving possible
- adjustable to CPU cache size
- works up to numbers 264
- user definable macro called for each found prime number
CPU1: HP PA-8000 180MHz with 400 MB RAM (256 KB Data-Cache) running HP-UX 10.20 (sieve size=200KB).
| Limit || Prime Count || CPU1 || CPU2 || CPU3 || CPU4 || CPU5 || CPU6 || CPU7 || CPU8 || CPU9 || Factor|
| 10^2 || 25|| 0.0 s||0.0 s|| 0.00 s||0.0 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s||1.0955|
| 10^3 || 168|| 0.0 s||0.0 s|| 0.00 s||0.0 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s||1.5010|
| 10^4 || 1229|| 0.0 s||0.1 s|| 0.00 s||0.0 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s||1.7887|
| 2^16 || 6542|| 0.0 s||0.1 s|| 0.01 s / 0.01 s||0.0 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s||1.9744|
| 10^5 || 9592|| 0.1 s||0.1 s|| 0.01 s / 0.01 s||0.0 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s|| 0.00 s||2.0118|
| 10^6 || 78498|| 0.1 s||0.2 s|| 0.02 s / 0.03 s||0.1 s|| 0.01 s|| 0.01 s|| 0.01 s/ 0.01 s|| 0.00 s|| 0.00 s||2.1941|
| 10^7 || 664579|| 0.2 s||1.6 s|| 0.14 s / 0.20 s||0.5 s|| 0.13 s|| 0.08 s|| 0.04 s/ 0.04 s|| 0.02 s|| 0.01 s||2.3483|
| 10^8 || 5761455|| 1.2 s||17.0 s|| 1.42 s / 2.02 s||4.9 s|| 1.36 s|| 0.80 s|| 0.36 s/ 0.37 s|| 0.18 s|| 0.11 s||2.4818|
| 10^9 || 50847534|| 11.3 s||187.8 s|| 16.2 s / 21.7 s||51.3 s|| 15.30 s|| 8.84 s|| 3.62 s/ 3.68 s|| 1.55 s|| 1.16 s||2.5996|
| 2^32 || 203280221|| 50.7 s||889.5 s|| 79.6 s / 104.7 s||249.5 s|| 73.85 s|| 43.01 s|| 15.97 s/ 15.98 s|| 7.55 s|| 5.14 s||2.6676|
| 10^10 || 455052511|| 120.4 s|| 268.9 s|| 191.35 s|| 38.49 s|| 16.72 s|| 12.34 s||2.7050|
| 10^11 ||4118054813||1268.6 s|| 4122.7 s|| || 482.77 s|| 214.51 s|| 143.71 s||2.8003|
| 10^12 ||37607912018||15207.7 s|| || 7466.49 s|| 3071.43 s|| 2074.49 s||2.8873|
| 10^13 ||346065536839||249032.9 s|| || 32327.34 s|| 30955.69 s||2.9673|
CPU2: MIPS 3000 33MHz with 32 MB RAM (no Cache) running Ultrix V4.4 (sieve size=15KB).
CPU3: AMD K6 233MHz with 64 MB RAM (32 KB Data-Cache) running Linux 2.032 (sieve size=22KB).
The C-source was compiled using gcc 22.214.171.124 for i486-linux one time for 32bit LONG and the other time for 64 bit LONG. Further, for limit > 2^32 one should
increase the sieve size to get shorter running times.
CPU4: Intel Pentium 133MHz with 64 MB RAM (8KB Data-Cache) running Windows 95 (sieve size=8000B).
Compiler: Visual C++ (max speed)
CPU5: DEC Alpha 21164a 400 MHz with 64 MB RAM (8 KB Data-Cache) running OSF1 V4.0 (sieve size=8000)
CPU6: Intel Pentium III 450 MHz with 128 MB RAM (16 KB Data-Cache) running Linux 2.2.14 using gcc 126.96.36.199 (i386 Linux/ELF) (sieve size=16384).
As you see, it is very important how well the code-optimizer and the caching logic of the cpu does. The sieve size are nearly optimal chosen for limits < 10^10.
CPU7: AMD Thunderbird 900 MHz with 256 MB RAM (64 KB 1st level Data-Cache) running Linux 2.2.19 using gcc 2.95.2 (i386 Linux/ELF) (sieve size=64000/64KB).
CPU8: PowerPC 970FX 2.5 GHz with 1.5 GB RAM running Mac OSX 10.3.8 using
compiler IBM XLF 6.0 Advanced Edition (sieve size=32000 for limit <= 10^11 else
the minimal necessary sieve size).
CPU9: AMD Athlon64 Winchester 2 GHz with 3 GB RAM (64 KB 1st level Data-Cache)
running Linux 2.6.9 using gcc 3.4.2 (x86-64 Linux/ELF) (sieve size=65000).
Factor = ln(1/2 ln(Limit))+0.2615
The average access for each bit in the sieve is PROD(1-1/p) (Factor - SUM1/p) whereby the primes p in the sum and the product runs over the smallest not-bother-primes, --- here 2,3,5, resulting in 8/30(Factor -31/30).
BTW: Because the gaps between successive primes are <= 250 up to p=436273009 and
<= 500 up to 304599508537, to hold a list of primes only their differences
need to be stored in a byte.
For interested persons: the frequency of primes
and a little problem for the mathematicians: estimate the magnitude of
SUMp<=n 1/p - ln(ln(n))-0.2614972128....
Hardy & Wright tell us O(1/ln(n)), but this seems to be too pessimisticly.
For intervals larger about 10^9, surely for those > 10^10, the Sieve of Eratosthenes is outperformed
by the Sieve of Atkins and Bernstein which uses irreducible binary quadratic forms. See their paper for background informations as well as paragraph 5 of W. Galway's Ph.D. thesis.
created: 1998-06-02 17:30 UTC+2
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From Wikipedia, the free encyclopedia
Schematic diagram of the planned rover components.
The Mars Science Laboratory (MSL), known as Curiosity, is a NASA rover scheduled to be launched in October 2011 and would perform the first-ever precision landing on Mars. It is a rover that will assess whether Mars ever was, or is still today, an environment able to support microbial life. In other words, its mission is to determine the planet's habitability. It will also analyze samples scooped up from the soil and drilled powders from rocks.
The MSL rover will be over five times as heavy and carry over ten times the weight in scientific instruments as the Spirit or Opportunity rovers. The United States, Canada, Germany, France, Russia and Spain will provide the instruments on board. The MSL rover will be launched by an Atlas V 541 rocket and will be expected to operate for at least 1 Martian year (668 Martian sols/686 Earth days) as it explores with greater range than any previous Mars rover.
Mars Science Laboratory is part of NASA's Mars Exploration Program, a long-term effort of robotic exploration of Mars, and is a project managed by NASA's Jet Propulsion Laboratory. The total cost of the MSL project is about $2.3 billion USD.
Goals and objectives
The MSL has four goals: To determine if life ever arose on Mars, to characterize the climate of Mars, to characterize the geology of Mars, and to prepare for human exploration. To contribute to the four science goals and meet its specific goal of determining Mars' habitability, Mars Science Laboratory has eight scientific objectives:
- Determine the nature and inventory of organic carbon compounds.
- Inventory the chemical building blocks of life as we know it: carbon, hydrogen, nitrogen, oxygen, phosphorus and sulfur.
- Identify features that may represent the effects of biological processes.
- Investigate the chemical, isotopic, and mineralogical composition of the Martian surface and near-surface geological materials.
- Interpret the processes that have formed and modified rocks and soils.
- Assess long-timescale (i.e., 4-billion-year) Martian atmospheric evolution processes.
- Determine present state, distribution, and cycling of water and carbon dioxide.
- Characterize the broad spectrum of surface radiation, including galactic radiation, cosmic radiation, solar proton events and secondary neutrons.
In September 2006, MSL was approved by NASA for a 2009 launch.
In April 2008, it was reported that the project was $235 million USD, or 24% over budget and that the money to compensate this overrun may have to come from other NASA Mars missions.
In October 2008, MSL was getting closer to a 30% cost overrun.
On November 19, 2008, NASA announced that MSL project leaders at the Jet Propulsion Laboratory (JPL) had reduced the list of candidate landing sites to four: Eberswalde, Gale, Holden, Mawrth.
As of November 2008, development is essentially finished, much of MSL hardware and software are complete and testing is ongoing.
On December 3, 2008, NASA announced that the MSL launch will be delayed until the fall of 2011 because of inadequate test time. The technical and budgetary reasons behind the delay were explained to the Planetary Science Community in a January 2009 meeting at NASA Headquarters.
From March 23–29, 2009, the general public had an opportunity to rank nine finalist names through a public poll on the NASA website as additional input for judges to consider during the MSL name selection process. On May 27, 2009, the winning name of Curiosity, which was submitted by a sixth-grader, Clara Ma, from Kansas was chosen.
The MSL will have a length of 9 feet (2.7 m) and weigh 1,984 pounds (900 kg) including 176 pounds (80 kg) of scientific instruments. It will be the same size as a Mini Cooper automobile. This compares to the Mars Exploration Rovers which have a length of 5 feet 2 inches (1.57 m) and weigh 384 pounds (174 kg) including 15 pounds (6.8 kg) of scientific instruments.
Once on the surface, the MSL rover will be able to roll over obstacles approaching 75 centimeters (30 in) high. Maximum terrain-traverse speed is estimated to be 90 meters (300 ft) per hour via automatic navigation, however, average traverse speeds will likely be about 30 meters (100 ft) per hour, based on variables including power levels, difficulty of the terrain, slippage, and visibility. MSL is expected to traverse a minimum of 12 miles (19 km) in its two-year mission.
The MSL will be powered by radioisotope thermoelectric generators (RTGs), as used by the successful Mars landers Viking 1 and Viking 2 in 1976. Radioisotope power systems are generators that produce electricity from the natural decay of plutonium-238, which is a non-weapons-grade form of that radioisotope used in power systems for NASA spacecraft. Heat given off by the natural decay of this isotope is converted into electricity, providing constant power during all seasons and through the day and night, and waste heat can be used via pipes to warm systems, freeing electrical power for the operation of the vehicle and instruments.
The MSL power source will use the latest RTG generation built by Boeing, called the "Multi-Mission Radioisotope Thermoelectric Generator" (MMRTG). The MMRTG is a flexible and compact power system under development that is based on conventional RTGs. The MMRTG is designed to produce 125 watts of electrical power at the start of the mission and 100 watts after 14 years. The MSL will generate 2.5 kilowatt hours per day compared to the Mars Exploration Rovers which can generate about 0.6 kilowatt hours per day. Although the primary mission is planned to last about 2 Earth years, the MMRTG will have a minimum lifetime of 14 years.
Heat Rejection System
The temperatures in the potential areas that the MSL might land at can vary from +86°F to −197°F (+30 to −127°C). Therefore, the Heat Rejection System (HRS) uses fluid pumped through 200 feet of tubes in the MSL body so that sensitive components are kept at optimal temperatures. Other methods of heating the internal components include using radiated heat generated from the components in the craft itself, as well as excess heat from the MMRTG unit. The HRS also has the ability to cool components if necessary.
The two identical on-board rover computers, called "Rover Electronics Module" (REM), contain radiation hardened memory to tolerate the extreme radiation environment from space and to safeguard against power-off cycles. Each computer's memory includes 256 kB of EEPROM, 256 MB of DRAM, and 2 GB of flash memory. This compares to 3 MB of EEPROM, 128 MB of DRAM, and 256 MB of flash memory used in the Mars Exploration Rovers.
The REM computers use the RAD750 CPU which is a successor to the RAD6000 CPU used in the Mars Exploration Rovers. The RAD750 CPU is capable of up to 400 MIPS while the RAD6000 CPU is capable of up to 35 MIPS.
The rover has an Inertial Measurement Unit (IMU) that provides 3-axis information on its position which is used in rover navigation. The rover's computers are constantly self-monitoring itself to keep the rover operational, such as by regulating the rover's temperature. Activities such as taking pictures, driving, and operating the instruments are performed in a command sequence that is sent from the flight team to the rover. In the event of problems with the main computer, the backup computer will take over.
At present, 10 instruments have been selected for development or production for the Mars Science Laboratory rover:
Cameras (MastCam, MAHLI, MARDI)
The MastCam, MAHLI, and MARDI cameras are being developed by Malin Space Science Systems and they all share common design components, such as on-board electronic imaging processing boxes, 1600x1200 CCDs, and a RGB Bayer pattern filter.
- MastCam: This system will provide multiple spectra and true color imaging with two cameras. The cameras can take true color images at 1200x1200 pixels and up to 10 frames per second hardware-compressed, high-definition video at 720p (1280x720). One camera will be the Medium Angle Camera (MAC) which has a 34 mm focal length, a 15 degree field of view, and can yield 22 cm/pixel scale at 1 km. The other camera will be the Narrow Angle Camera (NAC) which has a 100 mm focal length, a 5.1-degree field of view, and can yield 7.4 cm/pixel scale at 1 km. Each camera will have 8 GB of flash memory, which is capable of storing over 5,500 raw images, and can apply real time lossless or JPEG compression. The cameras have an autofocus capability which allows them to focus on objects from 2.1 meters (6.9 ft) to infinity. Each camera will also have a RGB Bayer pattern filter with 8 filter positions. In comparison to the 1024x1024 black & white panoramic cameras used on the Mars Exploration Rover (MER) the MAC MastCam will have 1.25X higher spatial resolution and the NAC MastCam will have 3.67X higher spatial resolution.
- Mars Hand Lens Imager (MAHLI): This system will consist of a camera mounted to a robotic arm on the rover. It will be used to acquire microscopic images of rock and soil. MAHLI can take true color images at 1600x1200 pixels with a resolution as high as 14.5 micrometers per pixel. MAHLI has a 18.3 mm to 21.3 mm focal length and a 33.8 to 38.5 degree field of view. MAHLI will have both white and UV LED illumination for imaging in darkness or imaging fluorescence. MAHLI will also have mechanical focusing in a range from infinite to mm distances. MAHLI can store either the raw images or do real time lossless predictive or JPEG compression.
- MSL Mars Descent Imager (MARDI): During the descent to the Martian surface, MARDI will take color images at 1600x1200 pixels with a 1.3 millisecond exposure time starting at distances of about 3.7 km to near 5 meters from the ground and will take images at a rate of 5 frames per second for about 2 minutes. MARDI has a pixel scale of 1.5 meters at 2 km to 1.5 millimeters at 2 meters and has a 90 degree circular field of view. MARDI will have 8 GB of internal buffer memory which is capable of storing over 4,000 raw images. MARDI imaging will allow the mapping of surrounding terrain and the location of landing.
ChemCam is a suite of remote sensing instruments, including the first laser-induced breakdown spectroscopy (LIBS) system to be used for planetary science and a remote micro-imager (RMI). The LIBS instrument can target a rock or soil sample from up to 7 meters away, vaporizing a small amount of it and then collecting a spectrum of the light emitted by the vaporized rock. An infrared laser with 1067 nm wavelength and a 5 nanosecond pulse will focus on a sub-millimeter spot with a power in excess of 10 megawatts, depositing 15mJ of energy. Detection of the ball of luminous plasma will be done in the visible and near-UV and near-IR range, between 240 nm and 800 nm. Using the same collection optics, the RMI provides context images of the LIBS analysis spots. The RMI resolves 1 mm objects at 10 m distance, and has a field of view covering 20 cm at that distance. The ChemCam instrument suite is being developed by the Los Alamos National Laboratory and the French CESR laboratory. NASA's cost for ChemCam is approximately $10M, including an overrun of about $1.5M , a very tiny fraction of the total mission costs. The flight model of the Mast Unit was delivered from the French CNES to Los Alamos National Laboratory and was able to deliver the engineering model to JPL in February 2008.
Alpha-particle X-ray spectrometer (APXS)
This device will irradiate samples with alpha particles and map the spectra of X-rays that are reemitted for determining the elemental composition of samples. It is being developed by the Canadian Space Agency. The APXS is a form of PIXE, which has previously been used by the Mars Pathfinder and the Mars Exploration Rovers.
Chemin stands for "Chemistry and Mineralogy" and is a X-Ray Diffraction/X-Ray Fluorescence Instrument. CheMin is a X-ray diffraction/X-ray fluorescence instrument that will quantify minerals and mineral structure of samples. It is being developed by Dr. David Blake at NASA Ames Research Center and the NASA's Jet Propulsion Laboratory.
Sample Analysis at Mars (SAM)
The SAM instrument suite will analyze organics and gases from both atmospheric and solid samples. It is being developed by the NASA Goddard Space Flight Center, the Laboratoire Inter-Universitaire des Systèmes Atmosphériques (LISA) of France's CNRS and Honeybee Robotics, along with many additional external partners. The SAM suite consists of three instruments:
- Quadrupole Mass Spectrometer (QMS)
- Gas Chromatograph (GC)
- Tunable Laser Spectrometer (TLS)
The Quadrupole Mass Spectrometer (QMS) will detect gases sampled from the atmosphere or those released from solid samples by heating. The Gas Chromatograph (GC) will be used to separate out individual gases from a complex mixture into molecular components with a mass range of 2–235 u. The Tunable Laser Spectrometer (TLS) will perform precision measurements of oxygen and carbon isotope ratios in carbon dioxide (CO2) and methane (CH4) in the atmosphere of Mars in order to distinguish between a geochemical and a biological origin.
The SAM also has three subsystems: The Chemical Separation and Processing Laboratory (CSPL), for enrichment and derivatization of the organic molecules of the sample; the Sample Manipulation System (SMS) for transporting powder delivered from the MSL drill to a SAM inlet and into one of 74 sample cups. The SMS then moves the sample to the SAM oven to release gases by heating to up to 1000 oC; and the Wide Range Pumps (WRP) subsystem to purge the QMS, TLS, and the CPSL.
Radiation Assessment Detector (RAD)
This instrument will characterize the broad spectrum of radiation found near the surface of Mars for purposes of determining the viability and shielding needs for human explorers. Funded by the Exploration Systems Mission Directorate at NASA Headquarters and developed by Southwest Research Institute (SwRI) and the extraterrestrial physics group at Christian-Albrechts-Universität zu Kiel, Germany.
Dynamic Albedo of Neutrons (DAN)
A pulsed neutron source and detector for measuring hydrogen or ice and water at or near the Martian surface, provided by the Russian Federal Space Agency.
Rover Environmental Monitoring Station (REMS)
Meteorological package and an ultraviolet sensor provided by the Spanish Ministry of Education and Science. It will be mounted on the camera mast and measure atmospheric pressure, humidity, wind currents and direction, air and ground temperature and ultraviolet radiation levels.
MSL Entry Descent and Landing Instrumentation (MEDLI)
The MEDLI project’s main objective is to measure aerothermal environments, sub-surface heat shield material response, vehicle orientation, and atmospheric density for the atmospheric entry through the sensible atmosphere down to heat shield separation of the Mars Science Laboratory entry vehicle. The MEDLI instrumentation suite will be installed in the heatshield of the MSL entry vehicle. The acquired data will support future Mars missions by providing measured atmospheric data to validate Mars atmosphere models and clarify the design margins on future Mars missions. MEDLI instrumentation consists of three main subsystems: MEDLI Integrated Sensor Plugs (MISP), Mars Entry Atmospheric Data System (MEADS) and the Sensor Support Electronics (SSE).
Hazard Avoidance Cameras (Hazcams)
The MSL will use four pairs of black and white navigation cameras located on the front left and right and rear left and right of the rover. The Hazard Avoidance Cameras (also called Hazcams) are used for autonomous hazard avoidance during rover drives and for safe positioning of the robotic arm on rocks and soils. The cameras will use visible light to capture three-dimensional (3-D) imagery. The cameras have a 120 degree field of view and map the terrain at up to 10 feet (3 meters) in front of the rover. This imagery safeguards against the rover inadvertently crashing into unexpected obstacles, and works in tandem with software that allows the rover to make its own safety choices.
The MSL will use two pairs of black and white navigation cameras mounted on the mast to support ground navigation. The cameras will use visible light to capture three-dimensional (3-D) imagery. The cameras have a 45 degree field of view.
The MSL will be launched using the Atlas V 541 which is a two stage rocket capable of launching up to 17,597 pounds (8,672 kg) to geostationary transfer orbit. The Atlas V has also been used to launch the Mars Reconnaissance Orbiter and New Horizons.
MSL landing diagram for outside Martian atmosphere and for entry.
MSL landing diagram for parachute descent, powered descent, and sky crane.
Landing a large mass on Mars is a difficult challenge: the atmosphere is thick enough to prevent rockets being used to provide significant deceleration, but too thin for parachutes and aerobraking alone to be effective. Although some previous missions have used airbags to cushion the shock of landing, the MSL is too large for this to be an option.
It is planned that the MSL will perform the first-ever precision landing on Mars by demonstrating the ability to land within a predetermined 20 km (12.4 miles) landing ellipse. For this, the MSL will employ a combination of several systems in a precise order, where the entry, descent and landing sequence will break down into four parts.
- Guided entry - The MSL will be set down on the Martian surface using a new high-precision entry, descent, and landing (EDL) system that will place it in a 20 kilometer (12 mile) landing ellipse, in contrast to the 150 kilometer by 20 kilometer (about 93 miles by 12 miles) landing ellipse of the landing systems used by the Mars Exploration Rovers. The rover is folded up within an aeroshell which protects it during the travel through space and during the atmospheric entry at Mars. Much of the reduction of the landing precision error is accomplished by an entry guidance algorithm, similar to that used by the astronauts returning to Earth in the Apollo space program. This guidance uses the lifting force experienced by the aeroshell to "fly out" any detected error in range and thereby arrive at the targeted landing site. In order for the aeroshell to have lift, its center of mass is offset from the axial centerline which results in an off-center trim angle in atmospheric flight, again similar to the Apollo Command Module. This is accomplished by a series of ejectable ballast masses. The lift vector is controlled by four sets of two Reaction Control System (RCS) thrusters that produce approximately 500 N of thrust per pair. This ability to change the pointing of the direction of lift allows the spacecraft to react to the ambient environment, and steer toward the landing zone.
The MSL test parachute. Note the people in the lower-right corner of the image.
- Parachute descent - Like Viking, Mars Pathfinder and the Mars Exploration Rovers, the Mars Science Laboratory will be slowed by a large parachute. After the entry phase is complete and the capsule has slowed to Mach 2, a supersonic parachute is deployed. The entry vehicle must first eject the ballast mass such that the center of gravity offset is removed. In March and April 2009 the parachute for the MSL was tested in the world's largest wind tunnel and passed flight-qualification testing. The parachute has 80 suspension lines, is over 165 feet (50 meters) long, and is about 51 feet (16 meters) in diameter. The parachute is capable of being deployed at Mach 2.2 and can generate up to 65,000 pounds of drag force in the Martian atmosphere.
- Powered descent - Following the parachute braking, the rover and descent stage drop out of the aeroshell. The descent stage is a platform above the rover with variable thrust mono propellant hydrazine rocket thrusters on arms extending around this platform to slow the descent. Meanwhile, the rover itself is being transformed from its stowed flight configuration to a landing configuration while being lowered beneath the descent stage by the "sky crane" system.
- Sky Crane - Like a large crane on Earth, the sky crane system will lower the rover to a "soft landing"–wheels down–on the surface of Mars. This consists of 3 bridles lowering the rover itself and an umbilical cable carrying electrical signals between the descent stage and rover. At roughly 7.5 meters below the descent stage the "sky crane" system slows to a halt and the rover touches down. After the rover touches down it waits 2 seconds to confirm that it is on solid ground and fires several pyros (small explosive devices) activating cable cutters on the bridle and umbilical cords to free itself from the descent stage. The descent stage promptly flies away to a crash landing, and the rover gets ready to roam Mars. The planned "sky crane" powered descent landing system has never been used in actual missions before.
Proposed landing sites
The essential issue when selecting an optimum landing site, is to identify a particular geologic environment, or set of environments, that would support microbial life. To mitigate the risk of disappointment and ensure the greatest chance for science success, interest is placed at the greatest number of possible science objectives at a chosen landing site. Thus, a landing site with morphologic and mineralogic evidence for past water, is better than a site with just one of these criteria. Furthermore, a site with spectra indicating multiple hydrated minerals is preferred; clay minerals and sulfate salts would constitute a rich site. Hematite, other iron oxides, sulfate minerals, silicate minerals, silica, and possibly chloride minerals have all been suggested as possible substrates for fossil preservation. Indeed, all are known to facilitate the preservation of fossil morphologies and molecules on Earth. Difficult terrain is the best candidate for finding evidence of livable conditions, and engineers must be sure the rover can safely reach the site and drive within it.
The current engineering constraints call for a landing site less than 45° from the Martian equator, and less than 1 km above the reference datum. At the first MSL Landing Site workshop, 33 potential landing sites were identified. By the second workshop in late 2007, the list had grown to include almost 50 sites, and by the end of the workshop, the list was reduced to six; in November 2008, project leaders at a third workshop reduced the list to four landing sites.
On August 20, 2009, NASA sent out a call for additional landing site proposals. The new proposals will be evaluated and reviewed until the summer of 2010. A fourth landing site workshop, taking both the new and existing proposals into account, is planned for September 2010. The fifth and final workshop is planned for March 2011.
- ^ a b c "Name NASA's Next Mars Rover". NASA/JPL. 2009-05-27. http://marsrovername.jpl.nasa.gov/. Retrieved 2009-05-27.
- ^ a b "NASA Selects Student's Entry as New Mars Rover Name". NASA/JPL. 2009-05-27. http://www.nasa.gov/mission_pages/msl/msl-20090527.html. Retrieved 2009-05-27.
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- ^ Mars Science Laboratory Mission Profile
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- ^ Mars Science Laboratory: Still Alive, For Now. 10 October 2008. Universe Today.
- ^ http://www.marstoday.com/news/viewpr.rss.html?pid=26970
- ^ MSL Technical and Replan Status. Richard Cook. (January 9, 2009)
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- ^ http://news.bbc.co.uk/1/hi/sci/tech/7664965.stm
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- ^ "Mars Science Laboratory Instrumentation Announcement from Alan Stern and Jim Green, NASA Headquarters". SpaceRef Interactive. http://www.marstoday.com/news/viewsr.html?pid=25991.
- ^ "Mars Descent Imager (MARDI) Update". Malin Space Science Systems. November 12, 2007. http://www.msss.com/msl/mardi/news/12Nov07/index.html.
- ^ a b c d e f g "MSL Science Corner: Chemistry & Camera (ChemCam)". NASA/JPL. http://msl-scicorner.jpl.nasa.gov/Instruments/ChemCam/. Retrieved 2009-09-09.
- ^ Spacecraft: Surface Operations Configuration: Science Instruments: ChemCam
- ^ Salle B., Lacour J. L., Mauchien P., Fichet P., Maurice S., Manhes G. (2006). "Comparative study of different methodologies for quantitative rock analysis by Laser-Induced Breakdown Spectroscopy in a simulated Martian atmosphere" (PDF). Spectrochimica Acta Part B-Atomic Spectroscopy 61 (3): 301–313. doi:10.1016/j.sab.2006.02.003. http://www.lpi.usra.edu/meetings/lpsc2005/pdf/1580.pdf.
- ^ CESR presentation on the LIBS
- ^ ChemCam fact sheet
- ^ Wiens R.C., Maurice S. (2008). "Corrections and Clarifications, News of the Week". Science 322 (5907): 1466. doi:10.1126/science.322.5907.1466a. http://www.sciencemag.org.
- ^ Wiens R.C., Maurice S. (2008). "ChemCam's Cost a Drop in the Mars Bucket". Science 322 (5907): 1464. doi:10.1126/science.322.5907.1464a. http://www.sciencemag.org.
- ^ ChemCam Status April, 2008
- ^ a b c "MSL Science Corner: Alpha Particle X-ray Spectrometer (APXS)". NASA/JPL. http://msl-scicorner.jpl.nasa.gov/Instruments/APXS/. Retrieved 2009-09-09.
- ^ R. Rieder, R. Gellert, J. Brückner, G. Klingelhöfer, G. Dreibus, A. Yen, S. W. Squyres (2003). "The new Athena alpha particle X-ray spectrometer for the Mars Exploration Rovers". J. Geophysical Research 108: 8066. doi:10.1029/2003JE002150.
- ^ a b c "MSL Science Corner: Chemistry & Mineralogy (CheMin)". NASA/JPL. http://msl-scicorner.jpl.nasa.gov/Instruments/CheMin/. Retrieved 2009-09-09.
- ^ Sarrazin P., Blake D., Feldman S., Chipera S., Vaniman D., Bish D. (2005). "Field deployment of a portable X-ray diffraction/X-ray flourescence instrument on Mars analog terrain". Powder Diffraction 20 (2): 128–133. doi:10.1154/1.1913719.
- ^ a b c d e f g "MSL Science Corner: Sample Analysis at Mars (SAM)". NASA/JPL. http://msl-scicorner.jpl.nasa.gov/Instruments/SAM/. Retrieved 2009-09-09.
- ^ Overview of the SAM instrument suite
- ^ Cabane M., Coll P., Szopa C., Israel G., Raulin F., Sternberg R., Mahaffy P., Person A., Rodier C., Navarro-Gonzalez R., Niemann H., Harpold D., Brinckerhoff W. (2004). "Did life exist on Mars? Search for organic and inorganic signatures, one of the goals for "SAM" (sample analysis at Mars)". Source: Mercury, Mars and Saturn Advances in Space Research 33 (12): 2240–2245.
- ^ a b "Sample Analysis at Mars (SAM) Instrument Suite". NASA. October 2008. http://ael.gsfc.nasa.gov/marsSAM.shtml. Retrieved 2008-10-09.
- ^ Tenenbaum, David (June 09, 2008):). "Making Sense of Mars Methane". Astrobiology Magazine. http://www.astrobio.net/news/modules.php?op=modload&name=News&file=article&sid=2765&mode=thread&order=0&thold=0. Retrieved 2008-10-08.
- ^ Tarsitano, C.G. and Webster, C.R. (2007). "Multilaser Herriott cell for planetary tunable laser spectrometers". Applied Optics, 46 (28): 6923–6935. doi:10.1364/AO.46.006923.
- ^ Tom Kennedy and Erik Mumm, Tom Myrick , Seth Frader-Thompson. "OPTIMIZATION OF A MARS SAMPLE MANIPULATION SYSTEM THROUGH CONCENTRATED FUNCTIONALITY" (PDF). http://pdf.aiaa.org/preview/CDReadyMSPACE06_1393/PV2006_7402.pdf.
- ^ a b "MSL Science Corner: Radiation Assessment Detector (RAD)". NASA/JPL. http://msl-scicorner.jpl.nasa.gov/Instruments/RAD/. Retrieved 2009-09-09.
- ^ "MSL Science Corner: Dynamic Albedo of Neutrons (DAN)". NASA/JPL. http://msl-scicorner.jpl.nasa.gov/Instruments/DAN/. Retrieved 2009-09-09.
- ^ a b "MSL Science Corner: Rover Environmental Monitoring Station (REMS)". NASA/JPL. http://msl-scicorner.jpl.nasa.gov/Instruments/REMS/. Retrieved 2009-09-09.
- ^ a b c d Michael Wright (2007-05-01). "Science Overview System Design Review (SDR)". NASA/JPL. http://www.mrc.uidaho.edu/~atkinson/SeniorDesign/ThermEx/MEDLI/MEDLI_SDR_Project_Overview.pdf. Retrieved 2009-09-09.
- ^ a b c d Michael Wright (2007-05-01). "Science Overview System Design Review (SDR)". NASA/JPL. http://www.mrc.uidaho.edu/~atkinson/SeniorDesign/ThermEx/MEDLI/MEDLI_SDR_Science_Overview.pdf. Retrieved 2009-09-09.
- ^ a b c d e "Mars Science Laboratory: Mission: Rover: Eyes and Other Senses: Four Engineering Hazcams (Hazard Avoidance Cameras)". NASA/JPL. http://marsprogram.jpl.nasa.gov/msl/mission/rover/eyesandother/. Retrieved 2009-04-04.
- ^ a b "Mars Science Laboratory Rover in the JPL Mars Yard". NASA/JPL. http://marsprogram.jpl.nasa.gov/msl/multimedia/interactives/photosynth/. Retrieved 2009-05-10.
- ^ a b c "Mars Science Laboratory: Mission: Rover: Eyes and Other Senses: Two Engineering Navcams (Navigation Cameras)". NASA/JPL. http://marsprogram.jpl.nasa.gov/msl/mission/rover/eyesandother/. Retrieved 2009-04-04.
- ^ "Mars Science Laboratory: Mission: Launch Vehicle". NASA/JPL. http://marsprogram.jpl.nasa.gov/msl/mission/launchvehicle/. Retrieved 2009-04-01.
- ^ "The Mars Landing Approach: Getting Large Payloads to the Surface of the Red Planet". Universe Today. http://www.universetoday.com/2007/07/17/the-mars-landing-approach-getting-large-payloads-to-the-surface-of-the-red-planet/. Retrieved 2008-10-21.
- ^ "Mission Timeline: Entry, Descent, and Landing". NASA and JPL. http://marsprogram.jpl.nasa.gov/msl/mission/tl_edl.html. Retrieved 2008-10-07.
- ^ "Mars Science Laboratory Entry, Descent, and Landing Triggers". IEEE. http://ieeexplore.ieee.org/stamp/stamp.jsp?arnumber=04161341. Retrieved 2008-10-21.
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- ^ a b c "Mars Science Laboratory Parachute Qualification Testing". NASA/JPL. http://marsprogram.jpl.nasa.gov/msl/news/index.cfm?FuseAction=ShowNews&NewsID=90. Retrieved 2009-04-15.
- ^ Sky crane concept video
- ^ "Landing — Discussion Points and Science Criteria" (Microsoft Word), MSL — Landing Sites Workshop, July 15, http://marsoweb.nas.nasa.gov/landingsites/msl2009/memoranda/sites_jul08/Discussion%20Points-Science%20Criteria.doc, retrieved 2008-10-21
- ^ "Survivor: Mars — Seven Possible MSL Landing Sites". Jet Propulsion Laboratory (NASA). 18 September 2008. http://mars.jpl.nasa.gov/msl/spotlight/20080918.html. Retrieved 2008-10-21.
- ^ "MSL Workshop Summary" (pdf). 2007-04-27. http://marsoweb.nas.nasa.gov/landingsites/msl/workshops/1st_workshop/docs/MSL_workshop_summary.pdf. Retrieved 2007-05-29.
- ^ "MSL Landing Site Selection User’s Guide to Engineering Constraints" (pdf). 2006-06-12. http://marsoweb.nas.nasa.gov/landingsites/msl/memoranda/MSL_Eng_User_Guide_v3.pdf. Retrieved 2007-05-29.
- ^ "Second MSL Landing Site Workshop". http://marsoweb.nas.nasa.gov/landingsites/msl2009/workshops/2nd_workshop/2nd_announcement.html.
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- ^ GuyMac. "Reconnaissance of MSL Sites". HiBlog. http://hirise.lpl.arizona.edu/HiBlog/?p=131. Retrieved 2008-10-21.
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- ^ http://marsoweb.nas.nasa.gov/landingsites/msl/memoranda/Call_for_new_MSL_Site_8-20-09.doc
- ^ http://mepag.jpl.nasa.gov/calendar/Mars_Explor_Sci_Monthly_Newsltr_12-09.pdf
- ^ "Mars Exploration Program Landing Sites". NASA. http://marsoweb.nas.nasa.gov/landingsites/index.html. Retrieved 2009-04-21.
- ^ "Looking at Landing Sites for the Mars Science Laboratory". YouTube. NASA/JPL. 2009-05-27. http://www.youtube.com/watch?v=sfYK8r6tlrg. Retrieved 2009-05-28.
- ^ "Final 7 Prospective Landing Sites". NASA. February 19, 2009. http://marsoweb.nas.nasa.gov/landingsites/index.html. Retrieved 2009-02-09.
M. K. Lockwood (2006). "Introduction: Mars Science Laboratory: The Next Generation of Mars Landers And The Following 13 articles " (PDF). Journal of Spacecraft and Rockets 43 (2): 257–257. doi:10.2514/1.20678. http://pdf.aiaa.org/jaPreview/JSR/2006/PVJA20678.pdf. | <urn:uuid:7b9d893c-2a1d-4d95-9556-83bc2507ec5c> | {
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Spooky Projects Introduction to Microcontrollers with Arduino Class 321 Oct 2006 - machineproject - Tod E. Kurt
What’s For Today• Controlling Arduino from a computer• Controlling a computer from Arduino• Servomotors• R,G,B LED color mixing
Remove ProtoShield First half of class, we don’t need it And we want to observe the Arduino board“Shields down, cap’n!”
Recap: Programming Edit Compile Reset UploadRemember: always start from a known working system
Communicating with Others • Arduino can use same USB cable for programming and to talk with computers • Talking to other devices uses the “Serial” commands • Serial.begin() – prepare to use serial • Serial.print() – send data to computer • Serial.read() – read data from computerCan talk to not just computers.Most things more complex than simple sensors/actuators speak serial.
Watch the TX/RX LEDS• TX – sending to PC• RX – receiving from PC• Used when programming or communicating (and keep an eye on that pesky pin13 LED too)
Arduino Says “Hi” “serial_hello_world” • Send “Hello world!” to your computer (and blink LED) • Click on “Serial Monitor” to see output • Watch TX LED compared to pin13 LEDThis sketch is located in the handout, but it’s pretty short.Use on-board pin 13 LED, no need to wire anything up.
Telling Arduino What To Do “serial_read_basic” • You type “H” – LED blinks • In “Serial Monitor” type “H”, press Send • Watch pin 13 LEDThis sketch is in “Examples/serial_comm/serial_read_basic”.Notice how you might not always read something, thus the “-1” check.Can modify it to print “hello world” after it receives something, but before it checks for ‘H’.This way you can verify it’s actually receiving something.
Arduino Communications is just serial communications • Psst, Arduino doesn’t really do USB • It really is “serial”, like old RS-232 serial • All microcontrollers can do serial • Not many can do USB • Serial is easy, USB is hard serial terminal from the olde days
Serial Communications • “Serial” because data is broken down into bits, each sent one-by-one on a single wire: ‘H’ = 0 1 0 0 1 0 0 0 = L H L L H L L L = HIGH LOW • Toggle a pin to send data, just like blinking an LED • Only a single data wire is needed to send data. One other to receive.Note, a single data wire. You still need a ground wire.
Arduino & USB-to-serial Arduino board is really two circuits USB to serial Arduino microcontrollerOriginal Arduino boards were RS-232 serial, not USB.
New Arduino Mini Arduino Mini separates the two circuits Arduino Mini USB adapter Arduino Miniaka. “Arduino Stamp”If you don’t talk with a computer, the USB-to-serial functionality is superfluous.
Arduino to Computer Laptop Arduino board TX USB RX Arduino USB to serial USB to serial programmer driver chip Arduino RX TX microcontroller -OR- Processing sketch -OR- Java program -OR- ... USB is totally optional for Arduino But it makes things easierOriginal Arduino boards were RS-232 serial, not USB.
Arduino & USB • Because Arduino is all about serial, • And not USB, • Interfacing to things like USB flash drives, USB hard disks, USB webcams, etc. is not possibleAlso, USB is a host/peripheral protocol. Being a USB “host” means needing a lot of processingpower and software, not something for a tiny 8kB microcontroller.It can be a peripheral. In fact, there is an open project called “AVR-USB” that allows AVR chips likeused in Arduino to be proper USB peripherals. See: http://www.obdev.at/products/avrusb/
Controlling the Computer • Can send sensor data from Arduino to computer with Serial.print() • There are many different variations to suite your needs:
Controlling the Computer You write one program on Arduino, one on the computer In Arduino: read sensor, send data as byte In Processing: read the byte, do something with itBut writing Processing programs is for another time
Controlling the Computer • Receiving program on the computer can be in any language that knows about serial ports • C/C++, Perl, PHP, Java, Max/MSP, Python, Visual Basic, etc. • Pick your favorite one, write some code for Arduino to controlIf interested, I can give details on just about every language above.
Another Example “serial_read_blink” • Type in a number 1-9 and LED blinks that number • Converts number typed into usable numberThis sketch is also in the handout
Pulse Width Modulation• More commonly called “PWM”• Computers can’t output analog voltages • Only digital voltages (0 volts or 5 volts)• But you can fake it • if you average a digital signal flipping between two voltages.• For example...
PWMOutput voltage is averaged from on vs. off time output_voltage = (on_time / off_time) * max_voltage 5 volts 3.75 Volts 0 volts 75% 25% 75% 25% 75% 25% 5 volts 2.5 Volts 0 volts 50% 50% 50% 50% 50% 50% 5 volts 0 volts 1.0 Volts 20% 80% 20% 80% 20% 80%
PWM• Used everywhere • Lamp dimmers, motor speed control, power supplies, noise making• Three characteristics of PWM signals width • Pulse width range (min/max) • Pulse period (= 1/pulses per second) height • Voltage levels (0-5V, for instance) period
Servomotors • Can be positioned from 0-180º • Internal feedback circuitry & gearing takes care of the hard stuff • Easy three-wire PWM 5V interfaceMore specifically, these are R/C hobby servos used by remote control enthusiastsIn general, “servomotor” is a motor with an inherent feedback mechanism that allows you to sendposition commands to it without requiring you to do the position reading.
Servos, good for what? • Roboticists, movie effects people, and puppeteers use them extensively • Any time you need controlled, repeatable motion • Can turn rotation into linear movement with clever mechanical leversEven clothes use servos now: http://www.technologyreview.com/read_article.aspx?id=17639&ch=infotech
Servos • Come in all sizes 9g • from super-tiny • to drive-your-car • But all have the same 3-wire interface 157ghttp://rctoys.com/http://hobbypeople.net/
Servos Ground (0V)180º Power (+5V) Control (PWM)• PWM freq is 50 Hz (i.e. every 20 millisecs)• Pulse width ranges from 1 to 2 millisecs • 1 millisec = full anti-clockwise position • 2 millisec = full clockwise position
Servo Movement 0 degrees 45 degrees 180 degrees high high high low low low 1000 microseconds 1250 microseconds 2000 microseconds • To position, send a pulse train from 1 to 2 ms • To hold a position, pulses must repeat • Takes time to rotate, so pulse too fast & it won’t move1 millisecond = 1000 microsecondSee http://www.societyofrobots.com/actuators_servos.shtml
Servo Movement 0 degrees 90 degrees 180 degrees 1000 microsecs 1500 microsecs 2000 microsecs In practice, pulse range can be 500 to 2500 microsecs (and go ahead and add a wire marker to your servo like the above)Put the red “arm” on your servo. Needs a philips screwdriver.Many commercial servo drivers have a calibration setting to deal with servo variability
Servo and Arduino First, add somejumper wires to the servo connector
Servo and Arduino Plug power lines in, Plug signal to digital pin 7
Moving a Servo Move the servo across its full range of motion “servo_move_simple” • Uses delayMicroseconds() for pulse width • Uses delay() for pulse frequencySketch is in the handoutCreated a custom function to handle making servo pulsesNew function “delayMicroseconds()”. Like “delay()”, but µsec instead of msec.(and actually, just delaying 20 msec is kinda wrong. should be: 20 - (pulsewidth/1000)
Serial-controlled Servo“servo_serial_simple” Drive the servo by pressing number keys Takes the last servo example and adds the last serial example to it.This sketch is located in the handout.Why that for loop? Because it takes time for the servo to get to a position and it has no memory.
Controlling Arduino • Any program on the computer, not just the Arduino software, can control the Arduino board • On Unixes like Mac OS X & Linux, even the command-line can do it: demo% export PORT=/dev/tty.usbserial-A3000Xv0 demo% stty -f $PORT 9600 raw -parenb -parodd cs8 -hupcl -cstopb clocal demo% printf "1" > $PORT # rotate servo left demo% printf "5" > $PORT # go to middle demo% printf "9" > $PORT # rotate servo rightUnix is rad.
Servo Timing Problems • Two problems with the last sketch • When servoPulse() function runs, nothing else can happen • Servo isn’t given periodic pulses to keep it at positionIf a servo is not being constantly told what to do, it goes slack and doesn’t lift/push/pull
Better Serial Servo“servo_serial_better” Works just like servo_serial_simple (but better) Update the servo when needed, not just when called at the right time Uses “millis()” to know what time it isThis sketch is located in the handout.Trades memory use (the extra variables), for more useful logic.Can call updateServo() as often as you want, servo is only moved when needed.
Multiple Servos• The updateServo() technique can be extended to many servos• Only limit really is number of digital output pins you have• It starts getting tricky after about 8 servos though
Arduino PWM why all the software, doesn’t Arduino have PWM? • Arduino has built-in PWM • On pins 9,10,11 • Use analogWrite(pin,value) • It operates at a high, fixed frequency (thus not usable for servos) • But great for LEDs and motors • Uses built-in PWM circuits of the ATmega8 chip -» no software neededThe PWM speed used for analogWrite() is set to 30 kHz currently.When programming AVRs, PWM speed can be set to just about any value.
R,G,B LEDs Three PWM outputs and three primary colors. Just screams to be made, doesn’t it? Arduino 220 (red,red,brown) or board 330 (orange,orange,brown) pin 11 pin 10 pin 9 gnd With RGB you can red green blue make any color (except black)Put back on the ProtoShield for this.Use either the 220 or 330 ohm resistors in your kit, if you don’t have enough of one or the otherI have lots more 220 if you need them
R,G,B LEDsCut leads of resistors and LEDs to make for a more compact circuit.Also, less likely to short against itself.
RGB Color Fading “dimmingLEDs” Slow color fading and mixing Also outputs the current color values to the serial portThis sketch is located in the handout.It just ramps up and down the red,green,& blue color values and writes them with analogWrite()from http://www.arduino.cc/en/Tutorial/DimmingLEDs
Mood Light Diffuser made from piece of plastic scratched with sandpaperAlso, can use plastic wrap scrunched up to make an interesting diffuser.
Serial-controlled RGB “serial_rgb_led” Send color commands to Arduino e.g. “r200”, “g50”, “b0” Sketch parses what you type, changes LEDs g50This sketch is located in the handout.Color command is two parts: colorCode and colorValuecolorCode is a character, ‘r’, ‘g’, or ‘b’.colorValue is a number between 0-255.Sketch shows rudimentary character string processing in Arduino
Reading Serial Strings • New Serial function in last sketch: “Serial.available()” • Can use it to read all available serial data from computer • Great for reading strings of characters • The “readSerialString()” function at right takes a character string and sticks available serial data into itPay no attention to the pointer symbol (“*”)Must be careful about calling readSerialString() too often or you’ll read partial strings
Going Further • R,G,B LEDS • You can pretty easily replicate the Ambient Orb ($150) functionality • Make a status display for your computer • Computer-controlled accent lighting (a wash of color against the walls)Ambient Orb doesn’t connect to computer though. Uses the pager network.Ambient Devices: http://www.ambientdevices.com/
Going Further • Servos • Mount servo on a video camera – computer-controlled camera motion • Make a robot (a little obvious) • Lots of spooky uses • they’re the core of movie animatronicsI’m not too mechanical, so I don’t have many concrete and still working examples of servo use.
Going Further• Serial communications • Not just for computer-to-Arduino communications • Many other devices speak serial • Older keyboards & mice speak are serial (good for sensors!) • Interface boards (graphic LCDs, servo drivers, RFID readers, Ethernet, Wi-Fi)
Serial Examples to Wi-Fi to Ethernet to graphic LCD to 8-servo controllerLantronix Wi-Port and Lantronix Xport http://lantronix.com/Seetron Serial Graphic display and Mini SSC http://www.seetron.com/slcds.htm http://www.seetron.com/ssc.htm
Serial Examples to Roomba“Hacking Roomba”, out in a few weeks, by me. ;-)http://hackingroomba.com/
Next Week• All about piezos• Building a melody player• Using piezos as pressure & knock sensors• Using Processing with Arduino• Stand-alone Arduino
END Class 3http://todbot.com/blog/spookyarduino Tod E. Kurt email@example.com | <urn:uuid:759f492a-66bc-4a39-9b08-ed80282521df> | {
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Get the facts on spinal fusion, instrumentation, and grafts
Editor’s note: This is the second article in a two-part series on spinal surgery coding. In this article, we will focus on fusions, instrumentation, and spinal grafts. In part one, we introduced the basic elements of a spinal surgery and took a closer look at decompression procedures.
A surgeon performs an arthrodesis of lumbar vertebrae L1–L2. What are the appropriate codes to report for this procedure? Would it be CPT® code 22612 (arthrodesis, posterior or posterolateral technique, single level; lumbar) or code 22612 and add-on code 22614 (each additional vertebral segment)?
A surgeon performing an arthrodesis fuses two bones together to stabilize the spinal motion unit. It is not possible to fuse a bone to itself, says Kim Pollock, RN, MBA, CPC, consultant and speaker with Karen Zupko & Associates, Inc., in Chicago. The least a surgeon can do is fuse one segment to another.
Here’s where the disconnect between code descriptions and the terminology surgeons use comes into play. Two vertebrae and the tissues that connect them make up the smallest working unit of the spine. This unit is sometimes referred to as a spinal motion unit. To a spinal surgeon, a segment is two movable units. To a coder, a segment indicates one bone.
So when it comes to choosing the correct CPT code for a spinal fusion, coders almost have to count interspaces instead of vertebrae to choose the correct code, Pollock says. For the case above, report only code 22612.
Take into account the reason for the fusion
When coding a spinal fusion, consider the reason for the procedure. Review the documentation to determine whether the physician performed the fusion for deformity, pain, or instability, says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for The Coding Network based in Beverly Hills, CA.
For a fusion for spinal deformity (e.g., scoliosis or kyphosis), coders should look to codes 22800–22819. This code series was created for, and intended to be used for, fusion procedures performed on younger patients with congenital spinal deformities, not for degenerative scoliosis, says Stumpf.
If the surgeon is performing the fusion for pain or instability, coders should reference one of the following code series:
- 22532–22534 (lateral extracavitary)
- 22548–22585 (anterior or anterolateral)
- 22590–22632 (posterior)
Identify the approach used in the procedure
Surgeons can use various approaches when performing a spinal fusion. Carefully read the documentation to find which approach the surgeon used, then choose the code that reflects that approach. Consider the following approaches:
- Lateral extracavitary (codes 22532–22534)
- Anterior or anterolateral (codes 22558–22585, 22808–22812)
- Posterior or posterolateral or lateral transverse process (codes 22590–22632, 22800– 22804
"Keep in mind that each of these approaches is coded with a different series of codes,” Stumpf says. “You need to understand your approaches. If you don’t, take time to pull them up on the web and see what structures [the surgeon] would be going through, so you can tell exactly what the approach is.” If all else fails, query the physician.
Also note that if the physician documents “direct lateral approach” for spinal fusion, coders should code it as an anterior approach per the North American Spinal Society and the American Association of Neurological Surgeons.
Note the spinal instrumentation
A surgeon may place instrumentation in the spine as part of the fusion procedure. Report the appropriate add-on code based on approach and instrumentation:
- 22840–22844 (posterior instrumentation)
- 22845–22847 (anterior instrumentation)
- 22848 (pelvic fixation)
Surgeons may use a biomechanical device, such as:
- Polyether ether ketone (PEEK) devices (e.g., Mosaic, LDR, GraftCage, Capstone, Zero-P, STALIF, Solitaire)
- HARMS cage
- BAK cage
- Methylmethacrylate (i.e., bone cement)
Report the application of the above listed intervertebral biomechanical device(s) using add-on code 22851. Note that coders should report code 22851 per interspace or vertebral defect, not per device, says Pollock. Append modifier -59 (distinct procedural service) for each code that indicates an additional interspace.
Although polyether ether ketone (PEEK) does not really fit the definition of a biomechanical device, coders should report it using code 22851, Stumpf says. Report all structural allografts using code 20931, so they need to pay careful attention to what the device is made of in order to bill biomechanical devices correctly, says Stumpf.
Consider the type of bone graft
Allograft is bone obtained from a donor—not from the patient (i.e., autograft). An allograft bone contains no living cells. Think of an allograft as bone in a bottle or a package. Coders should report all bone graft codes only once per surgery with, Pollock says.
The bone graft codes include:
- 20930 (allograft or osteopromotive material for spine surgery, morselized)
- 20931 (allograft for spine surgery, structural)
- 20936 (autograft, local)
- 20937 (harvest of graft through separate skin incision, commonly iliac crest)
- 20938 (autograft, structural, bicortical, or tricortical)
Coders should only report each bone graft code performed only once per operative session.
Bear in mind other factors
Once coders locate the fusion, instrumentation, grafts, and decompression if the physician performed it, they need to look for some additional elements.
Look to see whether the surgeon used a microscope for microdissection or microsurgical techniques. But note that some carriers—Medicare and private payers who follow Medicare guidelines—will not pay for the use of a microscope, Stumpf says.
However, other private payers will. So for those cases, follow CPT guidelines for reporting the use of the microscope, which are completely different from the National Correct Coding Initiative (NCCI) edits, she says. CPT guidelines instruct coders to report the microscope use, and CPT lists specific codes with which it should not be reported. However, NCCI edits bundle the microscope into the procedure code.
To report use of the microscope, however, physicians must document that they used it for a microsurgical technique and not just for magnification or illumination, Pollock says.
Also remember that CPT guidelines do not prohibit coders from reporting the use of a microscope for a discectomy or laminectomy, Pollock adds. Coders should report the use of the microscope even when the payer won’t reimburse for it because it is an appropriate CPT combination.
Medicare also sometimes reverses the NCCI edits, Pollock adds. “If you didn’t bill for it originally, you won’t be able to file for a redetermination.”
When the surgeon uses a microscope for microdissection, report CPT add-on code 69990 (use of operating microscope) separately in addition to the code for the primary procedure.
When coding for the microscope used for microdissection or microsurgical techniques, coders need to see documentation of the work involved in bringing the microscope into the field, leaving the field, and during the procedure, Stumpf says. The same holds true for the use of stereotactic navigation. The provider needs to set up, use, and document the use of the instrumentation to support the coding.
E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at email@example.com.
Interested in learning more about spinal coding? Shelley C. Safian, PhD, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA, AHIMA-approved ICD-10-CM/PCS trainer of Safian Communications Services and Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, senior orthopedic coder and auditor for the The Coding Network based in Beverly Hills, CA, discuss ICD-9-CM and CPT coding for spinal procedures during HCPro’s July 28 audio conference, “Spinal ICD-9 and CPT Coding: Get the Complete Picture for Accurate Reimbursement”. To learn more or to purchase, go to the HCMarketplace Web site. | <urn:uuid:8e16b5c9-0d73-418b-b770-720701f08541> | {
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|Classification and external resources|
Oxygen toxicity is a condition resulting from the harmful effects of breathing molecular oxygen (O
2) at elevated partial pressures. It is also known as oxygen toxicity syndrome, oxygen intoxication, and oxygen poisoning. Historically, the central nervous system condition was called the Paul Bert effect, and the pulmonary condition the Lorrain Smith effect, after the researchers who pioneered its discovery and description in the late 19th century. Severe cases can result in cell damage and death, with effects most often seen in the central nervous system, lungs and eyes. Oxygen toxicity is a concern for underwater divers, those on high concentrations of supplemental oxygen (particularly premature babies), and those undergoing hyperbaric oxygen therapy.
The result of breathing elevated partial pressures of oxygen is hyperoxia, an excess of oxygen in body tissues. The body is affected in different ways depending on the type of exposure. Central nervous system toxicity is caused by short exposure to high partial pressures of oxygen at greater than atmospheric pressure. Pulmonary and ocular toxicity result from longer exposure to elevated oxygen levels at normal pressure. Symptoms may include disorientation, breathing problems, and vision changes such as myopia. Prolonged exposure to above-normal oxygen partial pressures, or shorter exposures to very high partial pressures, can cause oxidative damage to cell membranes, the collapse of the alveoli in the lungs, retinal detachment, and seizures. Oxygen toxicity is managed by reducing the exposure to elevated oxygen levels. Studies show that, in the long term, a robust recovery from most types of oxygen toxicity is possible.
Protocols for avoidance of hyperoxia exist in fields where oxygen is breathed at higher-than-normal partial pressures, including underwater diving using compressed breathing gases, hyperbaric medicine, neonatal care and human spaceflight. These protocols have resulted in the increasing rarity of seizures due to oxygen toxicity, with pulmonary and ocular damage being mainly confined to the problems of managing premature infants.
In recent years, oxygen has become available for recreational use in oxygen bars. The US Food and Drug Administration has warned those suffering from problems such as heart or lung disease not to use oxygen bars. Scuba divers use breathing gases containing up to 100% oxygen, and should have specific training in using such gases.
- 1 Classification
- 2 Signs and symptoms
- 3 Causes
- 4 Mechanism
- 5 Diagnosis
- 6 Prevention
- 7 Management
- 8 Prognosis
- 9 Epidemiology
- 10 History
- 11 Society and culture
- 12 See also
- 13 References
- 14 Sources
- 15 Further reading
- 16 External links
- Central nervous system, characterised by convulsions followed by unconsciousness, occurring under hyperbaric conditions;
- Pulmonary (lungs), characterised by difficulty in breathing and pain within the chest, occurring when breathing elevated pressures of oxygen for extended periods;
- Ocular (retinopathic conditions), characterised by alterations to the eyes, occurring when breathing elevated pressures of oxygen for extended periods.
Central nervous system oxygen toxicity can cause seizures, brief periods of rigidity followed by convulsions and unconsciousness, and is of concern to divers who encounter greater than atmospheric pressures. Pulmonary oxygen toxicity results in damage to the lungs, causing pain and difficulty in breathing. Oxidative damage to the eye may lead to myopia or partial detachment of the retina. Pulmonary and ocular damage are most likely to occur when supplemental oxygen is administered as part of a treatment, particularly to newborn infants, but are also a concern during hyperbaric oxygen therapy.
Oxidative damage may occur in any cell in the body but the effects on the three most susceptible organs will be the primary concern. It may also be implicated in red blood cell destruction (haemolysis), damage to liver (hepatic), heart (myocardial), endocrine glands (adrenal, gonads, and thyroid), or kidneys (renal), and general damage to cells.
In unusual circumstances, effects on other tissues may be observed: it is suspected that during spaceflight, high oxygen concentrations may contribute to bone damage. Hyperoxia can also indirectly cause carbon dioxide narcosis in patients with lung ailments such as chronic obstructive pulmonary disease or with central respiratory depression. Hyperventilation of atmospheric air at atmospheric pressures does not cause oxygen toxicity, because sea-level air a has a partial pressure of oxygen (ppO
2) of 0.21 bar (21 kPa) and the lower limit for toxicity is more than 0.3 bar (30 kPa).
Signs and symptoms
|Exposure (mins.)||Num. of Subjects||Symptoms|
|96||1||Prolonged dazzle; severe spasmodic vomiting|
|60–69||3||Severe lip-twitching; Euphoria; Nausea and vertigo; arm twitch|
|50–55||4||Severe lip-twitching; Dazzle; Blubbering of lips; fell asleep; Dazed|
|31–35||4||Nausea, vertigo, lip-twitching; Convulsed|
|21–30||6||Convulsed; Drowsiness; Severe lip-twitching; epigastric aura; twitch L arm; amnesia|
|16–20||8||Convulsed; Vertigo and severe lip twitching; epigastric aura; spasmodic respiration;|
|11–15||4||Inspiratory predominance; lip-twitching and syncope; Nausea and confusion|
|6–10||6||Dazed and lip-twitching; paraesthesiae; vertigo; "Diaphragmatic spasm"; Severe nausea|
Central nervous system
Central nervous system oxygen toxicity manifests as symptoms such as visual changes (especially tunnel vision), ringing in the ears (tinnitus), nausea, twitching (especially of the face), irritability (personality changes, anxiety, confusion, etc.), and dizziness. This may be followed by a tonic–clonic seizure consisting of two phases: intense muscle contraction occurs for several seconds (tonic); followed by rapid spasms of alternate muscle relaxation and contraction producing convulsive jerking (clonic). The seizure ends with a period of unconsciousness (the postictal state). The onset of seizure depends upon the partial pressure of oxygen (ppO
2) in the breathing gas and exposure duration. However, exposure time before onset is unpredictable, as tests have shown a wide variation, both amongst individuals, and in the same individual from day to day. In addition, many external factors, such as underwater immersion, exposure to cold, and exercise will decrease the time to onset of central nervous system symptoms. Decrease of tolerance is closely linked to retention of carbon dioxide. Other factors, such as darkness and caffeine, increase tolerance in test animals, but these effects have not been proven in humans.
Pulmonary toxicity symptoms result from an inflammation that starts in the airways leading to the lungs and then spreads into the lungs (tracheobronchial tree). The symptoms appear in the upper chest region (substernal and carinal regions). This begins as a mild tickle on inhalation and progresses to frequent coughing. If breathing elevated partial pressures of oxygen is not discontinued, patients experience a mild burning on inhalation along with uncontrollable coughing and occasional shortness of breath (dyspnoea). Physical findings related to pulmonary toxicity have included bubbling sounds heard through a stethoscope (bubbling rales), fever, and increased blood flow to the lining of the nose (hyperaemia of the nasal mucosa). The radiological finding from the lungs shows inflammation and swelling (pulmonary oedema). Pulmonary function measurements are reduced, as noted by a reduction in the amount of air that the lungs can hold (vital capacity) and changes in expiratory function and lung elasticity. Tests in animals have indicated a variation in tolerance similar to that found in central nervous system toxicity, as well as significant variations between species. When the exposure to oxygen above 0.5 bar (50 kPa) is intermittent, it permits the lungs to recover and delays the onset of toxicity.
In premature babies, signs of damage to the eye (retinopathy of prematurity, or ROP) are observed via an ophthalmoscope as a demarcation between the vascularised and non-vascularised regions of an infant's retina. The degree of this demarcation is used to designate four stages: (I) the demarcation is a line; (II) the demarcation becomes a ridge; (III) growth of new blood vessels occurs around the ridge; (IV) the retina begins to detach from the inner wall of the eye (choroid).
Oxygen toxicity is caused by exposure to oxygen at partial pressures greater than those to which the body is normally exposed. This occurs in three principal settings: underwater diving, hyperbaric oxygen therapy, and the provision of supplemental oxygen, particularly to premature infants. In each case, the risk factors are markedly different.
Central nervous system toxicity
Exposures, from minutes to a few hours, to partial pressures of oxygen above 1.6 bars (160 kPa)—about eight times the standard atmospheric partial pressure—are usually associated with central nervous system oxygen toxicity and are most likely to occur among patients undergoing hyperbaric oxygen therapy and divers. Since sea level atmospheric pressure is about 1 bar (100 kPa), central nervous system toxicity can only occur under hyperbaric conditions, where ambient pressure is above normal. Divers breathing air at depths greater than 60 m (200 ft) face an increasing risk of an oxygen toxicity "hit" (seizure). Divers breathing a gas mixture enriched with oxygen, such as nitrox, can similarly suffer a seizure at shallower depths, should they descend below the maximum operating depth allowed for the mixture.
The lungs, as well as the remainder of the respiratory tract, are exposed to the highest concentration of oxygen in the human body and are therefore the first organs to show toxicity. Pulmonary toxicity occurs with exposure to partial pressures of oxygen greater than 0.5 bar (50 kPa), corresponding to an oxygen fraction of 50% at normal atmospheric pressure. Signs of pulmonary toxicity begins with evidence of tracheobronchitis, or inflammation of the upper airways, after an asymptomatic period between 4 and 22 hours at greater than 95% oxygen, with some studies suggesting symptoms usually begin after approximately 14 hours at this level of oxygen.
At partial pressures of oxygen of 2 to 3 bar (200 to 300 kPa)—100% oxygen at 2 to 3 times atmospheric pressure—these symptoms may begin as early as 3 hours after exposure to oxygen. Experiments on rats breathing oxygen at pressures between 1 and 3 bars (100 and 300 kPa) show that pulmonary manifestations of oxygen toxicity are not the same for normobaric conditions as they are for hyperbaric conditions. Evidence of decline in lung function as measured by pulmonary function testing can occur as quickly as 24 hours of continuous exposure to 100% oxygen, with evidence of diffuse alveolar damage and the onset of acute respiratory distress syndrome usually occurring after 48 hours on 100% oxygen. Breathing 100% oxygen also eventually leads to collapse of the alveoli (atelectasis), while—at the same partial pressure of oxygen—the presence of significant partial pressures of inert gases, typically nitrogen, will prevent this effect.
Preterm newborns are known to be at higher risk for bronchopulmonary dysplasia with extended exposure to high concentrations of oxygen. Other groups at higher risk for oxygen toxicity are patients on mechanical ventilation with exposure to levels of oxygen greater than 50%, and patients exposed to chemicals that increase risk for oxygen toxicity such the chemotherapeutic agent bleomycin. Therefore, current guidelines for patients on mechanical ventilation in intensive care recommends keeping oxygen concentration less than 60%. Likewise, divers who undergo treatment of decompression sickness are at increased risk of oxygen toxicity as treatment entails exposure to long periods of oxygen breathing under hyperbaric conditions, in addition to any oxygen exposure during the dive.
Prolonged exposure to high inspired fractions of oxygen causes damage to the retina. Damage to the developing eye of infants exposed to high oxygen fraction at normal pressure has a different mechanism and effect from the eye damage experienced by adult divers under hyperbaric conditions. Hyperoxia may be a contributing factor for the disorder called retrolental fibroplasia or retinopathy of prematurity (ROP) in infants. In preterm infants, the retina is often not fully vascularised. Retinopathy of prematurity occurs when the development of the retinal vasculature is arrested and then proceeds abnormally. Associated with the growth of these new vessels is fibrous tissue (scar tissue) that may contract to cause retinal detachment. Supplemental oxygen exposure, while a risk factor, is not the main risk factor for development of this disease. Restricting supplemental oxygen use does not necessarily reduce the rate of retinopathy of prematurity, and may raise the risk of hypoxia-related systemic complications.
Hyperoxic myopia has occurred in closed circuit oxygen rebreather divers with prolonged exposures. It also occurs frequently in those undergoing repeated hyperbaric oxygen therapy. This is due to an increase in the refractive power of the lens, since axial length and keratometry readings do not reveal a corneal or length basis for a myopic shift. It is usually reversible with time.
The biochemical basis for the toxicity of oxygen is the partial reduction of oxygen by one or two electrons to form reactive oxygen species, which are natural by-products of the normal metabolism of oxygen and have important roles in cell signalling. One species produced by the body, the superoxide anion (O
2–), is possibly involved in iron acquisition. Higher than normal concentrations of oxygen lead to increased levels of reactive oxygen species. Oxygen is necessary for cell metabolism, and the blood supplies it to all parts of the body. When oxygen is breathed at high partial pressures, a hyperoxic condition will rapidly spread, with the most vascularised tissues being most vulnerable. During times of environmental stress, levels of reactive oxygen species can increase dramatically, which can damage cell structures and produce oxidative stress.
While all the reaction mechanisms of these species within the body are not yet fully understood, one of the most reactive products of oxidative stress is the hydroxyl radical (·OH), which can initiate a damaging chain reaction of lipid peroxidation in the unsaturated lipids within cell membranes. High concentrations of oxygen also increase the formation of other free radicals, such as nitric oxide, peroxynitrite, and trioxidane, which harm DNA and other biomolecules. Although the body has many antioxidant systems such as glutathione that guard against oxidative stress, these systems are eventually overwhelmed at very high concentrations of free oxygen, and the rate of cell damage exceeds the capacity of the systems that prevent or repair it. Cell damage and cell death then result.
Diagnosis of central nervous system oxygen toxicity in divers prior to seizure is difficult as the symptoms of visual disturbance, ear problems, dizziness, confusion and nausea can be due to many factors common to the underwater environment such as narcosis, congestion and coldness. However, these symptoms may be helpful in diagnosing the first stages of oxygen toxicity in patients undergoing hyperbaric oxygen therapy. In either case, unless there is a prior history of epilepsy or tests indicate hypoglycaemia, a seizure occurring in the setting of breathing oxygen at partial pressures greater than 1.4 bar (140 kPa) suggests a diagnosis of oxygen toxicity.
Diagnosis of bronchopulmonary dysplasia in newborn infants with breathing difficulties is difficult in the first few weeks. However, if the infant's breathing does not improve during this time, blood tests and x-rays may be used to confirm bronchopulmonary dysplasia. In addition, an echocardiogram can help to eliminate other possible causes such as congenital heart defects or pulmonary arterial hypertension.
The diagnosis of retinopathy of prematurity in infants is typically suggested by the clinical setting. Prematurity, low birth weight and a history of oxygen exposure are the principal indicators, while no hereditary factors have been shown to yield a pattern.
The prevention of oxygen toxicity depends entirely on the setting. Both underwater and in space, proper precautions can eliminate the most pernicious effects. Premature infants commonly require supplemental oxygen to treat complications of preterm birth. In this case prevention of bronchopulmonary dysplasia and retinopathy of prematurity must be carried out without compromising a supply of oxygen adequate to preserve the infant's life.
Oxygen toxicity is a catastrophic hazard in diving, because a seizure results in near certain death by drowning. The seizure may occur suddenly and with no warning symptoms. The effects are sudden convulsions and unconsciousness, during which victims can lose their regulator and drown. One of the advantages of a full-face diving mask is prevention of regulator loss in the event of a seizure. As there is an increased risk of central nervous system oxygen toxicity on deep dives, long dives and dives where oxygen-rich breathing gases are used, divers are taught to calculate a maximum operating depth for oxygen-rich breathing gases, and cylinders containing such mixtures must be clearly marked with that depth.
In some diver training courses for these types of diving, divers are taught to plan and monitor what is called the oxygen clock of their dives. This is a notional alarm clock, which ticks more quickly at increased ppO
2 and is set to activate at the maximum single exposure limit recommended in the National Oceanic and Atmospheric Administration Diving Manual. For the following partial pressures of oxygen the limit is: 45 minutes at 1.6 bar (160 kPa), 120 minutes at 1.5 bar (150 kPa), 150 minutes at 1.4 bar (140 kPa), 180 minutes at 1.3 bar (130 kPa) and 210 minutes at 1.2 bar (120 kPa), but is impossible to predict with any reliability whether or when toxicity symptoms will occur. Many nitrox-capable dive computers calculate an oxygen loading and can track it across multiple dives. The aim is to avoid activating the alarm by reducing the ppO
2 of the breathing gas or the length of time breathing gas of higher ppO
2. As the ppO
2 depends on the fraction of oxygen in the breathing gas and the depth of the dive, the diver obtains more time on the oxygen clock by diving at a shallower depth, by breathing a less oxygen-rich gas, or by shortening the duration of exposure to oxygen-rich gases.
Diving below 56 m (184 ft) on air would expose a diver to increasing danger of oxygen toxicity as the partial pressure of oxygen exceeds 1.4 bar (140 kPa), so a gas mixture must be used which contains less than 21% oxygen (a hypoxic mixture). Increasing the proportion of nitrogen is not viable, since it would produce a strongly narcotic mixture. However, helium is not narcotic, and a usable mixture may be blended either by completely replacing nitrogen with helium (the resulting mix is called heliox), or by replacing part of the nitrogen with helium, producing a trimix.
Pulmonary oxygen toxicity is an entirely avoidable event while diving. The limited duration and naturally intermittent nature of most diving makes this a relatively rare (and even then, reversible) complication for divers. Guidelines have been established that allow divers to calculate when they are at risk of pulmonary toxicity.
The presence of a fever or a history of seizure is a relative contraindication to hyperbaric oxygen treatment. The schedules used for treatment of decompression illness allow for periods of breathing air rather than 100% oxygen (oxygen breaks) to reduce the chance of seizure or lung damage. The U.S. Navy uses treatment tables based on periods alternating between 100% oxygen and air. For example, USN table 6 requires 75 minutes (three periods of 20 minutes oxygen/5 minutes air) at an ambient pressure of 2.8 standard atmospheres (280 kPa), equivalent to a depth of 18 metres (60 ft). This is followed by a slow reduction in pressure to 1.9 atm (190 kPa) over 30 minutes on oxygen. The patient then remains at that pressure for a further 150 minutes, consisting of two periods of 15 minutes air/60 minutes oxygen, before the pressure is reduced to atmospheric over 30 minutes on oxygen.
Vitamin E and selenium were proposed and later rejected as a potential method of protection against pulmonary oxygen toxicity. There is however some experimental evidence in rats that vitamin E and selenium aid in preventing in vivo lipid peroxidation and free radical damage, and therefore prevent retinal changes following repetitive hyperbaric oxygen exposures.
Bronchopulmonary dysplasia is reversible in the early stages by use of break periods on lower pressures of oxygen, but it may eventually result in irreversible lung injury if allowed to progress to severe damage. One or two days of exposure without oxygen breaks are needed to cause such damage.
Retinopathy of prematurity is largely preventable by screening. Current guidelines require that all babies of less than 32 weeks gestational age or having a birth weight less than 1.5 kg (3.3 lb) should be screened for retinopathy of prematurity at least every two weeks. The National Cooperative Study in 1954 showed a causal link between supplemental oxygen and retinopathy of prematurity, but subsequent curtailment of supplemental oxygen caused an increase in infant mortality. To balance the risks of hypoxia and retinopathy of prematurity, modern protocols now require monitoring of blood oxygen levels in premature infants receiving oxygen.
In low-pressure environments oxygen toxicity may be avoided since the toxicity is caused by high partial pressure of oxygen, not merely by high oxygen fraction. This is illustrated by modern pure oxygen use in spacesuits, which must operate at low pressure (also historically, very high percentage oxygen and lower than normal atmospheric pressure was used in early spacecraft, for example, the Gemini and Apollo spacecraft). In such applications as extra-vehicular activity, high-fraction oxygen is non-toxic, even at breathing mixture fractions approaching 100%, because the oxygen partial pressure is not allowed to chronically exceed 0.3 bar (4.4 psi).
During hyperbaric oxygen therapy, the patient will usually breathe 100% oxygen from a mask while inside a hyperbaric chamber pressurised with air to about 2.8 bar (280 kPa). Seizures during the therapy are managed by removing the mask from the patient, thereby dropping the partial pressure of oxygen inspired below 0.6 bar (60 kPa).
A seizure underwater requires that the diver be brought to the surface as soon as practicable. Although for many years the recommendation has been not to raise the diver during the seizure itself, owing to the danger of arterial gas embolism (AGE), there is some evidence that the glottis does not fully obstruct the airway. This has led to the current recommendation by the Diving Committee of the Undersea and Hyperbaric Medical Society that a diver should be raised during the seizure's clonic (convulsive) phase if the regulator is not in the diver's mouth – as the danger of drowning is then greater than that of AGE – but the ascent should be delayed until the end of the clonic phase otherwise. Rescuers ensure that their own safety is not compromised during the convulsive phase. They then ensure that where the victim's air supply is established it is maintained, and carry out a controlled buoyant lift. Lifting an unconscious body is taught by most diver training agencies. Upon reaching the surface, emergency services are always contacted as there is a possibility of further complications requiring medical attention. The U.S. Navy has procedures for completing the decompression stops where a recompression chamber is not immediately available.
The occurrence of symptoms of bronchopulmonary dysplasia or acute respiratory distress syndrome is treated by lowering the fraction of oxygen administered, along with a reduction in the periods of exposure and an increase in the break periods where normal air is supplied. Where supplemental oxygen is required for treatment of another disease (particularly in infants), a ventilator may be needed to ensure that the lung tissue remains inflated. Reductions in pressure and exposure will be made progressively, and medications such as bronchodilators and pulmonary surfactants may be used.
Retinopathy of prematurity may regress spontaneously, but should the disease progress beyond a threshold (defined as five contiguous or eight cumulative hours of stage 3 retinopathy of prematurity), both cryosurgery and laser surgery have been shown to reduce the risk of blindness as an outcome. Where the disease has progressed further, techniques such as scleral buckling and vitrectomy surgery may assist in re-attaching the retina.
Although the convulsions caused by central nervous system oxygen toxicity may lead to incidental injury to the victim, it remained uncertain for many years whether damage to the nervous system following the seizure could occur and several studies searched for evidence of such damage. An overview of these studies by Bitterman in 2004 concluded that following removal of breathing gas containing high fractions of oxygen, no long-term neurological damage from the seizure remains.
The majority of infants who have survived following an incidence of bronchopulmonary dysplasia will eventually recover near-normal lung function, since lungs continue to grow during the first 5–7 years and the damage caused by bronchopulmonary dysplasia is to some extent reversible (even in adults). However, they are likely be more susceptible to respiratory infections for the rest of their lives and the severity of later infections is often greater than that in their peers.
Retinopathy of prematurity (ROP) in infants frequently regresses without intervention and eyesight may be normal in later years. Where the disease has progressed to the stages requiring surgery, the outcomes are generally good for the treatment of stage 3 ROP, but are much worse for the later stages. Although surgery is usually successful in restoring the anatomy of the eye, damage to the nervous system by the progression of the disease leads to comparatively poorer results in restoring vision. The presence of other complicating diseases also reduces the likelihood of a favourable outcome.
The incidence of central nervous system toxicity among divers has decreased since the Second World War, as protocols have developed to limit exposure and partial pressure of oxygen inspired. In 1947, Donald recommended limiting the depth allowed for breathing pure oxygen to 7.6 m (25 ft), or a ppO
2 of 1.8 bar (180 kPa). This limit has been reduced, until today a limit of 1.4 bar (140 kPa) during a recreational dive and 1.6 bar (160 kPa) during shallow decompression stops is accepted. Oxygen toxicity has now become a rare occurrence other than when caused by equipment malfunction and human error. Historically, the U.S. Navy has refined its Navy Diving Manual Tables to reduce oxygen toxicity incidents. Between 1995 and 1999, reports showed 405 surface-supported dives using the helium–oxygen tables; of these, oxygen toxicity symptoms were observed on 6 dives (1.5%). As a result, the U.S. Navy in 2000 modified the schedules and conducted field tests of 150 dives, none of which produced symptoms of oxygen toxicity. Revised tables were published in 2001.
The variability in tolerance and other variable factors such as workload have resulted in the U.S. Navy abandoning screening for oxygen tolerance. Of the 6,250 oxygen-tolerance tests performed between 1976 and 1997, only 6 episodes of oxygen toxicity were observed (0.1%).
Central nervous system oxygen toxicity among patients undergoing hyperbaric oxygen therapy is rare, and is influenced by a number of a factors: individual sensitivity and treatment protocol; and probably therapy indication and equipment used. A study by Welslau in 1996 reported 16 incidents out of a population of 107,264 patients (0.015%), while Hampson and Atik in 2003 found a rate of 0.03%. Yildiz, Ay and Qyrdedi, in a summary of 36,500 patient treatments between 1996 and 2003, reported only 3 oxygen toxicity incidents, giving a rate of 0.008%. A later review of over 80,000 patient treatments revealed an even lower rate: 0.0024%. The reduction in incidence may be partly due to use of a mask (rather than a hood) to deliver oxygen.
Bronchopulmonary dysplasia is among the most common complications of prematurely born infants and its incidence has grown as the survival of extremely premature infants has increased. Nevertheless, the severity has decreased as better management of supplemental oxygen has resulted in the disease now being related mainly to factors other than hyperoxia.
In 1997 a summary of studies of neonatal intensive care units in industrialised countries showed that up to 60% of low birth weight babies developed retinopathy of prematurity, which rose to 72% in extremely low birth weight babies, defined as less than 1 kg (2.2 lb) at birth. However, severe outcomes are much less frequent: for very low birth weight babies—those less than 1.5 kg (3.3 lb) at birth—the incidence of blindness was found to be no more than 8%.
Central nervous system toxicity was first described by Paul Bert in 1878. He showed that oxygen was toxic to insects, arachnids, myriapods, molluscs, earthworms, fungi, germinating seeds, birds, and other animals. Central nervous system toxicity may be referred to as the "Paul Bert effect".
Pulmonary oxygen toxicity was first described by J. Lorrain Smith in 1899 when he noted central nervous system toxicity and discovered in experiments in mice and birds that 0.43 bar (43 kPa) had no effect but 0.75 bar (75 kPa) of oxygen was a pulmonary irritant. Pulmonary toxicity may be referred to as the "Lorrain Smith effect". The first recorded human exposure was undertaken in 1910 by Bornstein when two men breathed oxygen at 2.8 bar (280 kPa) for 30 minutes while he went on to 48 minutes with no symptoms. In 1912, Bornstein developed cramps in his hands and legs while breathing oxygen at 2.8 bar (280 kPa) for 51 minutes. Smith then went on to show that intermittent exposure to a breathing gas with less oxygen permitted the lungs to recover and delayed the onset of pulmonary toxicity.
Albert R. Behnke et al. in 1935 were the first to observe visual field contraction (tunnel vision) on dives between 1.0 bar (100 kPa) and 4.1 bar (410 kPa). During World War II, Donald and Yarbrough et al. performed over 2,000 experiments on oxygen toxicity to support the initial use of closed circuit oxygen rebreathers. Naval divers in the early years of oxygen rebreather diving developed a mythology about a monster called "Oxygen Pete", who lurked in the bottom of the Admiralty Experimental Diving Unit "wet pot" (a water-filled hyperbaric chamber) to catch unwary divers. They called having an oxygen toxicity attack "getting a Pete".
In the decade following World War II, Lambertsen et al. made further discoveries on the effects of breathing oxygen under pressure as well as methods of prevention. Their work on intermittent exposures for extension of oxygen tolerance and on a model for prediction of pulmonary oxygen toxicity based on pulmonary function are key documents in the development of standard operating procedures when breathing elevated pressures of oxygen. Lambertsen's work showing the effect of carbon dioxide in decreasing time to onset of central nervous system symptoms has influenced work from current exposure guidelines to future breathing apparatus design.
Retinopathy of prematurity was not observed prior to World War II, but with the availability of supplemental oxygen in the decade following, it rapidly became one of the principal causes of infant blindness in developed countries. By 1960 the use of oxygen had become identified as a risk factor and its administration restricted. The resulting fall in retinopathy of prematurity was accompanied by a rise in infant mortality and hypoxia-related complications. Since then, more sophisticated monitoring and diagnosis have established protocols for oxygen use which aim to balance between hypoxic conditions and problems of retinopathy of prematurity.
Bronchopulmonary dysplasia was first described by Northway in 1967, who outlined the conditions that would lead to the diagnosis. This was later expanded by Bancalari and in 1988 by Shennan, who suggested the need for supplemental oxygen at 36 weeks could predict long-term outcomes. Nevertheless, Palta et al. in 1998 concluded that radiographic evidence was the most accurate predictor of long-term effects.
Bitterman et al. in 1986 and 1995 showed that darkness and caffeine would delay the onset of changes to brain electrical activity in rats. In the years since, research on central nervous system toxicity has centred on methods of prevention and safe extension of tolerance. Sensitivity to central nervous system oxygen toxicity has been shown to be affected by factors such as circadian rhythm, drugs, age, and gender. In 1988, Hamilton et al. wrote procedures for the National Oceanic and Atmospheric Administration to establish oxygen exposure limits for habitat operations. Even today, models for the prediction of pulmonary oxygen toxicity do not explain all the results of exposure to high partial pressures of oxygen.
Society and culture
Recreational scuba divers commonly breathe nitrox containing up to 40% oxygen, while technical divers use pure oxygen or nitrox containing up to 80% oxygen. Divers who breathe oxygen fractions greater than of air (21%) need to be trained in the dangers of oxygen toxicity and how to prevent them. In order to buy nitrox, a diver has to show evidence of such qualification.
Since the late 1990s the recreational use of oxygen has been promoted by oxygen bars, where customers breathe oxygen through a nasal cannula. Claims have been made that this reduces stress, increases energy, and lessens the effects of hangovers and headaches, despite the lack of any scientific evidence to support them. There are also devices on sale that offer "oxygen massage" and "oxygen detoxification" with claims of removing body toxins and reducing body fat. The American Lung Association has stated "there is no evidence that oxygen at the low flow levels used in bars can be dangerous to a normal person's health", but the U.S. Center for Drug Evaluation and Research cautions that people with heart or lung disease need their supplementary oxygen carefully regulated and should not use oxygen bars.
Victorian society had a fascination for the rapidly expanding field of science. In "Dr. Ox's Experiment", a short story written by Jules Verne in 1872, the eponymous doctor uses electrolysis of water to separate oxygen and hydrogen. He then pumps the pure oxygen throughout the town of Quiquendone, causing the normally tranquil inhabitants and their animals to become aggressive and plants to grow rapidly. An explosion of the hydrogen and oxygen in Dr Ox's factory brings his experiment to an end. Verne summarised his story by explaining that the effects of oxygen described in the tale were his own invention. There is also a brief episode of oxygen intoxication in his "From the Earth to the Moon".
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- Hampson Neal, Atik D. (2003). "Central nervous system oxygen toxicity during routine hyperbaric oxygen therapy". Undersea and Hyperbaric Medicine (Undersea and Hyperbaric Medical Society, Inc) 30 (2): 147–53. PMID 12964858. Retrieved 20 October 2008.
- Yildiz, S.; Aktas S; Cimsit M; Ay H; Toğrol E. (2004). "Seizure incidence in 80,000 patient treatments with hyperbaric oxygen". Aviation, Space and Environmental Medicine 75 (11): 992–994. PMID 15559001. Retrieved 1 July 2009.
- Bert, Paul (1943) [First published in French in 1878]. Barometric pressure: Researches in Experimental Physiology. Columbus, OH: College Book Company. Translated by: Hitchcock, Mary Alice; Hitchcock, Fred A.
- British Sub-aqua Club (1985). Sport diving : the British Sub-Aqua Club diving manual. London: Stanley Paul. p. 110. ISBN 0-09-163831-3. OCLC 12807848.
- Behnke, Alfred R.; Johnson, F.S.; Poppen, J.R.; Motley, E.P. (1935). "The effect of oxygen on man at pressures from 1 to 4 atmospheres". American Journal of Physiology 110: 565–572. Note: 1 atmosphere (atm) is 1.013 bars.
- Behnke, Alfred R.; Forbes, H.S.; Motley, E.P. (1935). "Circulatory and visual effects of oxygen at 3 atmospheres pressure". American Journal of Physiology 114: 436–442. Note: 1 atmosphere (atm) is 1.013 bars.
- Donald 1992.
- Taylor, Larry "Harris" (1993). "Oxygen Enriched Air: A New Breathing Mix?". IANTD Journal. Retrieved 29 May 2008.
- Davis, Robert H. (1955). Deep Diving and Submarine Operations (6th ed.). Tolworth, Surbiton, Surrey: Siebe Gorman & Company Ltd. p. 291.
- Lambertsen, Christian J.; Clark, John M.; Gelfand, R. (2000). "The Oxygen research program, University of Pennsylvania: Physiologic interactions of oxygen and carbon dioxide effects and relations to hyperoxic toxicity, therapy, and decompression. Summation: 1940 to 1999". EBSDC-IFEM Report No. 3-1-2000 (Philadelphia, PA: Environmental Biomedical Stress Data Center, Institute for Environmental Medicine, University of Pennsylvania Medical Center).
- Vann, Richard D. (2004). "Lambertsen and O2: Beginnings of operational physiology". Undersea and Hyperbaric Medicine 31 (1): 21–31. PMID 15233157. Retrieved 29 April 2008.
- Lang 2001, pp. 81–6.
- Northway, W.H.; Rosan, R.C.; Porter, D.Y. (1967). "Pulmonary disease following respirator therapy of hyaline-membrane disease. Bronchopulmonary dysplasia". New England Journal of Medicine 276 (7): 357–68. doi:10.1056/NEJM196702162760701. PMID 5334613.
- Shennan, A.T.; Dunn, M.S.; Ohlsson, A.; Lennox, K.; Hoskins, E.M. (1988). "Abnormal pulmonary outcomes in premature infants: prediction from oxygen requirement in the neonatal period". Pediatrics 82 (4): 527–32. PMID 3174313.
- Palta, Mari; Sadek, Mona; Barnet, Jodi H. et al. (January 1998). "Evaluation of criteria for chronic lung disease in surviving very low birth weight infants. Newborn Lung Project". Journal of Pediatrics 132 (1): 57–63. doi:10.1016/S0022-3476(98)70485-8. PMID 9470001.
- Natoli, M.J.; Vann, Richard D. (1996). "Factors Affecting CNS Oxygen Toxicity in Humans". Report to the U.S. Office of Naval Research (Durham, NC: Duke University). Retrieved 29 April 2008.
- Hof, D.G.; Dexter, J.D.; Mengel, C.E. (1971). "Effect of circadian rhythm on CNS oxygen toxicity". Aerospace Medicine 42 (12): 1293–6. PMID 5130131.
- Torley, L.W.; Weiss, H.S. (1975). "Effects of age and magnesium ions on oxygen toxicity in the neonate chicken". Undersea Biomedical Research 2 (3): 223–7. PMID 15622741. Retrieved 20 September 2008.
- Troy, S.S.; Ford, D.H. (1972). "Hormonal protection of rats breathing oxygen at high pressure". Acta Neurologica Scandinavica 48 (2): 231–42. doi:10.1111/j.1600-0404.1972.tb07544.x. PMID 5061633.
- Hart, George B.; Strauss, Michael B. (2007). "Gender differences in human skeletal muscle and subcutaneous tissue gases under ambient and hyperbaric oxygen conditions". Undersea and Hyperbaric Medicine 34 (3): 147–61. PMID 17672171. Retrieved 20 September 2008.
- Shykoff, Barbara E. (2007). "Performance of various models in predicting vital capacity changes caused by breathing high oxygen partial pressures". Nedu-Tr-07-13 (Panama City, FL: U.S. Naval Experimental Diving Unit Technical Report). Retrieved 6 June 2008.
- British Sub-Aqua Club (2006). "The Ocean Diver Nitrox Workshop" (PDF). British Sub-Aqua Club. p. 6. Retrieved 15 September 2010.
- Bren, Linda (November–December 2002). "Oxygen Bars: Is a Breath of Fresh Air Worth It?". FDA Consumer magazine. Retrieved 26 June 2009.
- O2Planet (2006). "O2 Planet – Exercise and Fitness Equipment". O2Planet LLC. Retrieved 21 October 2008.
- Verne, Jules (2004) . A Fantasy of Dr Ox. Hesperus Press. ISBN 978-1-84391-067-1. Retrieved 8 May 2009. Translated from French.
- Verne, Jules (1877) . "VIII" [At seventy-eight thousand one hundred and fourteen leagues]. Autour de la Lune [Round the Moon]. London: Ward Lock. ISBN 2-253-00587-8. Retrieved 2 September 2009. Translated from French.
- Clark, James M.; Thom, Stephen R. (2003). "Oxygen under pressure". In Brubakk, Alf O.; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders. pp. 358–418. ISBN 978-0-7020-2571-6. OCLC 51607923.
- Clark, John M.; Lambertsen, Christian J. (1970). "Pulmonary oxygen tolerance in man and derivation of pulmonary oxygen tolerance curves". IFEM Report No. 1-70 (Philadelphia, PA: Environmental Biomedical Stress Data Center, Institute for Environmental Medicine, University of Pennsylvania Medical Center). Retrieved 29 April 2008.
- Donald, Kenneth W. (1947). "Oxygen Poisoning in Man: Part I". British Medical Journal 1 (4506): 667–672. doi:10.1136/bmj.1.4506.667. PMC 2053251. PMID 20248086.
- Donald, Kenneth W. (1947). "Oxygen Poisoning in Man: Part II". British Medical Journal 1 (4507): 712–717. doi:10.1136/bmj.1.4507.712. PMC 2053400. PMID 20248096.
- Revised version of Donald's articles also available as:
- Donald, Kenneth W. (1992). Oxygen and the diver. UK: Harley Swan, 237 pages. ISBN 1-85421-176-5. OCLC 26894235.
- Hamilton, Robert W.; Thalmann, Edward D. (2003). "Decompression practice". In Brubakk, Alf O.; Neuman, Tom S. Bennett and Elliott's physiology and medicine of diving (5th ed.). United States: Saunders. pp. 475–479. ISBN 978-0-7020-2571-6. OCLC 51607923.
- Lang, Michael A., ed. (2001). DAN nitrox workshop proceedings. Durham, NC: Divers Alert Network, 197 pages. Retrieved 20 September 2008.
- Regillo, Carl D.; Brown, Gary C.; Flynn, Harry W. (1998). Vitreoretinal Disease: The Essentials. New York: Thieme, 693 pages. ISBN 978-0-86577-761-3. OCLC 39170393.
- Lamb, John S. (1999). The Practice of Oxygen Measurement for Divers. Flagstaff: Best Publishing, 120 pages. ISBN 0-941332-68-3. OCLC 44018369.
- Lippmann, John; Bugg, Stan (1993). The Diving Emergency Handbook. Teddington, UK: Underwater World Publications. ISBN 0-946020-18-3. OCLC 52056845.
- Lippmann, John; Mitchell, Simon (2005). "Oxygen". Deeper into Diving (2nd ed.). Victoria, Australia: J.L. Publications. pp. 121–4. ISBN 0-9752290-1-X. OCLC 66524750.
The following external site is a compendium of resources:
- Rubicon Research Repository. – Online collection of the oxygen toxicity research
The following external sites contain resources specific to particular topics:
- 2008 Divers Alert Network Technical Diving Conference. – Video of "Oxygen Toxicity" lecture by Dr. Richard Vann (free download, mp4, 86MB).
- Physiology at MCG 4/4ch7/s4ch7_7. – Wide and detailed discussion of the effects of breathing oxygen on the respiratory system.
- Rajiah, Prabhakar (11 March 2009). "Bronchopulmonary Dysplasia". eMedicine. Retrieved 29 June 2009. – Concise clinical overview with extensive references. | <urn:uuid:a5176acc-bad8-4950-8bee-fb945c56b895> | {
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Includes an equal part of paper and electronically produced documents
Which of the following is not a description of a hybrid health record?
Version control is unnecessary.
Which of the following is not a true statement about a hybrid health record system?
Tasks that need to be performed in a specific sequence
Incorporating a workflow function in an electronic information system would help support:
Use mirrored processing on redundant servers
Which of the following would be the best course of action to take to ensure continuous availability of electronic data?
Electronic document management system
Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
Clinical data repository
Which of the following technologies would be best for a hospital to use to manage data from its laboratory, pharmacy, and radiology information systems?
Which of the following encourages patients to take an active role in collecting and storing their health information?
Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
Ensures that appropriate data are collected
Why does an ideal EHR system include point-of-care template charting?
Electronic document management system
Which of the following is a transition strategy to achieve an EHR?
Pharmacy information system
To ensure that a computerized provider order entry (CPOE) system supports patient safety, what other system must also be in place?
Before contracting for an EHR product
As part of an EHR system selection, due diligence should be done:
Which form of wireless technology uses infrared light waves to beam data between devices in close proximity to one another?
A step-by-step approach to installing, testing, training, and gaining adoption for an EHR is referred to as:
Electronic point-of-care charting
Electronic systems used by nurses and physicians to document assessments and findings are called:
A SNF wanting to collect MDS assessments in a database and transmit them in a standard CMS format would use which of the following data entry software?
Data represent basic facts, while information represents meaning.
What is the difference between data and information?
Structure and content
Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called __________ standards.
Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called:
Laboratory data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards?
Harmonization of standards from multiple sources
Since many private and public standards groups promulgate health informatics standards, the Office of the National Coordinator of Health Information Technology has been given responsibility for:
As a health information professional, you've become involved in developing an HIE in your region. The agency that would provide the best resources for HIE development is:
Which of the following vocabularies is likely to be used to describe drugs in clinically relevant form?
When some computers are used primarily to enter data and others to process data, the architecture is called:
Set of technologies, standards, applications, systems, values, and laws
Which of the following best describes the national health information infrastructure proposed by the National Committee on Vital and Health Statistics?
In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards?
Print out all documents and maintain these as a general practice
In attempting to control the patient safety issues associated with hybrid medical records, which of the following would be the best practice for a healthcare facility to do?
Which of the following describes the step during implementation when data from an old system are able to be incorporated into the new system?
Clinical professionals who provide direct patient care
Who are the primary users of the health record for delivery of healthcare services?
Natural language processing
Which of the following types of electronic data entry applies sophisticated mathematical and probabilistic formulas to narrative text and converts them to structured data?
Use radio buttons to select multiple items from a set of options.
Which of the following is not true of good electronic forms design?
Clinical forms committee
What committee usually oversees the development and approval of new forms for the health record?
Identity matching algorithm
The key for linking data about an individual who is seen in a variety of care settings is:
Patient registration department
The first point of data collection and the area where the health record number is most commonly assigned in an acute care hospital is the:
Serial numbering system
In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare facility?
Incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies and procedures are called:
EHR project manager
Which of the following individuals is responsible for ensuring that the steps in an EHR implementation are performed and coordinated among the various organization teams, committees, and vendor staff?
Which type of health record is designed to measure clinical outcomes, collect data at the point of care, and provide medical alerts?
Which of the following computer architectures uses a single large computer to process data received from terminals into which data are entered?
A transition technology used by many hospitals to increase access to medical record content is:
When a hospital develops its EHR system by selecting one vendor to provide financial and administrative applications and another vendor to supply the clinical applications, this is commonly referred to as a __________ strategy.
Best of breed
When a hospital develops its electronic health record system by selecting multiple vendors to supply all of its applications including financial, administrative, and clinical applications, this is commonly referred to as a strategy.
Social Security number
Which of the following should not be used as a patient identifier in an electronic environment?
Added to the health record after it has been processed by the HIM department
"Loose" reports are health record forms that are:
In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the __________ file.
Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system? 36-45-99 / 37-45-99 / 38-45-99
The MPI is necessary to physically locate health records within the paper-based storage system for all types of filing systems, except:
25 hours per day
The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 600 clinic visits per day. The standard for filing records is 60 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day?
Unit numbering system
In which of the following systems are all encounters or patient visits filed or linked together?
Uneven expansion of file shelves or cabinets
Which of the following is a disadvantage of alphabetic filing?
File the record alphabetically by the last name, followed by alphabetical order of the first name, and then alphabetical order of the middle initial.
Which of the following statements describes alphabetical filing?
Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations?
Which of the following features of the filing folder helps best to locate misfiles within the paper-based filing system?
Transaction processing system
What type of information system would be used for processing patient admissions, employee time cards, and purchase orders?
A healthcare enterprise wants to analyze data from multiple computer systems across the organization to determine trends in patient care services. Which of the following would best consolidate data for this purpose?
A system that manages data for an entire healthcare business is referred to as a(n):
Transmitters, receivers, media, and data
What basic components make up every electronic network communications system?
The first computer systems used in healthcare were used primarily to perform payroll and __________ functions.
Exchange data from any system within the organization
The concept of systems interoperability refers to the healthcare organization's ability to:
Bidding for the contract
The RFP generally includes a detailed description of the system's requirements and provides guidelines for vendors to follow in:
The most common approaches to converting from an old information system to a new one are the parallel approach, the phased approach, and the __________ approach.
Clinical information system
Which of the following systems is designed primarily to support patient care by providing healthcare professionals access to timely, complete, and relevant information for patient care purposes?
Laboratory information system
Which of the following information systems is used for collecting, verifying, and reporting test results?
Clinical decision support system
Which of the following information systems is used to assist healthcare providers in the actual diagnosis and treatment of patients?
Financial information system
Which of the following information systems is considered an administrative information system?
In which phase of the systems development life cycle is the primary focus on examining the current system and problems in order to identify opportunities for improvement or enhancement of the system?
In which phase of the systems development life cycle are trial runs of the new system conducted, backup and disaster recover procedures developed, and training of end users conducted?
Business and strategic issues
What is the main focus of the system planning phase of the systems development life cycle?
A computer station that engages patients in healthcare organization's services
Which of the following best describes the function of kiosks?
A medication being ordered is contraindicated due to a patient allergy. The physician is notified. This is an example of a(n):
Historical data used for strategic decision support
Which of the following best describes a data warehouse?
Which of the following systems supports the creation, organization, and dissemination of business expertise throughout the organization?
Management information system
Which of the following systems would the HIM department director use to receive daily reports on the number of new admissions to, and discharges from, the hospital?
Which of the following is a snapshot in time and consolidates data from multiple sources to enhance decision making?
Which of the following uses artificial intelligence techniques to capture the knowledge of human experts and to translate and store it in a knowledge base?
Which of the following stores data in predefined tables consisting of rows and columns?
Which of the following is a technique for graphically depicting the structure of a computer database?
Which of the following is a fifth-generation programming language that uses human
language to allow users to speak to computers in a more conversational way?
Which of the following connects computers together in a way that allows for the sharing of information and resources?
Which of the following is a network that connects computers in a relatively small area, such as a room or a building?
Allow healthcare providers to readily access information about a patient's healthcare at any point in time
The primary purpose of the Continuity of Care Record (CCR) is to:
In a network environment, a database shared among several end-user workstations would be stored on a:
Which of the following is a type of computer network specifically designed to allow direct communication between the networks of separate companies?
Which of the following enables sharing resources such as printers or disk space across a computer network?
Online medical supply purchasing
Which of the following best describes B2B e-commerce in a healthcare environment?
Application service provider
Companies that deliver, manage, and remotely host systems, such as an EMR or patient registration software via a network through an outsourcing contract are known as a(n):
Which of the following protocols is used to transfer and display information in the form of Web pages on browsers?
Which of the following is a family of standards that aid the exchange of data among hospital systems and physician practices?
Which of the following translate digital data into analog data so that data can be transmitted over telephone lines and received by a remote computer?
The data type should be changed to Character
The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; data type: numeric; field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element?
The coding supervisor wants a daily report of health records that need to be coded. Which of the following systems would be best in meeting the supervisor's needs?
The type of testing of a new electronic information system that ensures that the system can adequately handle a large number of users or transactions is:
A clinic wants to purchase a new healthcare information system. Who is responsible for preparing the RFP to gather information about the functionality of the new system?
'Which of the following are used to associate relationships between entities (tables) in a relational database?
Validation rules for values in a field
In an EMR database, which of the following would be considered an integrity constraint?
Which of the following is a process that identifies patterns and relationships by searching through large amounts of data?
Which of the following types of network topologies has the least chance of failure for bringing down the entire computer network?
Which of the following would be used as an Internet standard for e-mail transmission across Internet protocol (IP) networks?
For at least 5 years
In the absence of state or federal law, AHIMA's retention standards recommend that diagnostic images such as x-rays be maintained:
For at least 10 years after the most recent encounter
In the absence of state or federal law, AHIMA's retention standards recommend that the health records of adults be maintained:
Security awareness program
Which of the following is not an automatic application control that helps preserve data confidentiality and integrity in an electronic system?
Access to information
Within the context of data security, protecting data privacy means defending or safeguarding:
The protection measures and tools for safeguarding information and information systems is a definition of:
The __________ provide(s) the objective and scope for the HIPAA Security rule as a whole.
The covered entity must conduct a risk assessment to determine if the specification is appropriate to its environment.
For HIPAA security implementation specifications that are addressable, which of the following statements is true?
Computer shutdowns caused by intentional or unintentional events
The primary reason that healthcare organizations develop business continuity plans is to minimize the effects of:
Physical access controls
Which of the following are security safeguards that protect equipment, media, and facilities?
Establish a contingency plan
Which of the following must covered entities do in order to comply with HIPAA security provisions?
Data must be encrypted when deemed appropriate from the results of a risk assessment.
Which of the following statements is true regarding HIPAA standards for encryption?
Which of the following are security controls built into a computer software program?
Which of the following are designed to prevent damage caused by computer hackers using the Internet?
Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security?
The mechanisms for safeguarding information and information systems
Which of the following best describes information security?
In the context of data security, which of the following terms means that data should be complete, accurate, and consistent?
Business continuity plan
Which of the following is an organization's planned response to protect its information in the case of a natural disaster?
Once a year
To ensure relevancy, an organization's security policies and procedures be reviewed at least:
Which of the following is a software program that tracks every access to data in the computer system?
Fully digital EHR system
A clinic is evaluating options for an EHR system. The selection committee wants a system that provides simultaneous access to the record by different providers and administrative services employees. It also wants the system to perform various types of data analyses on discrete data. The system must electronically store forms and information so paper storage is completely eliminated. Which of the following would be the best fit for the requirements the committee wants?
Implement a document scanning system for the paper records and interface data created in the current EHR with the document scanning system
A hospital is concerned about the difficulty in retrieving health records for patient care and legal purposes. Some of its data are stored electronically while the remainder are stored on paper. The hospital knows it will be several years before it will be able to implement an entire EHR system and go paperless. Given this information, which of the following would be the best solution for the hospital to ensure that all of the data for a patient are retrieved when needed?
A system whereby documents are scanned by a document imaging system and then integrated and indexed into the existing EHR
Which of the following hybrid models comes closest to a total EHR system?
Shading of bars or lines that contain text
Which of the following should be avoided when designing forms for an EDMS?
24 lb. weight paper for double-sided forms
Which of the following is recommended for design of forms for an EDMS?
Implement session terminations
A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that workstations are not left unattended at home offices?
User name, password, and security question
A home health agency plans to implement a computer system that permits nursing documentation on a laptop computer taken to the patient's home. The agency is in the process of identifying strategies to minimize the risks associated with the practice. With regard to access to data on the laptop, which of the following would be best for securing data?
Ask the security officer for audit trail data to confirm or disprove the suspicion
The HIM supervisor suspects that a departmental employee is using the Internet for personal business but has no specific data to support this suspicion. In this case, what should the supervisor do?
Scan all documents at the time of patient discharge
A HIM department is researching various options for scanning the hospital's health records. The department director would like to achieve efficiencies through scanning such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process?
Document name, media type, source system, electronic storage start date, stop printing start date
Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment?
What component of the departmental budget would include the expense of purchasing new reference books for clinical coding staff?
Which of the following is capable of providing video, audio, computer, and imaging system connectivity for virtual teamwork?
Determination of the quickest solution
Which of the following is not a step in quality improvement decision-making?
Be dedicated to achieving the organizational vision
During times of change, it is important for the supervisor to:
Environmental assessments are performed as part of which of the following processes?
Which of the following is a description of what the organization would like to be in the future?
A summary of the job position, a list of duties, and the qualifications required to perform the job are all elements of a(n):
The organizational structure affects the way its employees interact with each other
One unchanging principle of organizational behavior is that:
On the job training
Which of the following provides direct, realistic training in the specific tasks required by the job position?
Which of the following describes the type of behavior the organization wants to encourage among its employees?
A coding supervisor who makes up the weekly work schedule would engage in what type of planning?
360 degree evaluation
Which of the following would the supervisor and peers contribute to an individual's performance evaluation? | <urn:uuid:4f999077-1ed0-4155-846f-7b1580d427ae> | {
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The Index of Dependence on Government measures the growth in spending on dependence-creating programs that supplant the role of civil society. Dependence on government in the U.S. rose again in 2011, the year of the most recently available data, and which is principally assessed by this report. A solid majority of Americans polled by Rasmussen believe that government dependence is too high. In a September 2013 poll, 67 percent of adults nationwide said that too many Americans are dependent on the government.
Virtually no issue so dominates the current public policy debate as the future financial health of the United States. Americans are haunted by the specter of growing mountains of debt that sap the economic and social vitality of the country. The enormous growth in debt is largely driven by dependence-creating government programs. Only the painfully slow labor market recovery garners more attention, and many are beginning to believe that even that sluggishness is tied to the nation’s growing burden of publicly held debt. Carmen M. Reinhart and Kenneth S. Rogoff of Harvard University created a unique data set of countries’ financial crises covering eight centuries. Reinhart and Rogoff conclude that a unifying problem among the financial crises they analyzed is government debt. They coined the phrase “this-time-is-different syndrome,” that is, the “belief that financial crises are things that happen to other people in other countries at other times; crises do not happen to us, here and now. We are doing things better, we are smarter, we have learned from past mistakes.” This syndrome is often displayed despite indicators of a forthcoming financial crisis being apparent to all. The U.S. federal government has accumulated a debt of staggering proportions. While the Congressional Budget Office (CBO) estimates strongly suggest that the federal government’s spending pattern is unsustainable, Congress has done little to avert a foreseeable financial crisis.
Of course, the roots of the problems produced by the great and growing debt lie in the spending behaviors of the federal government. Annual deficits far greater than the government’s revenue are fueling explosive levels of debt. One such significant area of rapid growth is in those programs that create economic and social dependence on government.
The 2013 publication of the Index of Dependence on Government marks the 11th year that The Heritage Foundation has flashed warning lights about Americans’ growing dependence on government programs. When discussing dependence, one must make a careful distinction between different kinds of dependence. According to Yuval Levin, the editor of National Affairs:
We are all dependent on others. The question is whether we are dependent on people we know, and they on us—in ways that foster family and community, build habits of restraint and dignity, and instill in us responsibility and a sense of obligation—or we are dependent on distant, neutral, universal systems of benefits that help provide for our material wants without connecting us to any local and immediate nexus of care and obligation. It is not dependence per se, which is a universal fact of human life, but dependence without mutual obligation, that corrupts the soul.
This Index is designed to measure the pace at which federal government services and programs have grown in areas once considered to be the responsibility of civil society. Civil society is the space between the individual and the state where individuals, families, communities, neighborhood groups, religious institutions, and other institutions of civil society preside. America is increasingly moving away from a nation of self-reliant individuals, where civil society flourishes, toward a nation of individuals less inclined to practicing self-reliance and personal responsibility. Government programs not only crowd out civil society, but too frequently trap individuals and families in long-term dependence, leaving them incapable of escaping their condition for generations to come. Rebuilding civil society can rescue these individuals from the government dependence trap.
The Index uses data drawn from a carefully selected set of federally funded programs that were chosen for their propensity to duplicate or replace assistance—shelter, food, monetary aid, health care, education, or employment training—that was traditionally provided to people in need by local organizations and families. Thus, government dependence does not include traditional government services that provide public goods, such as defense, police protection, and transportation infrastructure. In contrast to public goods, dependence on government for basic tasks that individuals were traditionally expected to perform themselves, or were provided on a voluntary basis to those in need through the civil society, runs the risk of generating political pressure from interest groups—such as health care organizations, nonprofit organizations, and the aid recipients themselves—to expand and cement federal support. Readers should be aware that the increasing dependence on government is not limited to the lower class. The Social Security and Medicare entitlements, and other programs, such as government-backed higher education loans, provide services to the middle and upper classes.
For more than a decade, the Index has signaled troubling and rapid increases in the growth of dependence-creating federal programs, as measured by the amount of spending devoted to them, and every year Heritage has raised concerns about the challenges that rapidly growing dependence poses to this country’s republican form of government, its economy, and the broader civil society. Index measurements begin in 1962; since then, the Index score has grown by more than 20 times its original amount. This means that, keeping inflation neutral in the calculations, more than 20 times the resources were committed to paying for people who depend on government in 2011 than in 1962. In 2011 alone, the Index of Dependence on Government grew by 3.3 percent. This rise in government dependence occurred despite the modest economic recovery. The Index variables that grew the most from 2010 to 2011 were:
- Education: 40.4 percent
- Retirement: 3.1 percent
The Index has now grown by 80.1 percent since 2001. One of the most worrying trends in the Index is the coinciding growth in the non-taxpaying public. The percentage of the population who do not pay federal income taxes, and who are not claimed as dependents by someone who does pay them, jumped from 15 percent in 1984 to 48.5 percent in 2010. However, the portion of the population who did not pay federal income taxes dropped to 44.7 percent in 2011. The recent decrease is likely due to expiring tax credits that were temporarily authorized by the American Recovery and Reinvestment Act of 2009, and the start of the economic recovery. This means that in 1984, 35.3 million paid no taxes; in 2011, 139.3 million paid nothing.
It is the conjunction of these two trends—higher spending on dependence-creating programs, and a long-term trend in an increased portion of the population who do not pay for these programs—that concerns those interested in the fate of the American form of government. Americans have always expressed concern about becoming dependent on government, even while understanding that life’s challenges cause most people, at one time or another, to depend on some form of aid from someone else. Americans’ concern stems partly from deeply held views that life’s blessings are more readily obtained by independent people, and that growing dependence on government erodes the spirit of personal and mutual responsibility created through family and civil society institutions. These views help explain the broad public support for welfare reform in the 1990s.
This ethic of self-reliance combined with a commitment to the brotherly care of those in need appears threatened in a much greater way today than when the Index first appeared in 2002. This year, 2013, marks another year that the Index contains significant retirements by baby boomers. By 2040, 93.8 million people will be collecting Social Security checks and drawing Medicare benefits. Many retirees will also be relying on long-term care in assisted living facilities or home health care providers under Medicaid. No event will financially challenge these programs over the next two decades more than this shift into retirement of the largest generation in American history.
Some may argue that any measure of government dependence should not cover Social Security, because beneficiaries previously paid payroll taxes into the program before receiving benefits. However, the Index is designed to measure the amount of federal spending on programs that assume the responsibilities of individuals, families, communities, neighborhood groups, religious institutions, and other civil society institutions. Clearly, Social Security has greatly encroached on the responsibility of individuals for providing their own retirement resources.
It is not only financial tests that these programs will face. Certainly, financial challenges will be great over the next several decades, given that none of these “entitlement” programs can easily meet its obligations even now. Doubling the number of people in retirement will constitute a massive growth of the U.S. population that is largely dependent on government programs, and a potentially ruinous drain on federal finances. Even accounting for the increased productivity of current and future workers, the rapid increase in retirees coincides with historically fewer workers supporting those in retirement. Perhaps the most important aspect of the boomer retirement is its dramatic reminder of the rapidly growing dependence on government in the United States.
While the major contributors to the nation’s debt crisis are health and income support entitlement programs, such as Medicare and Social Security, Congress spends hundreds of billions of dollars on discretionary social programs each year. These social programs are intended to address a whole host of social problems, including low academic skills, poverty, sex outside marriage, out-of-wedlock births, unemployability and low wages, bad parenting, and relationship troubles within and outside marriage. Things that once were the subject of personal responsibility are now under the federal government’s jurisdiction. When rigorously evaluated, federal social programs have been found to be overwhelmingly ineffective.
There has been such a rapid growth in dependence in recent years that the twin concerns—how much damage this growth has done to the republican form of government and how harmful it has been to the country’s financial situation—have deepened significantly. Not only has the federal government effectively taken over half of the U.S. economy and expanded public-sector debt by more than all previous governments combined, it also oversaw a third year, in 2011, of enormous expansion in total government debt at the federal level. Much of that growth in new debt can be traced to programs that encourage dependence. Chart 2 illustrates how 69.4 percent of federal spending now goes to dependence-creating programs, up dramatically from 21.2 percent in 1962 and 48.5 percent in 1990.
Many Americans are expressing increasing frustration at this fiscally grim state of affairs. Most Members of recent Congresses have known that the major entitlement programs not only need major repairs, but also that these programs are starting to drive up annual deficits and promise to produce substantial deficits in the near future. Many Americans are especially frustrated by the way Congress ignores or, at best, claims to support, comprehensive budget reform plans. Plans like The Heritage Foundation’s Saving the American Dream and Representative Paul Ryan’s (R–WI) “Roadmap,” offer blueprints for getting federal finances under control, but Congress has not seriously debated these or any other such plans.
This absence of genuine efforts by Congress to manage the federal government’s worsening financial crisis is now worrying a number of international financial organizations, including the International Monetary Fund (IMF). On May 14, 2010, the IMF ranked the U.S. in second place among countries that must reduce their structural deficit (caused in part by spending on dependence-creating programs) or risk financial calamity. The IMF predicted that U.S. public-sector debt would equal 100 percent of its gross domestic product (GDP) by 2015 unless immediate actions were taken to cut the deficits by an amount equal to 12 percent of GDP by 2014. The IMF concluded that Greece needed to cut its deficits by 9 percent of its national output to avoid the risk of financial calamity.
Then, on August 5, 2011, the credit rating company Standard & Poor’s downgraded U.S. sovereign debt from its AAA rating to AA+. This dramatic and highly controversial assessment of the federal government’s financial health followed Moody’s Investors Service’s announcement three days earlier that the prospects for the fiscal health of the central government had turned “negative.” Not to be outdone, on November 28, the third big ratings agency, Fitch, also revised its outlook on U.S. credit from “stable” to “negative” (meaning there was a slightly greater than 50 percent chance that Fitch would downgrade U.S. credit from AAA over the next two years). On February 27, 2013, Fitch again warned that a downgrade could be imminent, stating:
During the course of this year Fitch expects to resolve the Negative Outlook placed on the sovereign ratings of the US in late 2011 after the failure of the Congressional Joint Select Committee on Deficit Reduction. In Fitch’s opinion, further delay in reaching agreement on a credible medium-term deficit reduction plan would imply public debt reaching levels inconsistent with the US retaining its “AAA” status despite its exceptional credit strengths.
The IMF, the rating agencies, and many watchful citizens are right to be concerned about the growing debt and growing dependence. Programs that encourage dependence quickly morph into political assets that policymakers readily embrace. Many voters support politicians or political parties that mandate higher incomes or subsidies for the essentials of life. No matter how well meaning policymakers are when they create such aid programs, these same programs quickly spiral beyond their mission and become severe liabilities.
Many countries have already passed the fiscal tipping point, at which reckless growth in dependence programs produces domestic debt crises. How far along the path to crisis is the United States? Are Americans closing in on a tipping point that endangers the workings of their democracy? Or have Americans already passed that point? Can this republican form of government withstand the political weight of a massively growing population of Americans who receive government benefits and who contribute little or nothing for them? How seriously have these federal programs eroded civil society by eroding once-social obligations, and by crowding out services that used to be provided by families, congregations, and community groups?
To explore these questions, one must measure how much federal programs have grown. The Index of Dependence on Government is an attempt to measure these patterns and provide data to help ascertain the implications of these trends. Specifically, the Index measures the amount of spending on federal programs that perform functions once primarily provided by civil society. Table 1 contains the 2013 Index scores—from 1962 to 2011, with 1980 as the base year. As the table indicates, dependence on government has grown steadily at an alarming rate.
Despite the prevailing view that people were left on their own to solve their problems before the creation of the welfare state, there is a rich history of Americans providing voluntary mutual aid before and during the Progressive Era. Assistance was often provided by private charity, mutual aid societies, and state and local governments.
For example, a considerable share of the Masonic mutual aid involved employment-seeking assistance, short-term housing, and character references. Other organizations, such as the Ancient Order of United Workmen, offered life insurance to members. While the exact numbers are unknown, University of Alabama professor of history David T. Beito estimates that fraternal life insurance societies in 1910 had at least 13 million members. These fraternal societies were characterized by “an autonomous system of lodges, a democratic form of internal government, a ritual, and the provision of mutual aid for members and their families.”
However, the rise of the welfare state, especially during the New Deal and Great Society, assumed much of the social responsibility that was once the province of voluntary associations. In essence, the welfare state “crowded out” or diminished the role of private charities and voluntary associations in benefiting members of society. The year after the Social Security Act of 1935 saw the beginning of benefit retrenchment by fraternal societies and their eventual decline. The decline in mutual aid societies and the growth of federal domestic programs are likely the direct results of the growth of the welfare state.
Complementary research to the Index indicates that federal dependence-creating programs crowd out assistance from civil society institutions, even replacing aid that used to come from family members. While the social science literature on crowd-out has found mixed results, the preponderance of the literature finds at least small crowd-out effects.
Theoretically, crowd-out can occur in two ways. First, charitable donors will treat the taxes they pay to provide government-run welfare services as a substitute for donations to private charities. In other words, the taxes paid to finance welfare programs make individuals less likely to make private donations, because they are already paying for assistance programs. This result has been coined the classic crowd-out effect. Second, private charities will substitute government grants for private donations.
An analysis of the impact of the New Deal on religious charitable activity confirms the presence of the classic crowd-out effect. Based on data from church activity from 1929 to 1939 for six of the largest Christian denominations (representing more than 20 percent of churches) during this period, the authors found “strong evidence that the rise in New Deal spending led to a fall in church charitable activity.” Specifically, the “New Deal crowded out at least 30% of benevolent church spending.”
A more current example of the welfare state crowding out voluntary assistance is the impact that unemployment insurance (UI) has on familial assistance. Familial assistance takes the form of family members helping relatives in times of need. For example, a recently unemployed son may receive financial assistance from his parents to help him get through a difficult period. A study using data from the Panel Study in Income Dynamics (PSID) found a negative association between the receipt of UI benefits and familial support. Specifically, one dollar in UI benefits displaces familial support by $0.24 to $0.40.
Additional studies have found classic crowd-out effects of government welfare spending. A national study that covered 1975 to 1994 found that a 10 percent increase in government aid to the poor is associated with a 5.87 percent decrease in private charitable donations. A similar study covering 1965 to 2003 also found that government welfare spending has a negative association with charitable giving.
Researcher Ralph M. Kramer finds that individual giving as a proportion of personal income fell by 13 percent between 1960 and 1976, while the proportion of philanthropic giving devoted to social welfare dropped 15 percent to 6 percent. By 1974, government was spending about 10 times as much on social services as did nonprofit agencies, and that year the nonprofit agencies themselves received close to half ($23 billion) of their total revenues from government (receiving $25 billion from all other sources combined). Such data also raise traditional concern about the long-term viability of the political institutions in a republic when a significant portion of the population becomes dependent on government for most or all of its income.
Alternatively, when government welfare services contract, charitable giving may increase. This proposition was tested when the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 cut federally funded welfare services to noncitizens. A nationwide analysis of Presbyterian Church congregations from 1994 to 2000 suggests that the reduction in federal welfare services to noncitizens was associated with an increase in charitable giving. Specifically, a one dollar decrease in county-wide per capita welfare spending was associated with an increase of $0.40 in the church congregation’s per-member donations to local community projects.
There is also evidence to support the second type of crowd-out effect of private charities and nonprofits substituting government grants for private donations. A study of more than 8,000 tax returns from American charities found a crowd-out effect of about 76 percent. For example, a government grant of $1,000 to a charity was associated with a decrease in $760 in private donations raised by the charity. However, the study found that most of this decline in private donations is the result of reduced private fundraising efforts by government-funded charities.
This second type of crowd-out increases the influence of government, for better or worse, over government-funded charities. The acceptance of government funding by private charities may cause these entities to become dependent on future government funding. Further, government funding opens charities to government mandates that may run counter to the mission of charities. To avoid such mandates, for example, Catholic Charities in Illinois has closed most of its affiliates in the state rather than comply with a state law requiring it consider same-sex couples as potential foster-care and adoptive parents, contrary to the tenets of its faith, in order to continue receiving state money.
The Fiscal Calamities Created by Growing Dependence
Entitlements. The issue of dependence is particularly salient today, when more and more Americans are increasing their reliance on government as they pass into retirement. Some may argue that any measure of government dependence should not include Social Security, because beneficiaries paid payroll taxes into the program before they received benefits. However, the Index is designed to measure spending on federal government programs that have assumed the responsibilities of individuals, families, communities, neighborhood groups, religious institutions, and other civil society institutions. Workers rationally view Social Security taxes as a substitute for private savings. Clearly, Social Security has greatly encroached on the responsibility of individuals for providing their own retirement funds, thus leaving millions of retirees dependent on younger, working generations to fund their retirement.
Current retirees become eligible for Social Security income, as well as for health care benefits from Medicare or Medicaid, at age 65.Each day, 10,000 baby boomers begin to collect these benefits. The three programs, along with the Children’s Health Insurance Program, currently make up 44 percent of all non-interest federal program spending. At the current growth rate, they will make up 57 percent in 2022. By 2048, Social Security, Medicare, and Medicaid will absorb the entire tax revenue of the United States. Any additional spending would have to be borrowed. All told, these programs will enable the government dependence of nearly 80 million baby boomers.
This phenomenon is particularly troubling because most of the soon-to-be users of these programs are middle-class to upper-class Americans who are less likely to need government support. Since eligibility for these programs is linked to age, not financial need, millionaires collect the same benefits, such as subsidized prescription drugs through Medicare Part D, as do low-income and struggling retirees.
Paying for these middle-class and upper-class entitlements in the coming years will require unprecedented levels of deficit spending. Focusing on Social Security and Medicare alone, Americans face $45.9 trillion in unfunded obligations (read: new borrowing) over the next 75 years. That was more than $160,000 per American citizen in 2010—an unsustainable level of debt that is sure to slow the economy and could force even higher rates of taxation in the future. The high costs of these programs, which will be shouldered by the children and grandchildren of baby boomers, could easily lead to further increases in dependence of future generations—which would be more likely to depend on welfare during a slow economy. This snowballing of dependence—caused by automatic reliance on Social Security, Medicare, and Medicaid—could easily send the country past the tipping point of endurable dependence, eroding civil society and endangering the functioning of democracy itself as citizens become dependent on government, instead of the other way around.
Additionally, the growing cost illustrates the budgetary problem of allowing dependence to expand unchecked. One reason this growth will be so significant is that these programs increase on autopilot, which further perpetuates dependence, since these programs are not subject to regular debate and evaluation. Unlike nearly all other federal outlays, Social Security, Medicare, and Medicaid are mandatory spending programs that operate outside the annual budget process. This exemption entitles these programs to call on all federal revenues first, regardless of other budgetary priorities. Substantive policy reform is required if this automatic dependence is to be halted. Part of the solution is to turn these programs into 30-year budgeted programs, subjecting the budgets to debate at least every five years.
Other policy reforms—that emphasize independence and self-reliance—must also be part of addressing the problems inherent in these and other programs. The concept of a safety net ought to be restored to gear Social Security, Medicare, and Medicaid toward those who truly need these programs. This restoration can be accomplished by relating benefits to retirees’ income and encouraging personal savings during working years.
Even though many Members of Congress and other policymakers show great hesitance in reforming these badly broken programs, good reforms that preserve the basic commitments this country has made to its retired and indigent populations do exist. The Heritage Foundation’s Saving the American Dream plan strengthens the anti-poverty elements of these mandatory programs while protecting them from financial ruin. Doing nothing guarantees that seniors one day will find themselves largely without the benefits that currently play such an important part of their retirement plans.
Growth in the Non-Taxpaying Population. The challenges that Congress faces in reforming these entitlement programs are heightened by the rapid growth of other dependence-creating programs, such as subsidies for food and housing and college financial aid, and by the growing number of Americans who incur no obligations for receiving them. How likely is Congress to reform entitlements in any meaningful way under such circumstances? Can Congress rein in the massive middle-class entitlements in an environment of fast-expanding dependence programs?
In 1962, the first year measured in the Index of Dependence on Government, the percentage of people who did not pay federal income taxes themselves and who were not claimed as dependents by someone who did pay federal income taxes stood at 24.0 percent; it fell to 12.6 percent by 1969 before beginning a ragged and ultimately steady increase. By 2000, the percentage was 34.1 percent; by 2010, it was 48.5 percent.Fortunately, this figure dropped to 44.7 percent in 2011. Despite the recent decline, the country is still at a point where nearly one-half of “taxpayers” do not pay federal income taxes, and where most of that same population receives generous federal benefits. (See Chart 1.) This high percentage of people who do not pay the federal income tax persists despite the nation undergoing an economic recovery since the economic collapse during 2008 and 2009.
This trend should concern everyone who supports America’s republican form of government. If the citizens’ representatives are elected by an increasing percentage of voters who pay no income tax, what will be the long-term consequences when these representatives respond more to demands of non-taxpaying voters who urge more spending on entitlements and subsidies than to the pleas of taxpaying voters who urge greater spending prudence?
Instead of encouraging more virtue, such as self-reliance, personal responsibility, and mutual cooperation, dependence on government encourages citizens who pay little taxes to view government as a source of ever expanding benefits, provided by other citizens who pay taxes, without any mutual obligations. Do Americans want a republic that encourages and validates a growing dependence on the state and a withering of civil society? Rejuvenating civil society can help people escape from dependence on government.
Section 1: The Purpose and Theory of the Index
The 2013 Index of Dependence on Government is divided into four major sections. Section 1 explains the purpose of and theory behind the Index; Section 2 features a methodology that describes how the Index is constructed; Section 3 discusses the Index in terms of the number of Americans who receive money from government programs; and Section 4 reviews major policy changes in five federal program areas.
The Index of Dependence on Government is designed to measure the pace at which federal government services and programs have grown in areas once considered to be the responsibility of individuals, families, communities, neighborhood groups, religious institutions, and other civil society institutions. By compiling and condensing these data into a simple annual score (composed of the scores for the five components in Section 4), the Index provides a useful tool for analyzing dependence on government. Policy analysts and political scientists can also use the Index and the patterns it reveals to develop forecasts of trends and consider how these trends might affect the politics of the federal budget.
The Index uses data drawn from a carefully selected set of federally funded programs. The programs were chosen for their propensity to duplicate or replace assistance, such as shelter, food, monetary aid, health care, education, or employment training, which was traditionally provided to people in need by local organizations and families.
In calculating the Index, the expenditures for these programs are weighted to reflect the relative importance of each service (such as shelter, health care, or food). The degree of a person’s dependence will vary with respect to the need. For example, a homeless person’s first need is generally shelter, followed by nourishment, health care, and income. Analysts in The Heritage Foundation’s Center for Data Analysis weighted the program expenditures based on this hierarchy of needs, which produces a weighted index of expenditures centered on the year 1980.
Historically, individuals and local entities have privately provided more assistance to members of society in need than they do today. Particularly during the 20th century, government gradually offered more and more services that were previously provided by self-help and mutual aid organizations. Lower-cost housing is a good example. Mutual aid, religious, and educational organizations long have aided low-income Americans with limited housing assistance; after World War II, the federal and state governments began providing the bulk of low-cost housing. Today, government provides nearly all housing assistance for the poor and low-income.
Health care is another example of this pattern. Before World War II, Americans of modest income typically obtained health care and health insurance through a range of community institutions, some operated by religious institutions and social clubs. That entire health care infrastructure has since been replaced by publicly provided health insurance, largely through Medicaid and Medicare. Regardless of whether the medical and financial results are better today, the relationship between the people who receive health care assistance and those who pay for it has changed fundamentally. Few would dispute that this change has affected the total cost of health care, and the relationships among patients, doctors, and hospitals, negatively.
Financial help for those in need has also changed profoundly. Local, community-based charitable organizations once provided the majority of aid, resulting in a personal relationship between those who received assistance and those who provided it. Today, Social Security and other government programs provide much or all of the income to low-income and indigent households. Nearly all the financial support that was once provided to temporarily unemployed workers by unions, mutual aid societies, and local charities is now provided by federal income, food, and health programs.
This shift from local, community-based, mutual aid assistance to anonymous government payments has clearly altered the relationship between the receiver and the provider of the assistance. In the past, a person in need depended on help from people and organizations in his or her local community. The community representatives were generally aware of the person’s needs and tailored the assistance to meet those needs within the community’s budgetary constraints. Today, housing and other needs are addressed by government employees to whom the person in need is a complete stranger, and who have few or no ties to the community in which the needy person lives.
Both cases of aid involve a dependent relationship. The difference is that support provided by families, religious institutions , and other civil society groups aims to restore a person to full flourishing and personal responsibility, and, ultimately, perhaps to be able to aid another person in turn. The reciprocal relationship is essential to the existence of civil society itself. This kind of reciprocal expectation does not characterize the dependent relationship with the government. Government aid is usually based on one-sided aid without accountability for a person’s regained responsibility for self and toward his community. Indeed, the “success” of such government programs is frequently measured by the program’s growth rather than by whether it helps recipients to escape dependence. While the dependent relationship with civil society leads to a balance between the interests of the person in need and the community, the dependent relationship with the government is inherently prone to generating political pressure from interest groups—such as health care organizations, nonprofit organizations, and the aid recipients themselves—to expand and cement federal support. Perhaps more troubling is the expansion of means-tested safety-net programs, which have the unintended consequence of reducing the rewards to activities that increase one’s market income. The unintended consequence of means-tested programs is that these welfare benefits penalize actions to improve one’s financial situation through one’s own labors. For example, increased working hours translate into increased income, meaning that means-tested assistance participants face decreased assistance if they earn more. Such a quandary can turn into a poverty trap for an individual weighing the “cost” of earning more income at the expense of means-tested assistance. In addition, the programs of the welfare state are likely to create an intergenerational cycle of dependence.
Welfare assistance causes intergenerational dependence because the welfare system generates a culture of dependence in both recipient parents and their children. First, parental welfare participation may encourage children to accept unneeded welfare assistance later in life. Second, parental welfare participation may decrease the employment prospects of the children through multiple avenues. For instance, the lower attachment to work of many welfare-receiving parents may lead their children to be less aware of proper on-the-job behavior. Additionally, such parents may be less able to teach their children job-search skills and provide contacts with those able to provide employment opportunities. Any combination of these factors can significantly inhibit the ability of children to become economically self-sufficient. Third, parental participation may encourage some children to “learn how to ‘play the system’ at an early age.”
A study using data from the PSID found that 20 percent of girls raised in families that were highly dependent on Aid to Families with Dependent Children (AFDC) when the girls were 13 to 15 years old were themselves highly dependent on AFDC between the ages of 21 and 23. The same was true for only 3 percent of girls from non-AFDC-recipient families. However, the results of this study should be interpreted with caution because the study failed to account for other factors that may contribute to participation in AFDC.
An analysis of intergenerational welfare participation based on the National Longitudinal Survey of Youth (NLSY) from 1979 to 1988 provides stronger evidence for welfare assistance causing intergenerational dependence. After controlling for factors that may influence welfare participation, the study found that “exposure to welfare at home increases later offspring dependency.” Specifically, children raised in families participating in AFDC were almost 4.6 times more likely to participate in AFDC during adulthood, compared to the adulthood participation rates of children raised in families never enrolled in AFDC. A similar study using NLSY data found that women raised in households that received welfare were 1.67 to 2.74 times more likely to be dependent on AFDC in adulthood than their counterparts from non-welfare households.
Other studies that account for factors that may influence welfare participation have confirmed an intergenerational link. According to a study based on a random sample of AFDC female recipients from Tennessee, growing up in a family that participated in AFDC was associated with an increased length of time for these women on AFDC in adulthood. An analysis of welfare assistance in Canada found that a 1 percent increase in parental participation during a child’s pre-adult years (ages seven to 17) was associated with a participation rate increase of 0.29 percent during the child’s early adulthood (ages 18 to 21). Converted to a monthly basis, a one-month increase in prior participation by parents is associated with a three-day increase in participation by their children when age 18 to 21.
The Index of Dependence on Government provides a way to assess the magnitude and implications of the change in government dependence in American society. The Index is based principally on historical data from the President’s fiscal year (FY) 2013 annual budget proposal. The last year measured in the 2013 Index is FY 2011. The Center for Data Analysis (CDA) used a simple weighting scheme and inflation adjustment to restate these publicly available data. CDA analysts encourage replication of their work and will gladly provide the data that support this year’s Index upon request to professionals. The steps to prepare this year’s Index are described in the methodology in Section 2.
Section 2: The Methodology
After identifying the government programs that contribute to dependence, the Center for Data Analysis further examined the data to identify the components that contributed to variability. Relatively small programs that required little funding and short-term programs were excluded. The remaining expenditures were summed up on an annual basis for each of the five major categories listed in Table 2. The program titles are those used by the federal Office of Management and Budget (OMB) for budget function and sub-function in the budget accounting system. For federal spending on higher education, U.S. Department of Education appropriations for higher education loans and grants were used instead of OMB data for fiscal years 1980 to 2011 because the CDA analysts determined them to be more accurate, and less prone to accounting technicalities in recent years.
The CDA analysts collected data for FY 1962 through FY 2011. Deflators centered on 2005 were employed to adjust for inflation.
Indices are intended to provide insight into phenomena that are either so detailed or complicated that simplification through chosen but reasonable rules is required for obtaining useful insights. The Consumer Price Index (CPI) of the Bureau of Labor Statistics, for instance, is a series based on a selected “basket of goods” that the bureau surveys periodically for price changes. The components of this basket are weighted to reflect their relative importance to overall price change. Energy prices are weighted as more important than clothing prices. Multiplying the weight by the price produces a weighted price for each element of the CPI, and the total of the weighted prices produces the rough CPI score.
The Index of Dependence on Government generally works the same way. The raw (unweighted) value for each program (that program’s yearly expenditures) is multiplied by the weight reasonably assigned to it by CDA. The total of the weighted values is the Index score for that year.
The Index is calculated using the following weights:
- Housing: 30 percent
- Health Care and Welfare: 25 percent
- Retirement: 20 percent
- Higher Education: 15 percent
- Rural and Agricultural Services: 10 percent
The same weighting procedure is consistently applied to each annual edition of the Index. The weights are “centered” on the year 1980. This means that the total of the weighted values for the Index components will equal 100 for 1980, and 1980 is the reference year in comparison to which all other Index values can be evaluated as percentages of 100.
The CDA chose the year 1980 due to its apparent significance in American political philosophy. Many analysts view 1980 as a watershed year in U.S. history because it seems to mark the beginning of the decline in left-of-center public policy and the emergence of right-of-center challenges to policies that were based on the belief that social systems fail without the guiding hand of government.
The Index certainly reflects such a watershed. Chart 3 plots the Index from 1962 to 2011. The scores have clearly drifted upward throughout the entire period.
There are two plateaus in the Index—the 1980s and the period from 1995 to 2001—that suggest that policy changes may significantly influence the Index growth rate. During the early 1980s, the growth of some domestic programs was slowed to pay for increased defense spending, and Congress enacted significant policy changes in welfare and public housing during the 1990s. Both of these cutbacks reduced the Index growth rate.
Chart 4 connects the Index to major public policy changes. The largest jump in the Index occurred during the Johnson Administration, following the passage of the Great Society programs. The Johnson Administration not only launched Medicare and other publicly funded health programs, but also vastly expanded the federal role in providing and financing low-income housing. The Index also jumped 90 percent (from 39 to 74) under the Nixon and Ford Administrations, when Republicans were funding and implementing substantial portions of the Great Society programs.
The two periods of relatively less liberal public policy (the 1980s and 1995–2001) stand out clearly in Chart 4. The slowdowns in welfare spending increases during the Reagan years and after the 1994 congressional elections produced two periods of slightly negative change in the Index. These periods saw significant retreats from Great Society methods, particularly in the nation’s approach to welfare, but the return of budget surpluses during the last years of the Clinton Administration led to significant spending increases for all of the components, particularly education and health care. The George W. Bush years saw more leaps in retirement, housing, health, and welfare spending, and since 2009, health care and welfare spending has blasted upward like a rocket. Health care and welfare now stand at four and a third times the 1980 level (inflation-adjusted). With the continuing implementation of Obamacare (the Patient Protection and Affordable Care Act of 2010), the parameters of Chart 4 will most likely have to be expanded again to fit the higher Index number in the years to come.
Section 3: The Five Index Components
CDA analysts began by reviewing the federal budget to identify federal programs and state activities supported by federal appropriations that fit the definition of dependence—providing assistance in areas once considered to be the responsibility of individuals, families, neighborhood groups, religious institutions, and other civil society institutions. The immediate beneficiary of the program or activity must be an individual. This method generally excludes state programs; federally funded programs in which the states act as intermediaries for benefits to individuals are included.
Elementary and secondary education are the principal state-administered programs that are excluded under this stipulation. Post-secondary education is the only part of federal government–funded education included in the Index. Expenditures on the military and federal employees are also excluded. National defense is the primary constitutionally mandated function of the federal government and thus does not promote dependence as measured by the Index. Non-military federal employees are also excluded from the Index based on the fact that these individuals are paid for their labor. In addition, military and federal employees are assumed to possess marketable skills that allow them to find work in the private sector should their federal jobs not exist.
CDA analysts then divided the qualifying programs into five broad components:
- (a) Health Care and (b) Welfare
- Higher Education
- Rural and Agricultural Services
The following sections discuss the pace and content of policy changes in these five components.
1) Housing. The Department of Housing and Urban Development (HUD) was created in 1965 by consolidating several independent federal housing agencies into one executive department. The purpose of the consolidation was to elevate the importance of government housing assistance within the constellation of federal spending programs. At that time it was believed that the destructive riots that broke out in many cities in the early 1960s were a consequence of poor housing conditions and that these conditions were contributing to urban decay.
In any given year, about 80 percent of HUD’s budget is aimed at housing assistance, and the other 20 percent is focused on urban issues by way of the Community Development Block Grant (CDBG) program. Given the nature of these programmatic allocations, HUD budgetary and staff resources are concentrated on low-income households to an extent unmatched by any other federal department.
Within the 80 percent of the HUD budget spent on housing assistance are a series of means-tested housing programs, some of which date back to the Great Depression. Typically, these programs provide low-income people, including the elderly and disabled, with apartments at monthly rents scaled to their incomes. The lower the income, the lower the rent. Traditionally, HUD and the local housing agencies have provided eligible low-income households with “project-based” assistance, an apartment unit that is owned and maintained by the government.
Public housing projects have historically been the most common form of such assistance, but they began to fall out of favor in the 1960s due to the rampant decay and deterioration that followed from concentrating low-income families in a single complex or neighborhood. Periodically, new forms of project-based programs are adopted as “reform,” which also tend to fall out of favor after years of disappointing results. HOPE VI is the most recent form of project-based assistance, and high costs and low benefits led the George W. Bush Administration to attempt, unsuccessfully, to terminate the program in 2006. Efforts are now underway by some in the Obama Administration to increase the program’s funding.
HUD also provides “tenant-based” housing assistance to low-income households in the form of rent vouchers and certificates. These certificates help low-income people rent apartments in the private sector by covering a portion of the rent. The lower the person’s or family’s income, the greater the share of rent covered by the voucher or certificate. Vouchers were implemented in the early 1970s as a cost-effective replacement for public housing and other forms of expensive project-based assistance; vouchers still account for only a portion of housing assistance, in part because of housing-industry resistance to terminating the lucrative project-based programs. However, the unintended consequence of the sliding contribution of vouchers based on income means that the assistance operates with the disincentives of marginal tax rates: Voucher participants face decreased housing assistance if they experience income gains. Such a dilemma can turn into a poverty trap for an individual weighing the “cost” of earning more income at the expense of losing housing assistance.
Finally, HUD provides block grants to cities and communities through the CDBG program according to a needs-based formula. Grant money can be spent at a community’s discretion among a series of permissible options. Among the allowable spending options is additional housing assistance, which many communities use to provide assistance to a greater number of low-income households. Although HUD programs are means-tested to determine eligibility, they are not entitlements. As a result, many eligible households do not receive any housing assistance due to funding limitations. In many communities, housing assistance requires waiting periods of several years—and in some cases local housing authorities no longer add new families to the waiting list because there is simply no foreseeable prospect of new applicants receiving an apartment.
Recognizing that HUD housing assistance can create dependence among those who receive its benefits, some Members of Congress have attempted to extend the work requirements of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWOR) to HUD programs. Self-described advocates for the poor have thwarted these efforts. To date, the most that can be required of a HUD program beneficiary is eight hours per month of volunteer service to the community or housing project in which the beneficiary lives.
After a mid-decade jump reflecting spending to rebuild infrastructure destroyed by Hurricanes Katrina and Rita, the housing component of the Index moderated, but in 2008 it jumped significantly as the federal government added several mortgage-bailout programs to its traditional low-income, housing-assistance focus.
The Federal Housing Finance Agency (FHFA) took over the supervision of operations of Fannie Mae and Freddie Mac on July 24, 2008, as part of the Housing and Economic Recovery Act (HERA). The federal government provides direct financing to the mortgage market through Fannie Mae and Freddie Mac due to HERA. The net loss to the federal government from November 2008 to the end of March 2011 totaled $130 billion ($154 billion minus $24 billion in dividends on the agencies’ respective preferred stock). Moreover, any agency debt issued by Fannie Mae and Freddie Mac is not considered official government debt, and, therefore, is not included in the accounting of federal publicly held debt.
The change in agency status is important since Fannie Mae and Freddie Mac directly hold purchased mortgages and issue mortgage-backed securities (MBS). Their role in the single-family residential mortgage market is substantial. Fannie Mae and Freddie Mac guarantee approximately half of outstanding U.S. mortgages, and they finance more than 70 percent of all single-family residential mortgages.
In the past two years, under the Obama Administration, there have been incremental steps to extend help to homeowners. The Administration established two broad programs to help U.S. homeowners through the Making Home Affordable (MHA) initiative—the Home Affordable Modification Program (HAMP) and the Home Affordable Refinancing Program (HARP).
These programs go beyond extending federal government support to low-income Americans. The HAMP program uses Troubled Asset Relief Program (TARP) funds to reduce the burden of mortgage-related debt service from homeowners at risk of foreclosure. These are targeted homeowners that took a sub-prime or alternative high-risk mortgage, and are paying more than 31 percent of their household income on their primary mortgage. HARP, however, extends federal support in housing to many moderate-income and upper-middle-income households by allowing eligible homeowners to refinance their mortgage at historically low interest rates and to change their term structure on loans. All mortgages refinanced under HARP are either owned or underwritten by Fannie Mae or Freddie Mac.
2(a) Health Care.Increasing spending and enrollment in public health care programs, and particularly Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), is leading to greater dependence on government. In 2011, total combined enrollment in these three programs was nearly 109 million individuals—approximately 32 percent of the entire U.S. population. The three programs accounted for $999 billion, or 6.6 percent of GDP. According to the Centers for Medicare and Medicaid Services (CMS), by 2021, government spending on health care will represent nearly 50 percent of total national health expenditures.
In its 2011 annual report on health insurance coverage, the U.S. Census Bureau published figures that underscore the current trend toward greater dependence on government health programs.The percentage of Americans enrolled in government health programs is rising faster than ever, in part due to a struggling economy, Medicaid and CHIP expansions, and a rapidly growing elderly population transitioning into Medicare. The consequence is greater dependence on taxpayer-subsidized coverage.
Medicare. Congress established Medicare in 1965 through Title XVIII of the Social Security Act. Medicare pays for health care for individuals ages 65 and above, and for those with certain disabilities. Medicare enrollment has steadily increased since its enactment due to increases in both population and individual life expectancy. In 1970, 20.4 million individuals were enrolled in Medicare. By 2011, the number of enrollees had more than doubled to 48.7 million.In 2011, the first of 81.5 million baby boomers became eligible for Medicare, leading to an expected dramatic increase in enrollment over the next 10 years.
The heavily taxpayer-subsidized Medicare coverage increases overall demand for health care and places upward pressure on health care pricing. Medicare fee-for-service is the primary source of coverage for beneficiaries. However, traditional Medicare’s fee-for-service structure adds to rising costs by rewarding providers for higher volumes of services. Moreover, gaps in coverage lead 90 percent of enrollees to carry supplemental plans, such as employer-provided retiree coverage, Medigap plans, or Medicaid. By design, supplemental policies shield seniors from the financial effects of their health care decisions.
Growing enrollment and rising spending are quickly leading Medicare to become an unsustainable program. Under current law, the program faces $26.9 trillion in long-term unfunded obligations; under an alternative, more plausible, scenario, the estimate reaches $36.9 trillion over the long term. Medicare Part A is already running yearly deficits, and according to the Trustees, the Hospital Insurance Trust Fund will become insolvent in 2024. Between 1985 and 2011, gross federal spending for Medicare rose from 1.7 percent of GDP to 3.7 percent, and under the CBO’s extended alternative fiscal scenario, gross federal spending on Medicare will reach 6.7 percent of GDP by 2037.
The last decade has seen a significant expansion of benefits provided by Medicare, including the addition of a prescription drug benefit (Medicare Part D). From 2004 to 2011, Part D was responsible for $337.9 billion in spending. Though the role of competition in its defined-contribution financing model has caused its costs during this period to be 48 percent lower than initial CMS projections, the program has added substantially to health care entitlement spending. Additionally, the publicly funded Part D program has crowded out private coverage alternatives. Research suggests that before Medicare Part D was enacted, 75 percent of seniors currently receiving public coverage held private drug coverage. Part D also increased average spending on prescription drugs by seniors, an expense that is funded by an increase in public spending of 184 percent, accompanied by a reduction in seniors’ out-of-pocket spending of 39 percent and private insurance plan spending of 37 percent.
Medicaid and CHIP. Medicaid, the joint federal–state health care program for specific categories of the poor, was also established in 1965, through Title XIX of the Social Security Act. In 2011, 56.1 million Americans were enrolled in Medicaid, an increase of 2.2 million individuals in just one year, and 21.6 million since 2000. Medicaid serves a diverse population of the poor, including children, mothers, the elderly, and the disabled. Combined, the total national cost of Medicaid and CHIP in 2011 is estimated at $441 billion, and is projected to rise to $963 billion by 2021.
The generous, open-ended federal reimbursement that states receive for Medicaid spending encourages many states to grow the program beyond what could be expected if state taxpayers funded the full cost. The structure of the Medicaid program varies from state to state because states determine their own eligibility and benefit levels after meeting a minimum federal standard. States have used this flexibility to expand eligibility and benefit packages. Indeed, past research has shown that a majority of Medicaid expenditures are for optional services or groups.
Incremental Medicaid expansions and the addition of CHIPhave increased the number of individuals eligible for government health programs. CHIP has led many working families who would otherwise enroll their children in private coverage to opt for public coverage. The CBO concluded that private coverage crowd-out from CHIP expansions ranges from 25 percent to 50 percent. In 2011, 5.7 million children were enrolled in CHIP—an increase of 300,000 children from the year before, and 3.7 million from 2000.
Impact of Obamacare. The Patient Protection and Affordable Care Act (PPACA), enacted in 2010, relies on a massive expansion in Medicaid and the creation of a new income-related subsidy to purchase insurance through government-controlled insurance exchanges.
The most recent CBO estimate projects that, by 2022, 25 million individuals will receive subsidized coverage in the new exchanges.CMS originally estimated that over 20 million additional Americans would be enrolled in Medicaid and CHIP by 2019 due to the PPACA. However, the CBO has an updated estimate that reflects the recent June 2012 Supreme Court decision, which made the Medicaid expansion optional for states, causing a smaller amount of additional Medicaid enrollees—11 million in 2022.
These new provisions are projected to cost the federal government nearly $1.7 trillion between 2012 and 2022. To reduce the impact on the federal deficit, the PPACA depends on a variety of offsetting provisions, including an estimated $716 billion from Medicare. Thus, instead of extending Medicare’s solvency, these reductions were used to fund the new spending provisions. Moreover, both the CMS Actuary and the CBO warn that much of these Medicare spending reductions are unlikely to materialize due to the effects they will have on health care providers’ profitability, and subsequently, seniors’ access to care.
Conclusion. The growing dependence on government health programs, the result of recently enacted legislation, and other factors will have a direct negative impact on federal and state taxpayers. Spending on Medicare and Medicaid, two of the largest entitlement programs, is on track to well surpass current levels. By 2021, Medicare spending is expected to surpass $1 trillion, and total spending (federal and state) for Medicaid and CHIP will reach $963 billion, with exchange spending totaling $136 billion, at which point government spending will represent nearly half of all health care expenditures.
2(b) Welfare.The 1996 Welfare Reform Act (PRWORA) replaced the decades-long Aid to Families with Dependent Children (AFDC)—which entitled recipients to unconditional benefits—with the Temporary Assistance for Needy Families (TANF) program. Enacted during the Great Depression, AFDC, an old cash-welfare program, was intended to provide financial assistance to children in need. Over the decades, the program swelled and added adults, such as unemployed parents of enrolled children. Welfare rolls peaked in 1994, reaching more than 5 million cases—14.2 million individual recipients. Before welfare reform, one child in seven received AFDC.
An open-ended assistance program, AFDC granted states more money as their welfare rolls continued to increase. At the individual level, AFDC handed out benefits without any expectations from the recipients, who were entitled to cash aid as long as they fell below the need standards set by the states. The entitlement created perverse incentives—discouraging work among able-bodied adults and discouraging marriage.
Welfare reform effectively altered the fundamental premise of receiving public aid and ended it as an entitlement. Receiving assistance became temporary and tied to demonstrable efforts by able-bodied adult recipients to find work or take part in work-related activities. Self-sufficiency became the goal. The successes of welfare reform are undeniable. Between August 1996 and December 2011, welfare caseloads declined by 59.1 percent—from 4.4 million families to 1.8 million families. The legislation also reduced child poverty by 1.6 million children.
The initial years after welfare reform brought significant progress. By the late 1990s, most states had met the PRWORA’s work goals, and motivation to reduce dependence and encourage work among recipients even more began to wane. The national TANF caseload has flatlined in the past few years, and the percentage of TANF families with work-eligible adults who worked at least 30 hours per week (20 hours for those with young children) never rose above the 38.3 percent attained in 1999, and has hovered near 30 percent in recent years.
In February 2006, after four years of debate, Congress reauthorized TANF under the Deficit Reduction Act. The new legislation reiterated the need to engage recipients in acceptable work activities and promote self-sufficiency. Once again, states were required to increase work participation and to reduce their welfare caseloads, using the lower 2005 caseload levels as the new baseline—which essentially restarted the 1996 reform. As required by Congress, the Department of Health and Human Services also issued new regulations to strengthen work-participation standards.
The 2006 TANF reauthorization also contained a notable measure that began to rectify the inattention to the other two 1996 welfare reform goals: reducing unwed childbearing and restoring stable family formation. The erosion of marriage and family is a primary contributing factor to child poverty and welfare dependence, and it figures significantly in a host of social problems. A child born outside marriage is nearly six times more likely to be poor than a child raised by married parents, and more than 80 percent of long-term child poverty occurs in single-parent homes. Moreover, unwed parents and the absence of fathers in the home negatively affects a child’s development, educational achievement, and psychological well-being, as well as increases children’s propensity toward delinquency and substance abuse.
For the past four decades, the unwed birth rate in America has been rising steadily, from 5.3 percent in 1960 to 40.7 percent in 2011. Among blacks, 72.3 percent of children born in 2011 were to unmarried parents; among Hispanics, the percentage was 53.3 percent. The percentage among whites was 29.0 percent. Although the pace of growth in the proportions of births to unmarried women slowed in the immediate years after welfare reform, more recently, it has risen rapidly. From 2002 to 2009, the share of non-marital births increased by one-fifth—34.0 percent to 41.0 percent. Since then, the share of non-marital births appears to have leveled off at 40.8 percent and 40.7 percent in 2010 and 2011, respectively.
In 2011, 1.6 million children were born to unmarried parents. Contrary to popular belief, the typical single mother is not a teenager, but in her twenties. Whereas in 1970 one-half of all out-of-wedlock births were to teens, in 2011 births to girls younger than 18 years of age comprised only 5.9 percent of such births. Almost 61 percent of out-of-wedlock births are to women in their twenties.About 49 percent are high-school dropouts, and 34 percent are high-school graduates. Fourteen percent have had some college education; only 2 percent have a college degree. Tragically, the Obama Administration seems bent on derailing the successful 1996 welfare reforms. In July 2012, the Administration’s Department of Health and Human Services announced that it would allow states to waive the work requirement, the heart of the reform law. The Administration’s policy threatens the success of the law in helping those in need attain self-sufficiency.
Welfare reform should be restored. Additionally, comprehensive welfare reform of the federal government’s many other welfare programs is needed. Today’s welfare system is a convoluted machinery of 80 programs, 13 federal departments, and a voluminous collection of state agencies and programs. Overall, the welfare system amounts to over $900 billion in spending per year.
Since President Lyndon Johnson declared the War on Poverty in 1964, the federal government has spent approximately $20 trillion on means-tested welfare aid. Today, means-tested assistance is the fastest-growing part of government, with the nation spending more on welfare than on national defense. Under the Obama Administration, welfare spending has increased dramatically. For example, since FY 2008, spending on the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp program, more than doubled from $37.6 billion to $78.4 billion for FY 2012. The tremendous growth in the SNAP budget means that more and more Americans are dependent on the program. In 1969, 1.4 percent of the population or about 2.9 million people participated in the program. By 2008, the participation rate increased to 9.3 percent of the population with 28.2 million individuals receiving benefits. In 2011, 44.7 million people (14.3 percent of the population) participated in the program. (See Chart 12.) The figure for FY 2012 is 14.8 percent—meaning that one of every 6.7 people in the nation is participating in the program. Over the next 10 years, total welfare spending is expected to cost taxpayers $12.7 trillion. The Obama Administration has worked rapidly to expand the welfare state further.Such growth is clearly unsustainable.
The 1996 Welfare Reform Act was the first phase of meaningful welfare reform. The work requirements in this law must be restored and strengthened. The next phase of welfare reform should focus on the following: First, since means-tested welfare spending goes to more than 80 federal programs, Congress should require the President’s annual budget to detail current and future aggregate federal means-tested spending. The budget should also provide estimates of state contributions to federal welfare programs. Second, continuing reform should rein in the explosive growth in spending. When the unemployment rate returns to the historically normal level of approximately 5 percent, aggregate welfare funding should be capped at pre-recession (FY 2007) levels plus inflation. Third, building on the successful 1996 model, further reform should continue to promote personal responsibility by encouraging work. For example, SNAP, one of the largest means-tested programs, should be restructured to require able-bodied adult recipients to work or prepare to work, in order to be eligible for food stamps.
3) Retirement.Since the time of President Franklin D. Roosevelt, the American retirement system has been described as a three-legged stool consisting of Social Security, employment-based pensions, and personal retirement savings. The reality is quite different. Almost half of American workers (about 78 million) are employed by companies that do not offer any type of pension or retirement savings plan. This proportion of employer-based retirement savings coverage has remained roughly stable for many years, and experience has shown that few workers can save enough for retirement without such a payroll-deduction savings plan. For workers without a pension plan, the reality of their retirement consists almost entirely of Social Security.
Since 1935, Social Security has provided a significant proportion of most Americans’ retirement incomes. The program pays a monthly check to retired workers, and monthly benefits to surviving spouses and children under the age of 18. Monthly benefits are based on the indexed average of a worker’s monthly income over a 35-year period, with lower-income workers receiving proportionately higher payments and higher-income workers receiving proportionately less. The lowest-income workers receive about 70 percent of their pre-retirement income; average-income workers receive 40 percent to 45 percent; and upper-income workers average about 23 percent.
However, the demographic forces that once made Social Security affordable have reversed, and the program is on an inexorable course toward fiscal crisis. To break even, Social Security needs at least 2.9 workers to pay taxes for each retiree who receives benefits. The current ratio is 3.3 workers per retiree and dropping because the baby boomers produced fewer children than their parents did and have begun to reach retirement. The ratio will reach 2.9 workers per retiree around 2015 and drop to two workers per retiree in the 2030s.
Current retiree benefits are paid from the payroll taxes collected from today’s workers. Social Security has not collected enough taxes to pay for all its promised benefits since 2010. Both the Social Security Administration and the CBO say that these deficits are permanent.
Between 1983 and 2009, workers paid more in payroll taxes than the Social Security program needed in order to pay benefits. These additional taxes were supposed to be retained to help finance retirement benefits for baby boomers. But the government did not save or invest the excess taxes for the future. Instead, the government used the money to finance other government programs. In return for the diverted revenue, Social Security’s trust fund received special-issue U.S. Treasury bonds. Now that Social Security has begun to spend the interest that is accumulating on those Treasury bonds and will soon begin to redeem them, the federal government will be required to raise the money through higher taxes or massive borrowing.
Social Security’s uncertain future is a problem for all workers, and especially for roughly half the American workforce that has no other retirement program. Few of these Americans have any significant savings, and unless the situation improves, they will depend heavily on the government for their retirement incomes.
This dependence is largely the result of government policies. By soaking up money that should have been invested for the future, Social Security’s high tax rate makes it much harder for lower-income and moderate-income workers to accumulate any substantial savings. Workers logically view Social Security taxes as a substitute for private savings—the problem is that the government is spending, rather than saving that money, and the complexity of the program, along with its long-term fiscal insolvency, prevents workers from knowing precisely what they will receive in return for their Social Security taxes.
Additionally, Social Security reduces private savings by relieving people of the responsibility for factors such as securing assets to last into very old age or to pay for medical treatments not covered by insurance. If Social Security did not provide a guaranteed lifetime benefit, people would have to increase their private savings to provide for a longer retirement. And, the Supplemental Security Insurance (SSI) component of Social Security, which provides additional income and medical benefits to individuals who run out of private savings, discourages lower-income workers from saving money that could prevent them from receiving additional government assistance.
Complex government regulations also discourage the expansion of occupational pensions to cover a higher proportion of the workforce. Over the past few decades, the costs of traditional pension plans have skyrocketed, and thousands of them have shut down. Efforts to develop innovative hybrid pension plans stalled when confusing laws and regulations resulted in lawsuits.
4) Higher Education.Federal post-secondary education spending continues to grow at a rapid pace. During the 2011–2012 school year, total federal spending on student aid programs (including tax credits and deductions, grants, and loans) was approximately $236.7 billion—making total federal aid 218 percent higher than for the 2001–2002 school year (total inflation-adjusted federal aid totaled $108.6 billion that year). In the 2010–2011 school year, federal grant aid increased to $50.3 billion, a 2.7 percent increase over the previous year (Pell Grants: $34.5 billion; other federal grants: $14.8 billion; Work Study: $1 billion). Between 2000 and 2011, inflation-adjusted Pell Grant funding grew 191 percent. Notably, federal intervention into the student lending market has also continued to grow. The U.S. Department of Education notes that “as of July 1, 2010, all Subsidized and Unsubsidized Stafford Loans, PLUS, and Consolidation Loans are originated in the Direct Loan (DL) program.”
The data in Chart 11 is limited to spending expressed in 2005 dollars, so tax credits, deductions, and loan liabilities are not included. As the chart shows, higher education spending steadily increased since 1962. Higher education increased from $1.8 billion in 1962 to $40.9 billion in 2011—an increase of a staggering 2,172 percent.
Over the past decade, growing federal higher-education subsidies have increased the number and percentage of post-secondary students who depend on government aid. In the 2011–2012 school year, 9.4 million students received Pell Grant scholarships—more than double the number of students who received Pell Grants in the 2001–2002 school year.The maximum Pell Grant award rose to $5,550 during the 2011–2012 school year. Moreover, during the 2007–2008 school year (the most recent data available), 47 percent of students received federal student aid (including both grants and loans). Federal borrowing through the Stafford loan program grew to 10.4 million loans from just 5.4 million loans during the 2001–2002 school year, a 95 percent increase.
Both federal spending and students’ dependence on government are likely to continue to rise in 2013. In seeking to make the United States the country with “the highest proportion of college graduates in the world by 2020,” President Obama has pushed for significant increases in federal subsidies. The President’s 2013 budget request increases funding for federal grants, loans, and work-study programs to $165 billion—a 69 percent increase since 2008.Moreover, “the administration’s budget would provide a record $36.1 billion in Pell Grants to nearly 10 million students during the 2013–2014 award year.”
Increases in federal student aid subsidies over the years have done nothing to mitigate ever-rising college costs. Tuition and fees at private and public four-year institutions rose by 13 percent and 27 percent, respectively, after adjusting for inflation, from the 2007–2008 academic year to the 2012–2013 academic year. In the decade from 2002 to 2012, tuition and fees rose by an average annual rate of 5.2 percent at public universities.Since 1982, the cost of college tuition and fees has increased by 439 percent—more than four times the rate of inflation.
Decades-long increases in federal subsidies for college have led to increases in college tuition and fees because universities know that more aid makes students less sensitive to rising college costs. Economist Richard Vedder argues that “some of these [federal] financial aid programs have contributed mightily to the explosion in tuition and fees in modern times.” Vedder also notes that it “is not clear that higher education has major positive spillover effects that justify government subsidies in the first place, and the private loan market that can handle anything from automobile loans to billion-dollar government bond sales can handle financial assistance to students if necessary.”
Instead of continuing to expand the government’s role in student lending, federal subsidies should be limited to those students with the greatest financial need. Limiting the number of years that students are able to receive federal subsidies would also likely begin to tackle the college cost problem.
5) Rural and Agricultural Services. Government dependence in the rural and agriculture sector is largely driven by farm subsidies. Direct payments are designed to supplement farm income; production quotas inflate crop prices; and premium subsidies offset the cost of crop insurance. The government also pays farmers to adopt conservation methods, and provides export subsidies that enable them to undercut commodity prices overseas.
Supporters of farm subsidies often characterize farmers as particularly vulnerable to both natural and economic forces. But risk exists in all types of commercial endeavors, and there are a host of nongovernmental methods with which farmers themselves can manage risk, including crop diversification, credit reserves, and private insurance.
In fact, American farmers are doing quite well. Net farm income hit a record $117.9 billion in 2011, and is forecast by the U.S. Department of Agriculture (USDA) to reach $128.2 billion in 2013—the highest level on record in four decades. Chart 12 shows that average farm-household income began to eclipse the average of all U.S. households in 1996, and remains so (despite the fact that most farm-household income is derived from off-farm sources).
Meanwhile, the top five earnings years during the past three decades have all occurred since 2004. The debt-to-asset ratio for 2012 is pegged at just 10.3 percent, meaning that debt is only about one-tenth of total assets—the strongest position in some 40 years, due largely to rising land values. Farm subsidies are higher now than in the early 1990s, when farm-household income and that of the rest of America were roughly equal.
Farm subsidies, commodity quotas, and tariffs largely enrich upper-income producers of grains, oilseeds, cotton, milk, and sugar, and ignore most other commodities. Nearly 80 percent of farms with gross cash farm income of $250,000 to $999,999 receive government payments, compared to 24 percent of farms with gross cash farm income of $10,000 to $249,999.
Instead of payments based on need, farm subsidies are largely based on the type of crops grown, and the volume produced over time. Because yield has long been a primary factor in the allocation of subsidies, bigger farms receive a larger proportion of the payments. Since the operators of bigger farms tend to have higher household incomes than their smaller counterparts, subsidies have shifted to higher income households.
This is where the rationale for farm subsidies falls apart. Large farms are generally more viable than small farms by virtue of economies of scale and access to technology. Large farms can afford more sophisticated machinery and can take advantage of the latest scientific advances—both of which allow operators to manage more acreage and increase yields. To the extent that taxpayers absorb the costs of farming, farmers are less likely to optimize efficiency or minimize risk.
In 1996, Congress appeared to acknowledge the failures of centrally planned agriculture. That year’s Federal Agricultural Improvement and Reform Act(also known as the Freedom to Farm Act) was designed to phase out farm subsidies by 2002 and allow the agricultural sector to operate as a free market. After spending just $6.2 billion on what is called farm “income stabilization” in 1997—half the amount that was spent in 1992—Congress overreacted to a temporary dip in crop prices in 1998 (resulting from the Asian economic slowdown) by passing the first in a series of annual emergency bailouts for farmers.
By 2000, farm income stabilization spending hit a record $33.4 billion. Farmers quickly grew accustomed to massive government subsidies, and competition for the farm vote induced a bipartisan bidding war on the eve of the 2002 elections. That same year, lawmakers gave up on reform and enacted the largest farm bill in American history, projected to cost at least $180 billion over the following decade. Despite escalating costs and negative economic effects, farm subsidization continued to be the overwhelming preference of Congress and the White House.
Rather than fix this broken system, the 2008 farm bill made it worse. Congress repealed key limits on the subsidies a farmer may receive, thereby ignoring President George W. Bush’s call to subsidize only those farmers who earn less than $200,000 a year, which would have effectively ended subsidies for corporate farms. The bill created a permanent new disaster program, increased subsidy rates, and used gimmicks to cover up a spending increase of approximately $25 billion over 10 years. Even corn farmers, who already benefit from soaring prices resulting from federal ethanol policies, continued to receive billions in annual subsidies.
With the national debt above $16 trillion, lawmakers are finally considering cuts to some farm subsidies. For example, the House and Senate have passed farm bills that would repeal a set of wasteful and antiquated commodity programs. Unfortunately, they would supplant those cuts with new subsidy programs, dubbed “shallow loss” and “target price” programs. A shallow loss program protects farmers from even minor (shallow) losses, effectively removing virtually all risk from farming. In the Senate, farmers would be guaranteed protection for up to 88 percent of their revenue; in the House it would be 85 percent of the revenue. Since the cost of the shallow loss programs is based on an average of commodity prices from the previous five years, the numbers could skyrocket if prices are higher than expected. For both bills, the Congressional Budget Office assumed that commodity prices would stay at or near record highs. If the prices return to long-term averages, taxpayers could pay far more than what is projected.
A target price program sets a specific price in law. If a commodity price falls below that level, farmers of the specific commodity receive a payment. In the House bill particularly, the target prices have been set so high that payments for some commodities would likely be guaranteed, such as payments to peanut farmers.
Not surprisingly, decades of farm subsidies have created an entitlement mentality among a class of farmers who have significant influence in Congress. Prospects for reform also are stymied by the sprawling scope of previous farm bills, which have encompassed food stamps, child nutrition, forestry, telecommunications, energy, and rural development. This concentration of special interests constitutes a powerful force for the status quo.
Major reforms are sorely needed to reduce farmers’ unnecessary dependence on taxpayers. First and foremost, lawmakers must separate the food stamp program from the agriculture-related programs of the farm bill so that reform is a possibility. Nearly 80 percent of the farm bill is composed of food stamps, making it really the “food stamp bill.” These distinct programs are combined solely for political reasons in order to get them passed. If the programs are separated, lawmakers could have the chance to consider each of these programs on its own merits. Thereafter, Congress can move toward elimination of numerous subsidies, placing restrictions on eligibility, and imposing income limits and subsidy caps.
Public policy decisions can alter the fabric of society. Changes in the Index of Dependence on Government are clearly traceable to public policy decisions that expanded or constricted the reach of government. The rapid increase in the 1960s and 1970s corresponds with a new commitment by the federal government to solve local social and economic problems, which had previously been the responsibility of local governments, civil society organizations, communities, and families. Both the number of government employees and people covered by government programs surged in the wake of the War on Poverty.
The 1980s and 1990s generally witnessed much slower growth in the Index as public policy emphasized reining in the size and influence of government. Unfortunately, the first decade of the new millennium was a different story: The Index resumed the growth rates attained during the era of big government and they are now growing even faster.
Americans should be concerned about this relentless upward march in Index scores. Dependence on the federal government for life’s many challenges strips civil society of its historical—and necessary—role in providing aid and renewal through the intimate relationships of family, community, and local institutions and local governments. While the Index does not measure the decay of civil society, it reflects an increase in the size and scope of government with a concurrent displacement of the institutions of civil society.
Today, the growth of government spending is of particular concern as the retirement of the baby-boomer generation has caused sharp increases in government spending. At the same time, the tax code has become a morass of tax credits and deductions that remove millions of Americans from the tax rolls, insulating them from the cost of government.
Perhaps the greatest danger is that the swelling ranks of Americans who enjoy government services and benefits for which they pay few or no taxes will lead to a spreading sense of entitlement that is simply incompatible with self-government. Americans have reached a point in the life of their republic at which the democratic political process has become a means for many voters to defend and expand the “benefits” they receive from government. Do Americans want a republic that encourages and validates a growing dependence on the state and a withering of civil society? Do Americans want sharp class lines drawn between those who receive government largesse and those who pay for it? These are questions increasingly in need of urgent answers. How Americans answer them may well determine the ultimate fate of their political system—and of their society.
It is not too late: The individual genius of Americans, acting through their civil society institutions, can still steer the nation from its present disastrous course. Civil society is not dead today. While government programs have crowded out civil society, Americans do not have to look far beyond their own neighborhoods to find fellow citizens voluntarily helping each other in times of need. Such noble examples should inspire Americans to shed their dependence on government programs that breed a sense of entitlement without any responsibility. The alternative—nurturing family and community relationships that foster voluntary mutual assistance—will help restore civil society as a strong pillar of American exceptionalism.
About the Authors
David B. Muhlhausen, PhD, is Research Fellow in Empirical Policy Analysis in the Center for Data Analysis at The Heritage Foundation.
Patrick D. Tyrrell is Research Coordinator in the Center for Data Analysis.
The former Director of the Center for Data Analysis, William Beach, made a substantial contribution to this report. Former Heritage Foundation policy expert David C. John and current Heritage Foundation policy experts Daren Bakst, Diane Katz, Lindsey Burke, Alyene Senger, Rachel Sheffield, and John Ligon contributed significantly to the 2013 Index. | <urn:uuid:0408ba23-ce7f-465e-b2d7-ba22799bfc23> | {
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
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Dr. Jill F Diamond has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Jill F Diamond has the following 5 expertise
- Pediatric Diabetes
Dr. Jill F Diamond has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Jill F Diamond is Board Certified in 1 specialty
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Showing 2 of 6
I would never recommend anyone to Dr. Diamond or to this practice. In addition to seeing Dr. Diamond, he saw several other doctors as well as the nurse practioner, all of whom mid-diagnosed him with something that is very common. It wasn't until we changed pediatricians that we are now seeing positive results. It's sad that so many health care professionals couldn't figure it out. I think the practice is too big and there is no continuity. Awful experience and I want people to know so you don't have to go through months of your child suffering for something that could've been treated much sooner. Because I had to give a rating, I chose one star, but if I had my choice it would've been none.
Dr. Diamond is affiliated (can practice and admit patients) with the following hospital(s).
20 Years Experience
Tufts University School Of Medicine
Graduated in 1998
Baystate Medical Center
Dr. Jill F Diamond accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS MA Blue Care Elect PPO
- BCBS MA HMO Blue with Managed Care Behavioral Health
- BCBS MA Preferred Blue PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Harvard Pilgrim ChoiceNet HMO
- Harvard Pilgrim HMO
- Harvard Pilgrim PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Multiplan PPO
- PHCS PPO
Tufts Health Plan
- Tufts PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsPediatric Health Care Associates PC, 10 Centennial Dr Ste L, Peabody, MA
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
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Dr. Roosje S De Grauw has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Roosje S De Grauw has the following 5 expertise
- Pediatric Diabetes
Dr. Roosje S De Grauw has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Roosje S De Grauw is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
There are no reviews for Dr. Roosje S De Grauw yet. Be the first to review this doctor!
Bridges to Excellence: Physician Office Systems Recognition Program
This program is designed to recognize practices that use information systems to enhance the quality of patient care. To obtain Recognition, practices must demonstrate that they have implemented systematic office
8 Years Experience
University Of Cincinnati College Of Medicine
Graduated in 2010
Indiana University Hospital
Dr. Roosje S De Grauw accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS MA Blue Care Elect PPO
- BCBS MA Preferred Blue PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Empire Blue Priority EPO
- Empire HMO
- Empire PPO
- Empire Prism EPO Blue Priority
MVP Health Plan
- MVP Preferred PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsAdvanced Specialty Care, 500 Commack Rd, Commack, NY
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Arrhythmia Facts about arrythmia, inclding the types, symptoms and causes.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Atrial Fibrillation Facts about atrial fibrillation, including symptoms and risk factors.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Coronary Artery Angioplasty with Stent Coronary artery angioplasty with stent facts, including who needs it.
- Coronary Heart Disease Get the facts about coronary heart disease.
- Deep Vein Thrombosis Facts about deep vein thrombosis (DVT), including symptoms & causes.
- Erectile Dysfunction Facts about erectile dysfunction (ED), including causes.
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Dr. Bradley W Robinson has the following 2 specialties
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
- Pediatric Cardiology
Pediatric cardiologists are pediatricians with additional, specialized, training in the heart health of your children. When infants are born with congenital heart disease or abnormal hearts, pediatric cardiologists get involved as soon as possible — sometimes before the child is even born.
Through specific testing, they can diagnose the problem and care for the child throughout their treatment, which could range from medication to surgery and transplants. Other heart conditions they treat include arrhythmias, heart murmurs, holes in the heart and viral infections that affect blood flow.
Dr. Bradley W Robinson has the following 3 expertise
- Congenital Heart Disease (Patent Ductus Arteriosus)
- Congenital Heart Defects
Dr. Bradley W Robinson has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Bradley W Robinson is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 1 of 2
Castle Connolly Regional Top Doctors
Castle Connolly is America's trusted source for the identification of Top Doctors. Their physician-led research team reviews and screens the credentials of tens of thousands of physicians who are nominated by their peers annually, via a nationwide online process, before selecting those physicians who are regionally or nationally among the very best in their medical specialties. Castle Connolly believes strongly that Top Doctors Make a Difference™.
32 Years Experience
University Of North Carolina At Chapel Hill School Of Medicine
Graduated in 1986
Jackson Health System
Dr. Bradley W Robinson accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Select
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry DE PPO
- Coventry HealthAmerica PPO
- Coventry Southern Health PPO
- First Health PPO
Geisinger Health Plan
- Geisinger Health Plan
- Highmark Community Blue PPO
- Horizon BCBS OMNIA - TIER1
- Horizon Direct Access
- Horizon HMO
- Horizon POS
- Horizon PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- IBC Keystone HMO POS
- IBC Personal Choice PPO
- Multiplan PPO
- QualCare HMO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsNemours Alfred I Dupont Hospital For Children, 1600 Rockland Rd, Wilmington, DE
Take a minute to learn about Dr. Bradley W Robinson, MD - Pediatric Cardiology in Wilmington, DE, in this video.
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
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About Dr. Amaraseeli S Durayappah
Dr. Amaraseeli S Durayappah, MD is a Doctor primarily located in Houston, TX. She has 46 years of experience. Her specialties include Family Medicine. She speaks English.
Dr. Amaraseeli S Durayappah has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Amaraseeli S Durayappah has the following 7 expertise
- Family Planning
- Weight Loss
- Weight Loss (non-surgical)
Dr. Amaraseeli S Durayappah has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 3 of 10
Dont get me wrong but she was a verry good doctor at one point.we have been going to her office since my first born 15yrs ago but know she has slacked off alot..I have two younger children now a 4yr.old and 1yr.old & dosent do her job like she use to.shes not really intrested in what you have to say or what your diagnosed results are its more like a get in & get out visit..I think shes getting to old and always looks tired & not intrested in her job anymore.
My kids changed doctors several times in the beginning then I was introduced to Dr. Durayappah and they have been in her office since they were 18 months and 6 months old. My kids are now 9 and 7 and we will continue going there until she retires from practice. I was introduced to this Dr. by a family friend who had her when she was young and now takes her children to her office.
46 Years Experience
Medical College Of Georgia School Of Medicine
Graduated in 1972
Dr. Amaraseeli S Durayappah accepts the following insurance providers.
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS TX Blue Advantage HMO
- BCBS TX BlueChoice
- BCBS TX HMO Blue Texas
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana HMO
- Humana HMO Premier
- Humana National HMO
- Humana National POS
- Humana Preferred PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsFamily Care Clinic, 8762 Long Point Rd Ste 106, Houston, TX
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Get the facts about bipolar disorder, including the different types and symptoms of each.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- Alzheimer's Disease Facts about Alzheimer’s Disease, including the symptoms and stages.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Chronic Pain Facts about chronic pain, including body parts most commonly affected.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Diabetic Neuropathy Facts about diabetic neuropathy, including the symptoms and doctors.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
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About Dr. Kellee R Clougherty
Dr. Kellee R Clougherty, MD is a Doctor primarily located in Laguna Niguel, CA, with another office in Del Mar, CA. She has 26 years of experience. Her specialties include Child and Adolescent Psychiatry, Psychiatry and Neurology. Dr. Clougherty has received 1 award. She speaks English.
Dr. Kellee R Clougherty has the following 3 specialties
- Child and Adolescent Psychiatry
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
Dr. Kellee R Clougherty has the following 13 expertise
- Personality Disorder
- Manic Depressive Disorder
- Mental Illness
- Clinical Depression
- Depressive Disorder
- Mood Disorders
- Sleep Disorders
- Bipolar Disorder
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
Dr. Kellee R Clougherty has 2 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Kellee R Clougherty is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 5 of 22
I brought my 8 year old daughter in for an ADHD evaluation, as the school counselor suggested my daughter may had adhd. I found Dr Clougherty to be very thorough in her evaluation. She spent a lot of time with us before the appointment over the phone, and then a lot of time both with me and with our daughter. We are considering medication, but she went over all our options, risks vs benefits and how it would benefit my daughter. I found her helpful and beneficial
I saw Dr Clougherty for depression and anxiety. I have had terrific results with the medication and Therapy. I find her courteous, conscientious, compassionate, and thoughtful. I had some slight stomach upset with the meds in the beginning, and she got me in the same day to discuss my care. I'm doing great thanks to Dr Clougherty.
Don't make the same painful mistake my family made. I thought all physicians got poor ratings posted about them...but the stern cautions voiced here could have saved us great anguish. We trusted Dr. Kellee Clougherty with the care of our teenager struggling with depression. Our 8 visit experience was so detrimental, I am compelled to share here the sternest of warnings! This psychiatrist was unprofessional, impatient, rude, superficial, disconnected and self-serving. Her real concern was only felt when we left. Even if Dr. Clougherty is the ONLY adolescent psychiatrist on your health plan, go out-of-network before wasting your time with this one!
I have been seeing Dr Clougherty for over a year now, and must say that she is at the top of her game.Not only did she get me off the medication that was causing me numerous problems, but she has been the one that has caused me to be much more in control of my life. Her practice is busy, and she has rules about cancellations. She has to! if you follow the rules that she outlines for her office, all will be good!
On-Time Doctor Award (2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
26 Years Experience
Loyola University Chicago Stritch School Of Medicine
Graduated in 1992
University Of California At Davis
Dr. Kellee R Clougherty accepts the following insurance providers.
Blue Cross California
- Blue Cross CA PPO Prudent Buyer Small Group
- Blue Cross CA Advantage PPO Preferred DirectAccess Plus
- Blue Cross CA PPO Prudent Buyer Individual
- Blue Cross CA PPO Prudent Buyer Large Group
- Blue Cross CA Pathway X PPO
- Blue Cross CA Select PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- CIGNA Southern CA Value
- Cigna Southern CA Select
Locations & Directions
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M-50 50/C high-speed modem cable - The 50/C cable assembly has the same function as the V.35 but allows for more circuit capability.
mA (milliampere) - One-thousandth of an ampere.
MAC (media access control) - The method by which network stations gain access to the network media and transmit information as part of the second layer of the OSI model.
Magnet wire - Insulated wire used in the windings of motors, transformers and other electromagnetic devices.
Magnetic field - The field created when current flows through a conductor; especially a coiled conductor.
Main cross-connect - A cross-connect for first level backbone cables, entrance cables and equipment cables.
Main distribution Ethernet - See STANDARD ETHERNET.
Main ring path - The party of the ring made up of access units and the cables connecting them.
Main trunk - The major link(s) from the headend or hub to downstream branches.
MAN (metropolitan area network) - A data network linking together terminals, memories and other resources at many sites within a city area. Each site may have its own local area network (LAN). Links between sites are usually on digital circuits rented from the local telephone company using a bit-rate appropriate to traffic requirements.
Manchester code - A means of coding a single bit of data with two signaling pulses in the same time slot (0, 11, 1, 00), so there is a signal event for every bit of data, whether a 1 or a 0. This simplifies the clocking needed to interpret the bit stream at the receiving end.
Manual iris lens - A lens with a manual adjustment to set the iris opening (f-stop) in a fixed position. Generally used for fixed lighting applications.
MAP (Manufacturing Automation Protocol) - The OSI profile championed by General Motors Corporation to provide interconnectivity between plant hosts, area managers and cell controllers over a broadband token-passing bus network.
MAP (multiservice access platform) - Like a DSLAM they can provide service over copper wire using DSL technology but MAPs carry additional capabilities by also supporting FTTH and other types on interfaces out of the same platform. It has Quos capabilities also.
MAP/TOP (Manufacturing Automation Protocol/Technical Office Protocol) - MAP originally developed by General Motors, defines OSI protocols and application utilities for use in the manufacturing environment. TOP, originally developed by Boeing, performs the same function for the office.
Mark - 1. In single-current telegraph communications, represents the closed, current-flowing condition. 2. In data communications, represents a binary 1; the steady state, no-traffic state for asynchronous transmission. 3. The idle condition.
Marker tape - A tape laid parallel to the conductors under the sheath in a cable, imprinted with the manufacturer’s name and the specification to which the cable is made.
Marker thread - A colored thread laid parallel and adjacent to the strand in an insulated conductor that identifies the manufacturer and sometimes the specification to which the wire is made.
Mastic - A meltable coating used on the inside of some shrink products that when heated flows to help create a waterproof seal.
MAT - Metropolitan area trunks.
Matrix switcher - A switcher able to route any of its (camera) inputs to any of its (monitor) outputs, they often include telemetry control.
MATV (master antenna television system) - A small, less expensive cable system usually restricted to one or two buildings such as hospitals, apartments, libraries, hotels, office buildings, etc.
MAU (media access unit) - Circuitry used in LANs to enable data terminal equipment to access the transmission medium.
Maximum cable diameter - The largest cable diameter that a high-voltage cable termination is designed to accommodate.
Maximum design voltage - The maximum voltage at which a high-voltage cable termination is designed to operate continuously under normal conditions.
Mbps (megabits per second) - A unit of data transmission speed.
MC - Main cross connect.
MDF - Main distribution frame.
MDPE (medium-density polyethylene) - Usually used as cable jacketing.
MDU (multiple dwelling units) - Apartment buildings and condominiums.
Mechanical focus (back-focus) - The mechanical aligning of the imaging device with the focal point of the lens; it is most important on zoom lenses to be sure the image stays in focus throughout the zoom range.
Mechanical water absorption - A check of how much water will be absorbed by material in warm water for seven days (mg/sq. in. surface).
Medium frequency - The band of frequencies between 300 and 3,000 kilohertz.
Medium voltage - A class of nominal power system voltage ratings between 2.4 and 46 kV.
Medium-and hard-drawn wire - As applied to copper wire, having tensile strength less than the minimum for hard drawn wire, but greater than the maximum for soft wire.
Mega - Prefix meaning million.
Megahertz (MHz) - One million cycles per second.
Megger - A special ohmmeter for measuring very high resistance. Primarily used for checking the insulation resistance of cables; however, it is also useful for leakage tests.
Melinex - ICI trademark for polyester. See MYLAR.
Melt index - The extrusion rate of a material through a specified orifice under specified conditions.
Member - A group of wires stranded together that is in turn stranded into a multiple member conductor.
Messenger wire - A metallic supporting member either solid or stranded which may also perform the function of a conductor.
MFD - Microfarad (one-millionth of a farad). Obsolete abbreviation.
MFT - Abbreviation for 1,000 feet. M is one thousand in the Roman numeral system.
MG - Glass reinforced mica tape insulated cable with an overall sheath of woven glass yarn impregnated with a flame, heat and moisture resistant finish. 450°C, 600 V appliance wire.
MHO - The unit of conductivity. The reciprocal of an ohm.
MHz (megahertz) - One million cycles per second.
MI - A UL cable type. One or more conductors insulated with highly compressed refractory minerals and enclosed in a liquid-tight and gas-tight metallic tube sheathing.
MIB (management information base) - A set of descriptions of manageable features, used with SNMP devices. MIBS are unique per manufacturer and assigned by the IANA (Internet Assigned Numbers Authority).
MIC - 1. Media interface connector. A FDDI fiber connector or an IBM Type 1 connector. 2. Multifiber indoor cable. A corning term.
MICA - A transparent silicate that separates into layers and has high insulation resistance, high dielectric strength and high heat resistance.
MICE (mechanical, ingress, climatic and electromagnetic) - A TIA rating system for the survivability of cabling components in varying degrees of environmental challenges.
Micro - Prefix meaning one-millionth.
Micro-bending loss - A signal loss due to small geometrical irregularities along the core cladding interface of optical fibers.
Microfarad - One-millionth of a farad (µf, µfd, mf, and mfd are common abbreviations).
Micro-microfarad - One millionth of a microfarad (µµf, µµfd, mmf, mmfd are common abbreviations). Also, a picofarad (pf or pfd).
Micron (µm) - One-millionth of a meter.
Microphone cable - A very flexible, usually shielded cable used for audio signals.
Microphonics - Noise caused by mechanical movement of a system component. In a single conductor microphone cable, for example, micro phonics can be caused by the shield rubbing against the dielectric as the cable is flexed.
Microprocessor - A computer-on-a-chip.
Microwave - A short (usually less than 30 cm wavelength) electrical wave.
Mid-split - A broadband cable system in which the cable bandwidth is divided between transmits and receives frequencies. The bandwidth used to send toward the headend (reverse direction) is approximately 5 MHz to 100 MHz and the bandwidth used to send away from the head-end (forward direction) is approximately 160 MHz to 300 MHz.
Mil - A unit of length equal to one thousandth of an inch.
MIL-DTL-16878 - A military specification covering various wires intended for internal wiring of electric and electronic equipment. Formerly MIL-C-16878.
MIL-DTL-17 - A military specification covering many coaxial cables. Formerly MIL-C-17.
Milli - Prefix meaning one-thousandth.
MIL-SPEC - Military specification.
MIL-W-22759 - A military specification for fluorocarbon insulated copper and copper alloy wire. Replaced by SAE AS22759.
Minimum cable diameter - The smallest cable diameter that a high-voltage cable termination is designed to accommodate.
Minimum object distance (MOD) - The closest distance a given lens will be able to focus upon an object. This is measured from the vertex (front) of the lens to the object. Wide angle lenses generally have a smaller MOD than large focal length lenses.
MIPS (millions of instructions per second) - One measure of processing power.
Mj (modular jack) - A jack used for connecting voice cables to a faceplate.
MMDS (multichannel multipoint distribution service) - Fixed wireless/wireless broadband.
MMJ (modified modular jack) - A jack used for connecting data cables to a faceplate.
Modem eliminator, modem emulator - A device used to connect a local terminal and a computer port in lieu of the pair of modems that they would expect to connect to; allows DTE to-DTE data and control signal connections otherwise not easily achieved by standard cables or connectors. Modified cables (crossover cables) or connectors (adapters) can also perform this function.
Modem - A contraction of modulate and demodulate; a conversion device installed in pairs at each end of an analog communications line. The modem at the transmitting end modulates digital signals received locally from a computer or terminal; the modem at the receiving end demodulates the incoming analog signal, converts it back to its original (i.e., digital) format and passes it to the destination device.
Modular plug - A series of connecting devices adopted by the FCC as the standard interface for telephone and data equipment to the public network. The most common is the RJ11, used to connect a single line phone and RJ45 for data.
Modular - Equipment is said to be modular when it is made of plug-in-units that can be added together to make the system larger and improve its capabilities or expand its size. There are very few phone systems that are truly modular.
Modulate - To change or vary some parameter such as varying the amplitude of a signal for the amplitude modulation or the frequency of a signal for frequency modulation. The circuit that modulates the signal is called a modulator.
Modulation - 1. The act of modifying the amplitude, phase or frequency of a carrier to allow the transmission of information. 2. The process by which a carrier is varied to represent an information carrying signal. See AM, FM and PHASE MODULATION.
Module - 1. In hardware, short for card module. 2. In software, a program unit or subdivision that performs one or more functions.
Modulus of elasticity - The ratio of stress (force) to strain (deformation) in a material that is elastically deformed.
MOF - Metal-clad optical fiber.
Moisture absorption - The amount of moisture, in percentage, that a material will absorb under specified conditions.
Moisture resistance - The ability of a material to resist absorbing moisture from the air or when immersed in water.
Molded plug - A connector molded on either end of a cord or cable.
Mono filament - A single-strand filament as opposed to a braided or twisted filament.
Monochrome signal - In monochrome television, a signal for controlling the brightness values in the picture. In color television; the signal that controls the brightness of the picture, whether the picture is displayed in color or in monochrome.
Monochrome - Having only one color. In television it is black and white.
Monomer - The basic chemical unit used in building a polymer.
Motor lead wire - Wire that connects to the fragile magnet wire found in coils, transformers and stator or field windings.
MPEG - Motion Picture Experts Group.
MPF - Mine power feeder cables. Usually rated 5, 8, or 15 kV.
MPLS (Multiprotocol Label Switching) - A connection-oriented switching, not routing, technology, used as a mechanism for assuring QOS on IP networks.
MSDS - Material safety data sheets.
MSHA - Mine Safety and Health Administration. The Federal enforcement agency for employee safety in mines and mills. Formerly known as MESA, Bureau of mines. MSHA regulations appear in CFR (Code of Federal Regulations) Title 30, Chapter 1.
MTU - Multiple tenant units (office buildings).
MTW - Machine tool wire, a UL cable type. Thermoplastic insulated, 90°C to 105°C, 600 V. UL 1063 is the governing standard.
Multicast - The ability to broadcast messages to one node or a select group of nodes.
Multi-drop - See MULTIPOINT CIRCUIT.
Multimode - Optical fiber that allows more than one mode of light to propagate. A step-index fiber has a core of uniform refractive index while in a graded-index fiber the refractive index of the core smoothly varies with the radius.
Multiple-conductor cable - A combination of two or more conductors cabled together and insulated from one another and from sheath or armor where used.
Multiple-conductor concentric cable - An insulated central conductor with one or more tubular stranded conductors laid over it concentrically and insulated from one another.
Multiplex - The use of a common physical channel in order to make two or more logical channels, either by splitting of the frequency band (frequency-division multiplex) or by utilizing this common channel at different points in time (time-division multiplex).
Multiplexing/multiplexers - 1. Equipment that permits simultaneous transmission of multiple signals over one physical circuit. 2. The division of a composite signal among several channels; concentrators, FDMs and TDMs are different kinds of multiplexers.
Multipoint circuit - A single line connecting three or more stations.
Multipoint circuit - A single line connecting three or more stations.
Multiport repeater - A repeater that is used to connect more than two cable segments.
Multiport transceiver - Multiple transceiver connection packaged in a common rack. Provides one transceiver attachment to the trunk cable and the ability to serve up to eight stations.
Multi-segment LAN - A LAN that is composed of more than one coaxial cable segment.
Multi-station access unit - In the IBM Token-Ring Network, a wiring concentrator that can connect up to eight lobes to a ring network, the 8228. Also the four-lobe unit from General Instrument that uses Type 3 Media Cable.
Murray loop test - A method used to localize cable faults.
Mutual capacitance - Capacitance between two conductors in a cable.
MUX (multiplex) - To transmit two or more signals over a single channel.
Muxer - Multiplexer. Electronic equipment which allows two or more signals to pass over one telephone line.
MV (medium voltage) - Cables usually rated 5 to 35 kV.
mV (millivolt) - One-thousandth of a volt.
mW (milliwatt) - One-thousandth of a watt.
Mylar - DuPont trademark of polyethylene terephtalate (polyester) film. See MELINEX. | <urn:uuid:2211ea26-4489-4e37-8396-5cac44ebaf63> | {
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Billable Medical Code for Dermatophytosis of Nail
Diagnosis Code for Reimbursement Claim: ICD-9-CM 110.1
Code will be replaced by October 2015 and relabeled as ICD-10-CM 110.1.
Onychomycosis is also known as dystrophic onychomycosis, onychomycosis, onychomycosis (nail fungal infection), onychomycosis/dystrophy, and total dystrophic onychomycosis. This applies to dermatophytic onychia, onychomycosis, and tinea unguium.
Onychomycosis Definition and Symptoms
Onychomycosis is a fungal infection in the toe or fingernails that can include all components of the nail. The infection begins underneath the nail and causes the nail to look opaque and brittle. Symptoms include thickening of the nail, pain when standing, and a sensation of prickling or tingling in the toe or finger. | <urn:uuid:88b35aeb-b9e3-44b5-a33c-20b5882a1bca> | {
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More than 22 million Americans of all ages have asthma. Prepare to talk to your doctor about symptoms, diagnosis and treatment options.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
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Dr. Domenico Zanolin has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Domenico Zanolin has the following 5 expertise
- Pediatric Diabetes
Dr. Domenico Zanolin has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Domenico Zanolin is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 2 of 10
Patients' Choice Award (2012, 2013, 2014)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2012, 2013, 2014)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
On-Time Doctor Award (2014)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
33 Years Experience
Universita Degli Studi Di Padova
Graduated in 1985
University Hospital Suny Stony Brook
Dr. Domenico Zanolin accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Elect Choice EPO
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna NYC Community Plan
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS MA Blue Care Elect PPO
- BCBS MA Preferred Blue PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Connecticare Flex Connecticut
- Empire Blue Priority EPO
- Empire HMO
- Empire PPO
- Empire Prism EPO Blue Priority
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
MVP Health Plan
- MVP Preferred PPO
- Multiplan PPO
- PHCS PPO
- Oxford Metro
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsSuffolk Pediatric Associates Pc, 1111 Montauk Hwy Ste 104, West Islip, NY
Dr. Domenico Zanolin is similar to the following 3 Doctors near West Islip, NY. | <urn:uuid:fbdddfa1-c3ca-44b5-b775-c25da3059f8d> | {
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Get the facts about bipolar disorder, including the different types and symptoms of each.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- Alzheimer's Disease Facts about Alzheimer’s Disease, including the symptoms and stages.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Chronic Pain Facts about chronic pain, including body parts most commonly affected.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Diabetic Neuropathy Facts about diabetic neuropathy, including the symptoms and doctors.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Book Online Now
Dr. Dena B Dubal has the following 2 specialties
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
Dr. Dena B Dubal has the following 10 expertise
- Multiple Sclerosis (MS)
- Migraine Disorder
- Middle Cerebral Artery Infarction
- Brain Ischemia
- Alzheimer's Disease
- Nerve Conduction Studies
Dr. Dena B Dubal has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 8
Patients' Choice Award (2008, 2009, 2010, 2011)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2010)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
15 Years Experience
University Of Kentucky College Of Medicine
Graduated in 2003
Dr. Dena B Dubal accepts the following insurance providers.
- Aetna Basic HMO
- Aetna Choice POS II
- Aetna HMO
- Aetna HMO Deductible Plan CA only
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Aetna Vitalidad Plus CA con Aetna
BCBS Blue Card
- BCBS Blue Card PPO
- Health Net CA HMO Employer Group
- Health Net CA Individual and Family PPO
- Health Net CA PPO
- Humana Choice POS
- Multiplan PPO
- PHCS PPO
- PHCS PPO Kaiser
Locations & DirectionsUcsf Medical Center, 505 Parnassus Ave, San Francisco, CA
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Am Fam Physician. 2014 Mar 1;89(5):368-377. Up to 50% of children will experience a sleep problem. Early identification of sleep problems may prevent negative ...
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Sleep debt is the effect of not getting enough sleep; a large debt causes fatigue, both mental and physical. Sleep debt results in diminished abilities to ...
Pediatric Parasomnias - Sleep
(sleep disorders - parasomnia)
Types of parasomnia sleep disorders. There are many different types of parasomnia, but one of the most well-known or talked about is night terrors.
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THE SLEEP CLINIC in Edmond, OK - Oklahoma County is a business listed in the categories Sleep Disorders Centers, Physicians & Surgeons, Offices Of Physicians (Except ...
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Harrisonburg Virginia Sleep Specialist Doctors physician ... Learn about sleep apnea, including a description of types of sleep apnea, ... Sleep Disorders ...
Health News and Information - News Medical
Cyclothymia is a mild form of bipolar disorder. It is characterized by mood fluctuations that shift between depressive and hypomanic phases.
Sleep Disorders Type | Froedtert Hospital | Milwaukee, Wis.
A list of all mental disorders, mental illness and related mental health conditions, their symptoms and treatment.
Biphasic and polyphasic sleep - Wikipedia
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Sleep Genius - World's #1 Sleeping App - Sleep Better & Longer
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(sleep disturbed by anxiety)
MDGuidelines is the most trusted source of disability guidelines, disability durations, and return to work information on anxiety disorder generalized. | <urn:uuid:28548028-6eef-48d8-bb3d-ce18f701290c> | {
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Support World Kidney Day with Proper Coding
On World Kidney Day, March 8, take a moment to refresh your understanding of chronic kidney disease (CKD) and how to properly code this unfortunate diagnosis.
One in seven Americans has CKD — more women than men: CKD affects 16 percent of women and 13 percent of men, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health (NIH). Most people with this condition don’t know they have it.
Stages of Chronic Kidney Disease
CKD is a mixed bag of conditions characterized by changes in kidney structure and function. The manifestation of these conditions is based on the underlying cause and severity of the disease.
According to the National Kidney Foundation, Kidney Disease Outcomes Quality Initiative (NKF KDOQI) for renal diseases, the list of clinical parameters shown in the table below is provided for staging CKD. The provider must document the stage and be queried in the absence of documentation.
|Stage||Description||GFR (mL/min/1.73 m2)|
|1||Kidney damage with normal or ↑ GFR||≥ 90|
|2||Kidney damage with mild ↓ GFR||60 – 89|
|3||Moderate ↓ GFR||30 – 59|
|4||Severe ↓ GFR||15 – 29|
|5||Kidney failure||< 15 (or dialysis)|
|Chronic kidney disease is defined as either kidney damage or < 60 mL/min/1.73 m2 for ≥ 3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.|
Coding the Stages of CKD
The ICD-10-CM code is assigned to depict the documented severity (stage) of CKD:
- N18.1 Chronic kidney disease, stage 1
- N18.2 Chronic kidney disease, stage 2 (mild)
- N18.3 Chronic kidney disease, stage 3 (moderate)
- N18.4 Chronic kidney disease, stage 4 (severe)
- N18.5 Chronic kidney disease, stage 5
Code N18.6 End stage renal disease is assigned only when the provider has documented end-stage renal disease (ESRD). Encounters where both a stage of CKD and ESRD are documented, report N18.6, only.
Coding Cause-and-Effect Relationships
CKD is often due to nephrotic syndrome. Nephrotic syndrome is associated with overexcretion of protein in the urine (proteinuria); edema of lower extremities, face, and abdomen; and damage to the blood vessels of the nephron. Only assign the code for nephrotic syndrome when the physician specifically states the patient has it. See N04.1-N04.9 in ICD-10-CM for the appropriate code assignment.
Hypertension is one of the leading causes of CKD. ICD-10-CM presumes a cause-and-effect relationship between hypertension and CKD. You are directed to combine the two when the chart indicates the patient has both hypertension and CKD. The exception to this rule is when the provider specifically states the two are not related.
Code I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease or I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease is assigned with the appropriate N18.x code.
Healthy lifestyle changes can help prevent and manage kidney disease and its main causes: diabetes and high blood pressure. Given the impact of kidney disease on women, the NIDDK encourages all women to learn about risk factors and talk with healthcare professionals. Taking action now can help protect your kidneys. Here are ways to reduce your risk:
- Choose healthier foods, such as fresh fruits, fresh or frozen vegetables, whole grains, and low-fat or fat-free dairy products.
- Be physically active for 30 minutes or more on most days.
- Reduce screen time, and aim for 7 to 8 hours of sleep each night.
- Join family, friends, or coworkers in encouraging each other to stick to a healthy routine.
- Use the NIH Body Weight Planner to help achieve and stay at a healthy weight.
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Building Mobile Web Sites
There are around 500 million smartphones out there in the world (early 2012). Android is growing at 850000 device activations per day. Apple’s iOS devices are in the range of 500000 per day and
a recent study by Gartner suggest that within the next 2 years more people will use mobile devices than traditional computers to go online. Furthermore web only companies like Facebook and Google are already reporting that well over a third of their usage is from mobile devices. If you are reading this article these numbers may not be surprising but the stunning part is that only a small fraction of web sites are optimized for mobile. The reasons are varied but the short version is that web capable mobile devices are spreading far faster than anticipated — and most companies have just started to consider mobile optimization a core requirement. The good news is that this gap creates opportunity for people with the skills to create a mobile optimized web experience.
The skills tools and techniques required to create a web page are quite mature. However many of these techniques were conceived and designed for use on larger screens with a keyboard and a mouse rather than for a small screen with a touch interface. Thankfully over the last 5 years many of the early adopters of mobile web identified a number of useful patterns and techniques.
In this master class we look at the core areas to cover when create a mobile optimized web page. The article is presented with the assumption that the reader has a basic working knowledge of HTML and CSS. We will discuss the accepted best practices and highlight issues that one should address when creating mobile web sites rather than purely presenting code snippets. Additionally a typical question that arises when designing mobile application is — “Should we build a native application or create a mobile optimized web site?”. This article ends with some guidance on how to answer this question when it arises in your own projects. All resources used in the master class series are available on GitHub at http://github.com/rvasa/medroid.
A Short Recap
Before getting into the details of mobile web here is a recap of the core Android concepts covered in the previous masterclasses. An Android application is made up of Activities that map to an individual window / screen of functionality in an application. We place UI components (called Views) inside a container called a layout and attach this layout container to an activity. The UI is described in an XML file and paired with a Java class that provides the interactivity. The Android framework mandates conventions which specify a set of folders that every Android project must have. The conventions specify location of resource such as images and data for the development tools to process them and generate references to use these resources from within the XML UI description files and Java code. The framework is designed to help developers construct UI that works on devices with varying screen sizes with minimal pain.
Every activity in an Android application has its own life cycle and activities communicate between each other using short messages known as intents. The Android architecture allows any application to send a message to another other application via intents. This flexibility permits developers to make use of functionality provided by other applications with minimal pain. For instance we can broadcast a message requesting display of a web page and all registered browsers will respond – the user then has the choice of selecting the application that they want to use (we will make specific use of this feature in this master class).
As elaborated in previous master class articles Android applications can make use of Maps via the use of Google APIs that are available as a free add-on from within the Eclipse IDE. We can also build applications that incorporate image galleries video and audio by using the media APIs provided as part of the SDK. The platform also provides us with a rich data persistence layer including a light weight database management system that allows us to use SQL. Furthermore as discussed in the previous master class Android allows us to style and theme applications globally as well as at the activity level.
Mobile Web Vs Traditional Web
Many smartphone users initially start by having fun with games and the new apps. However as soon as they start exploring the web on their new devices they find the whole experience frustrating. An example of how a traditional web site will render on a mobile phone is shown in Figure 1. In effect the entire web page will render in a 3″ or a 4″ physical screen and feels like a caricature rather than a site that provides useful information. The only way a user can use these unoptimized sites is via a pinch-zoom and then wandering around to find what they want. If the user is familiar with the web page they may be able to issue sufficient touch gestures and squint their eyes into various angles to get some information out of it. Of course a safe assumption is that most users will move on to a competitor that offers an optimal mobile web experience.
Figure 1 – The web page of Australian Securities Exchange (Stock Market) as it will render on a smartphone
The differences between mobile web and traditional web boil down to the following:
- There are many different web browsers for the mobile — each of them with its own personality.These browsers have varying levels of maturity and support web standards ever so differently. More importantly many users never update the browser or the operating system of their phone. In fact most users would not even know what an operating system is.
- Mobile devices are smaller and also slower. In fact much slower than a traditional computer if they have to render a complex page.
- There is no physical keyboard and we all have fat fingers (compared to a mouse pointer)
- There is a significant font size difference in what we can read on screen and what we need to touch. We often can read a 14 pt font but will not be able to touch a hyper-link in that size accurately especially if there are 3 links nearby.
- The mobile network is comparatively unreliable and the bandwidth varies with signal strength.
- A good chunk of mobile devices are incapable of Flash and embedded plugin scripts (e.g. Youtube) may not work.
In practice due to these differences a traditional web page will take a long time to load may have links that are just too hard to click may not be able to show embedded videos and most likely will render inaccurately on many devices. The bottom line of course is that the unoptimized website is sending an “off limits” signal to many existing and new users. So what are the key areas that one should address? Is it just a matter of changing the CSS as is generally recommended? The short answers first – ideally you should cut the content down and use a single column layout with mobile optimized images. Also simply switching CSS is insufficient. A more detailed answer to these questions and more is in the sections that follow.
Why do web pages need mobile optimization?
A traditional web page used to be simple back when the web was young (circa 2000). These days a web page may appear quite simple but there is significant amount of detail that the browser has to process and render. The latest version of Firefox ships with a 3D page visualizer that highlightsthis complexity and Figure 2 illustrates the point by showing a 3D break-down of the APC home page. A traditional computer often has the grunt and more importantly the RAM to load all of the objects needed to determine the proper layout for a web page. Unfortunately mobile devices do not have the RAM and only recently have started to carry serious CPU power. So how much RAM do we really need to render a web page? The precise answer will depend on the actual page but a crude benchmark shows that Firefox needed nearly 40Mb of RAM to load and render the non-mobile optimized APC home page. That number may appear quite small but on a mobile phone it is quite a big chunk of the RAM available and very much precious.
Figure 2 – 3D visualization of the APC home page. There is a lot more complexity than is visible to the user.
The most obvious feature (a curse and a boon) of a mobile device is its relatively small screen. The implication of this is that the traditional two or three column web page layout just does not work on smart phone even for young eyes (of course it is the classic fail scenario for anyone with a more mature eye sight). Furthermore any link or zone that we want the users to touch has to be fairly large. In practice this means that if a web page has too many hyper-links in close proximity then the user cannot click them without using a zoom-in gesture. Figure 3 illustrates this exact point using the web site of Roget Ebert a well regarded movie critic. The links in the right half of the image cannot be clicked without a pinch-zoom. Unfortunately if your zooming-in skills are in need of practice you are quite likely to click on one of these links unintentionally while attempting a pinch-zoom.
Figure 3 – A web site that illustrates the difficulty of selecting links when they are too close to each other.
Mobile Optimized Web Page
Keep it Quick: Studies on behavior of mobile users show that the typical user tends to look at a mobile site for only a few minutes. This will mean that the design has to ensure that the content is properly targeted for mobile use with small paragraphs of content that make minimal use of images. It also has to rely on a simple layout to speed up rendering and reduce the need for RAM (see Figure 4 that illustrates a mobile optimized web page from NineMSN).
Figure 4 – A mobile optimized web page has minimal rendering complexity and fewer objects.
Fit the Mobile Context: Users tend to use their mobile devices to find information on the go. In practice the design has to be focused to get the user to key information in the least number of steps and also any data input fields should be sufficient large with as many fields as possible automatically filled in. In particular try not to ask the user for too much information and anything that they need to look up from another source other than their memory.
Simplify Navigation and Prioritize Content: The traditional two or three column web page layout model emphasis navigation either at the top of the page or to the left. On a mobile device when you are using a single column layout the best option is to prioritize the core content and move all navigation down to the bottom of the page. In general users tend to look up specific information on their mobile devices rather than use it to graze for information (although it may happen on a long commute). Even when using navigation links it is best to keep the number small — as in well under 10. The other good practice is to reduce the nesting hierarchy of the navigation and to communicate the depth using bread crumbs or similar design hints.
Be thumb friendly: Links should be large and touch friendly. We said that earlier as well — but another design choice is to make the web page single-hand use friendly. That is make the touch zones large enough for the thumb — although this is not always practical.
Seamless Interactions: This aspect is best illustrated with an example. Consider the design of a mobile optimized web site with a shopping cart. In the early days of web commerce when users added a product into their shopping cart they got moved to a different page and had to navigate back to the product listing. These days many sites use AJAX to ensure that they can add a product into the shopping cart in the background. On the mobile a similar AJAX like interaction is needed along with a strong visual cue to confirm the interaction. Additionally it is also important to provide access to the shopping cart icon (with a number next to it to indicate the size) through out the web site.
Visibility and Contrast: Mobile phones are used in a range of lighting conditions. But the light often reflects off the surface much differently to a computer screen as well. In effect this means that we have to select colors that work well in the external (natural) environment rather than under artificial lighting conditions. The other limitation is that the font often has to be larger than on the traditional desktop with an option to potentially change the font size if needed.
We covered the issues facing mobile web as well as suggested good practices. But what are the technical aspects? The short answer is that we need to create a mobile CSS and set the view port carefully. We also have to serve optimized images for mobile devices and be aware of the fact that Flash video may not work on many devices. The rest of this article addresses each of these in some detail.
Switching CSS for Mobile Web Page
The browsers on even older generation smartphones have excellent support for HTML and CSS standards. Hence when creating a web page we can certainly change the styling for mobile devices using a great deal of precision. The typical way to achieve this is via the use of CSS media queries. Currently many web sites use this feature for creating printable pages but this feature can also be used for supporting a mobile device. In fact these queries are powerful enough to allow us to create different style sheets for different mobile screen sizes allowing us to target tablets as well as a range of different screen sizes more precisely.
A CSS media query is shown in the code snippet below and this is inserted into the header section of the HTML document. The link tag is used to connect a HTML page with a CSS style file but the real power is that it also allows the developers to specify rules to select different style files. The code below translate to — if you have a screen with a horizontal resolution equal to or less than 320 pixels then apply the mobile style sheet. If the device has a larger screen this particular line has no effect.
<link rel="stylesheet" type="text/css" media="screen and (max-device-width: 320px)" href="mobile.css" />
The media query standard allows quite a bit of flexibility. In fact we can specify orientation DPI minimum width and combine the rules using both OR and AND conditionals. Depending on time available for designers and importance of mobile customers you can create CSS files for different mobile devices and orientations that you want to support. See http://bit.ly/xD1jeS for a complete reference of the various rules that are possible and how to mix them for your needs.
A short note is warranted regarding media queries. Sadly IE8 browser (or below) do not understand media queries. They support linking to a style sheet but do not understand the query component and hence you need to put in a bit of hack around for it. The following lines of code in the HTML head section will provide that work around. If you have ever wondered why web developers dislike older IE browsers this is just one of the many reasons. Microsoft claims to be a changed company these days — you can see the reality of support for current and emerging technologies by loading http://html5test.com/ using a MS browser.
<!--[if lt IE 9]> <link rel="stylesheet" type="text/css" media="all" href="style-ie.css"/> <![endif]-->
Using Viewport to Control Layout
Using mobile specific CSS is one part of the story. However in some cases we want to explicitly tell the browser the intended dimensions for the content and more importantly the scaling (zoom level) to use. In HTML we have a meta tag specifically to control this behavior and we can use that in combination with CSS media queries as needed.
One feature that we get with view ports is that we can disable the pinch zoom gesture on certain pages. If you are wondering why one would want to do this — it all comes down to allowing components like maps to work properly. That is when the user issues a touch gesture on top of a map view we can pass that information to the scripts and get the zooming to work as expected. An additional reason is that in some devices if we zoom in and then rotate then the content gets cut off rather than get loaded again for that orientation.
The code snippets below shows how to control the view port. These lines are also placed as part of the HTML header section. The first line shows how to set the initial zoom level of ensure that the content is styled for the device width (as opposed to getting the 980px default from the browser). The second line shows how we can set the maximum scale and in effect disable zooming in.
<meta name="viewport" content="width=device-width initial-scale=1" /> <meta name="viewport" content="width=device-width initial-scale=1 maximum-scale=1" />
Serving Optimized Images
We mentioned earlier that we need to serve images optimized for mobile web. Sadly the HTML standard does not allow us to serve different images based on device capabilities. So what is the way around this? If you are using a content management system that support mobile web then the CMS software will do the magic for you (to some extent). However if you are serving a smaller web site then you can make use of a cloud service called Sencha.io which will serve the most optimal image based on the device user-agent information. As a developer you upload the image to Sencha’s servers and then point to them from the IMG tag. The service offed by Sencha is quite powerful and allows a great level of control on how the image is resized as well as optimized. A detailed discussion on how to make use of Sencha’s service is provided at http://bit.ly/xXCcCY.
Video on Mobile Web
The use of video on the traditional web is near ubiquitous and is slowly starting to increase on the mobile web. Interestingly many mobile devices do not have Flash support — the most widely used technology for delivering video. The added problem is that Android devices (in theory) support Flash but iOS devices do not. Though tempting to punish iOS users with the “no video for you” message we need to serve all mobile web users to ensure a large customer base for our services. So what is the way out? We can rely on the video tag supported by many of the new browsers but most video streaming services prefer to use the iframe tag. The motivation is that using this tag the streaming server will auto-detect the device and its capabilities and will serve content either using Flash or built-in HTML5. The following code snippet shows how to make use of this tag to embed a Youtube video — you have to provide the video identifier. Other streaming services have their own documentation but the model is similar.
<iframe class="youtube-player" type="text/html" width="310" height="160" src="http://www.youtube.com/embed/VIDEO_ID" frameborder="0"> </iframe>
Server Side Detection
Mobile web sites should aim to load faster and fit the context and usage profile of the users. A typical starting point for anyone with an existing web site is to adjust the CSS and retain the content as much as possible. This is an excellent starting point and better than serving the traditional multi-column page. However if you study the web sites that are attracting great usage via mobile they adjust the layout and serve different content for mobile. They also change the entire navigation structure to suit a mobile context. The content change is often needed because we need to communicate a different story often using different images to ensure strong engagement. However how do we serve mobile users their special content automatically? The safest and best option is to place the content is different locations on the server and point to that via the use of a script in the web server. Although this may appear hard there is a web service called Detect Mobile Browsers that will do the actual hard work by generating a script to direct traffic based on device capabilities. We have to tell this service the language that we want the script to be and it does the rest with support for scripts in PHP Apache scripts C# and a number of other languages including Java.
Native App or Mobile Optimized Web Application
In this master class series the focus has predominantly been on constructing native applications. A popular question that is receiving a lot of attention is — “Are native applications better than mobile optimized web applications?”. The best way to respond to this question is to say “it depends” — and then quietly run away from the scene. However if you are still pressed to answer then the following information will help. Sadly you will still have to perform a trade-off based on the actual situation and problem at hand.
Existing traditional web sites with a regular user base should work on providing a mobile optimized version of their content. At a minimum a mobile CSS. If resources and budget permit create a site designed for mobile users that loads fast and has a navigation designed for mobile users. The same advise applies to existing web applications. However this often involves fairly serious design work especially to find an elegant navigation model as well as adjusting content to fit the smaller screen space.
The decision for new services is much harder of course. Going for a mobile optimized web application allows the business to target both iOS and Android users. However the primary downside is that smartphone users are used to launching applications from an icon rather than going to a web site like we tend to do on the traditional computer. Research also shows that mobile users do not make use of features like bookmarks on smartphones making it clumsy to navigate to a web application. A work around that offers the launch icon as well as the ability to serve a web application is possible by using hybrid technologies — essentially these involve creating an application with a WebView component that is hard wired to pull in a preset web site. We made use of this technique already in the Masterclass series to display the twitter feeds in the MeDroid application. We can do the same but for our own web site. If you intend to go down the hybrid path frameworks like PhoneGap and Sencha Touch also help web developers create applications using web technologies — the best part is that these frameworks help us make use of the touch interface effectively and also offer some access to the device sensors.
Mobile optimized web applications do offer some compelling benefits: (i) they allow us to make changes on the server side without having to ship a new version of the application (ii) we can create a single application and ship to both Android as well as iOS users and (iii) we can build these application using web technologies that are more accessible. When we combine this with a technology like PhoneGap we get the best of both worlds — so why should we bother with native application at all? The simple answer is that users expect silky smooth user interface and a robust experience. Currently the best way to achieve it is via the use of native applications as they have direct access to all the sensors on the device. Native applications also do not need to download static resources like application images and media used for sound effects. A mobile web application will hit the server each time to get a lot of resources again and again (although the cache will help if it is not cleared). The elephant in the room really is that mobile broadband is erratic. Currently native applications can be constructed carefully to deal with this erratic network much better than mobile web applications. Frameworks like Sencha are making progress and are close to offering a solution for this problem but for now if you want users to have a great experience and feel like the application is responsive and behaves well when connections drop out for short intervals then native applications are the way to go.
Another compelling reason to consider a native application over mobile web is that you can create applications that feel natural to the platform. For example Google and Facebook build applications using the native toolkit and adjust the UI is subtle ways to take advantage of the platform and ensure that the application fits in with the rest of the system. On Android native application also have access to a range of services via the Intent mechanism in that they can make use of features offered by other applications easily (e.g. Camera Photo gallery etc.). These small factors add up and the users get a better experience when using native application. As you can see there are benefits for going down both path ways and the final choice should depend on a careful trade-off analysis. Although currently many developers lean towards building using native toolkit the future will very likely be heavily based on HTML5 — even on mobile. Just don’t ask me for a specific date.
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Dr. Neil P Fullan has the following 2 specialties
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
- Adolescent Medicine
Adolescent specialists are doctors who have advanced training in the health issues that adolescents face. These physicians deal with issues like the onset of puberty, reproductive health, eating disorders, irregular periods, mood changes, drugs and pressures from home and school. For girls entering adulthood, adolescent specialists can act as both pediatrician and gynecologist, so they only have to see one doctor for all their needs.
Dr. Neil P Fullan has the following 11 expertise
- Sexually Transmitted Diseases
- Birth Control
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
- Sleep Disorders
- Eating Disorders
- Depressive Disorder
- Substance Abuse
Dr. Neil P Fullan has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
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Dr. Fullan treated both of my sons. One of my sons saw Dr. Fullan from age five to age nineteen. My other son saw Dr. Fullan from age eleven to age twenty three. Both of my sons have ADD. One of my sons has Bipolar Depression and Asperger's Syndrome, in addition to ADD. Dr. Fullan was like part of our family. He always spent an adequate amount of time with us and his treatments were successful. If it was not for Dr. Fullan our son with multiple diagnoses would not be the functional, hardworking, and happy adult that he is. I am not going to say that there were not ups and downs because there were. There always are ups and downs with mental illness, such as medication changes, and sometimes hospitalizations. I recommend Dr. Fullan all the time to parents. He was our rock for so many years.
When I was 13, Dr. Fullan tried to place a diagnosis of Anti-social Personality Disorder into my files, despite it having an age requirement of 18. A lazy attempt, as I had PTSD, ADHD, a neurologically-based anxiety disorder, and moderately abusive parents who were going through a divorce.Dr. Fullan also broke the confidentiality agreement numerous times, encouraging me to tell him things in confidence and then informing my parents of specific details. I was physically and emotionally abused off of what he revealed to my parents.I would never bring my child to him. Children seeking treatment, especially those with PTSD, need a safe environment where their words will not be betrayed.
Our two sons have been under Dr. Fullan's care for approx. 8 years. Each had issues of great concern. Our eldest has depression, severe OCD, and anxiety disorder. Our younger son has ADHD, depression, and anxiety disorder. Both were diagnosed correctly by Dr. Fullan who, with counseling, medication, and genuine care and concern, changed our troubled sons into happy, well-adjusted, on-track young gentlemen. Dr. Fullan's gifts of a deeply caring nature, acute listening skills, discerning treatment, and follow-up regarding his patient's overall well-being, make him an amazing physician. Dr. Fullan's rapport gained our sons' trust and respect and provided a safe place for them to share. I have no doubt that without him, one of our sons probably wouldn't be with us. We owe him our lives for having saved those of our sons. God gifted us with Dr. Fullan who is the best pediatric/adolescent psychiatrist in the world, and we are forever grateful parents to this awesome man!
On-Time Doctor Award (2015)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
36 Years Experience
Rush Medical College Of Rush University Medical Center
Graduated in 1982
University Of Wisconsin Hospital
Dr. Neil P Fullan accepts the following insurance providers.
- Aetna Signature Administrators PPO
- Anthem Blue Access PPO
- Anthem Blue Preferred HMO
- Anthem Blue Preferred Plus POS
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
Network Health Plan
- Network Health Plan HMO POS
- Network Health Plan Individual
- WPS Group
Locations & DirectionsAnima Family Counselnig Llc, 2475 University Ave Ste A, Green Bay, WI
Take a minute to learn about Dr. Neil P Fullan, MD - Adolescent Medicine in Green Bay, WI, in this video.
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Using Boolean Algebra to simplify or reduce Boolean expressions which represent circuits.Boolean expression. Your answer.The following shows an example of using algebraic techniques to simplify a boolean expression. Boolean Algebra Examples (Part 1). Neso Academy. ЗагрузкаLogic Simplification Examples Using Boolean Rules - Продолжительность: 34:37 Columbia Gorge Community College 170 435 просмотров. boolean-algebra. answered Sep 20 17 at 15:55. ColdLogic.It would look like this: You process the textual representation finding the highest priority items first Each simple statement (true OR false for example) would be put into a node You could have different types of nodes for the different boolean algebra examples with answers. boolean algebra examples in discrete mathematics. Boolean algebra 1: Basic laws and rulesVladimir Keleshev. Boolean algebra Axioms Useful laws and theorems Examples. 1. The big picture.
Find the complement of F(AB)(AC). Answer: F(AB)(AC). Related Posts of Gorgeous Boolean Operators Python Example Algebra Examples Simplify In Discrete Mathematics Logic Real Life Gates Tutorial For Recruiters With Answers Circuits Java Expression Cdss. Learn boolean algebra and logic gates MCQs test, digital logic design of boolean algebra as boolean algebra is also called, with answers.How to use Boolean algebra to simplify circuits. Boolean laws, simplification examples and De Morgans Theorem. This example begs two questions. First, how did we come up with Circuit 1? Second, how did we know to apply the Boolean algebra laws in those orders to get the other circuits? We will answer the first question here, and the second question in the next section. For example, if we want to include the proposition I will take the car, we may make a statement such as: If I do not take the car then I will take the umbrella if it is raining or the weather forecast is bad.Boole developed Boolean Algebra in the last century, us Boolean algebra with 5 sets. up vote 0 down vote favorite.
Not the answer youre looking for? Browse other questions tagged boolean- algebra or ask your own question.Example request. A Boolean algebra is a set B with two binary operations and , elements 0 and 1, and a unaryIdentity laws Complement laws Associative laws Commutative laws Distributive laws. Example. Let B be a power set of a set S, 0 , 1 S , (union), (intersection) and (Complement). Factoring Boolean Algebra Circuits. By Madeleine Catherine.Examples of electronic output devices include computer monitors, LCD alphanumeric panels (as on a calculator), small lamps or light-emitting diodes (LED), etc. Boolean Algebra Sample Problems With Solutions. Boolean Algebra Examples With Answers Pdf Morphic. XClose. Boolean algebra is a special branch of algebra which is mostly used in digital electronics. Boolean algebra was invented in the year of 1854, by an English mathematician George Boole.For example. In this worked example with questions and answers, we start out with a digital logic circuit, and you have to make a Boolean expression, which describes the logic of this circuit. For the first step, we write the logic expressions of individual gates. BOOLEAN ALGEBRA. BOOLE is one of the persons in a long historical chain who were concerned with formalizing and mechanizing the process of logical thinking.Example: Show that the algebra of subsets of a set and the algebra of propositions are Boolean algebras. Boolean Algebra is a mathematical technique that provides the ability to algebraically simplify logic expressions.Example. Simplify the following Boolean expression and note the Boolean theorem used at each step. Put the answer in SOP form. F 1. A. Boolean Algebra Operators and how they work in part 1 of this tutorial on Boolean Algebra.Lets run through an example to better understand whats going on. If g is True and p is False then Electricity Diagram Information lerheebouquets. boolean algebra examples.Your Comments . Rate This boolean algebra examples. 92/100 by 990 users.algebra examples and solutions boolean algebra examples with answers boolean algebra examples truth tables boolean algebra Related posts to boolean algebra examples with answers pdf.Digital electronics boolean algebra problem example demorgan s theorem examples b copy or print out the truth table below and use it to prove t a cpt logic gate . Examples. Problems. On-line Quiz. Introduction. The most obvious way to simplify Boolean expressions is to manipulate them in the same way as normal algebraic expressions are manipulated.Table 1: Boolean Postulates. Laws of Boolean Algebra.Click here for answers. Using the theorems of Boolean Algebra, the algebraic forms of functions can often be simplified, which leads to simpler (and cheaper) implementations. Example 1. English examples for "Boolean algebra" - It is a Boolean algebra if and only if n is square-free. The British mathematician George Boole devised an algebra that soon evolved into what is now called Boolean algebra, in which the only numbers were 0 and 1. Boolean algebra is the starting point of Boolean algebra simplifications are based on the list of theorems and rules of Boolean algebra.Given below are some of the examples in boolean algebra. Example 1: Using Boolean algebra techniques, simplify the expression X . Y X (Y Z) Y (Y Z). This Chapter provides only a basic introduction to boolean algebra.For example, logical AND is closed in the boolean system because it accepts only boolean operands and pro-duces only boolean results.
The answer is because the larger the rectangles are, the more terms they will eliminate. Boolean Algebra Tutorial and Examples of How Boolean Algebra can be used for Digital Logic Gate Reduction and the use of Boolean Algebra and Truth Tables.The final answer whole circuit (example 2) is not single Exclusive-NOR Gate but Exclusive- OR gate. Boolean algebra rules are based on the Boolean logic that was proposed by George Boole in the 1840s.Algebra Study Tips That Youll Remember Forever. Math Riddles with Answers.Real-life Examples of a Parabola for a Better Understanding. In mathematics and mathematical logic, Boolean algebra is the branch of algebra in which the values of the variables are the truth values true and false, usually denoted 1 and 0 respectively. Instead of elementary algebra where the values of the variables are numbers Boolean algebra is a different kind of algebra or rather can be said a new kind of algebra which was invented by world famous mathematician George Boole in the year of 1854.De Morgans Therem, Proof from truth table, Examples of Boolean Algebra. Definitions and examples of Boolean Algebra with Matlab.These are the four logical operators for Boolean Algebra in Matlab. It was named after George Boole, who first defined an algebraic system of logic in 19th. century. Boolean algebra is a deductive mathematical system closed over the values zero and one (false and true).The answer is because the larger the rectangles are, the more terms they will eliminate.To see some examples of algebraic manipulation of boolean expressions, check out. Boolean Algebra. The algebraic system usually used to work with binary logic expressions. There are many different ways to write the same expression Example: xyz xyz xy xy xz. Note that this is a rule of thumb and does not always give an optimum answer. The answer is with tiny little machines called gates.This mathematics is called, Boolean Algebra.(c) To build a circuit, just add gates as you read the expression. Examples a-plenty on page 714-717. Sun, 21 Jan 2018 23:03:00 GMT Boolean Algebra Examples With Answers Pdf - lbartman.com - Laws of Boolean Algebrathe use of Boolean Algebra and Truth Tables Boolean Algebra Tutorial and Boolean Algebra Examples -Related PDFs Boolean algebra was invented by George Boole in 1854.Following are the important rules used in Boolean algebra. Variable used can have only two values.For example ORing of A, B, C is represented as A B C. Which law of boolean algebra emphasizes the elimination of brackets from logical expression along with the re-arrangement of grouping variables ? a. Distributive Law b. Commutative Law c. Associative Law d. None of the above. View Answer / Hide Answer. Boole introduced the world to Boolean algebra when he published his work called An Investigation of the Laws of Thought, on Which Are Founded the Mathematical Theories of Logic and Probabilities.Be sure to put your answer in Sum-Of-Products (SOP) form. Boolean algebra examples with answers PDF digital.Boolean Algebra Examples With Answers Pdf Digital PDF. Pocket Style ManualSoft Water SystemsLisa Jackson Boolean algebra simplification exercises pdf. Example 1.3. The n-dimensional binary space is the Cartesian product Bn 0, 1n B B (with n copies), and is a Boolean algebra under the Boolean operations.If the sum is 0 or 1, we write the sum in the answer line and carry a digit 0 to the column on the left. Sun, 13 Dec 2015 23:57:00 GMT Boolean Algebra Examples With Answers Pdf - lbartman.com - nanohub org resources ece 595z lecture 4 advanced boolean algebra laws pd full size 2 pages kp3414 jaminan kualiti tutorial 3 pdf digital logic circuits important The proper answer is: either one. If we have 1 1 1 then we essentially are working in a Boolean Algebra, but if on the other hand we take 1 1 0 we are working in a Boolean Ring.Suppose, for example, that F is a Boolean function of four Boolean. variables. JEE Main 2017 Answer Key. BYJUS App Review on JEE.Boolean algebra problems can be solved using these Boolean algebra laws.Boolean algebra examples: Using the above laws, we can simplify the given expression: (A B)(A C). Boolean Algebra Examples ?Boolean Algebra. No answers yet! What is the estimated Big-O complexity for solving a Tower of Hanoi Problem of size n ? Boolean algebra or boolean logic is the formal mathematical discipline that deals with "truth values"—"true" or "false". Its fundamental operations are "and", "or" and "not". One can write "propositions" (equations) of boolean algebra, such as. problem example 24 demorgan s theorem examples b copy or print out the truth table below and use it to prove t11 a cpt logic gate wo, 28 dec 2016 23:56:00 GMT Boolean Algebra Examples With Answers Pdf - lbartman.com Boolean Algebra Examples. Binary and Boolean Examples. Truth Table Examples. In mathematics and mathematical logic, Boolean algebra is the branch of algebra in which the values of the variables are the truth values true and false, usually denoted 1 and 0 respectively. Instead of elementary algebra where the values of the variables are numbers boolean algebra 24 dem an s theorem examples youtube. fundamental hardware elements of computers boolean gate.boolean algebra examples pdf component boolean algebra laws. logic gates and boolean algebra questions and answers pdf. Boolean algebra can be AND GATE. What symbol is used to represent the Simplify following Boolean Functions examples with complete answers. B A. From the definition of it follows that if. Solved examples with detailed answer description, explanation are given and it would be easy to understand. All students, freshers can download Digital Electronics Boolean Algebra and Logic Simplification quiz questions with answers as PDF files and eBooks. | <urn:uuid:3187de96-7443-41b3-9ae2-a2f0a9fb325f> | {
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
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About Dr. Marjorie A Alvir
Dr. Marjorie A Alvir, DO is a Doctor primarily located in Arcadia, CA. She has 13 years of experience. Her specialties include Family Medicine. She speaks English.
Dr. Marjorie A Alvir has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Marjorie A Alvir has the following 10 expertise
- Preventive Medicine
- Weight Loss
- Family Planning
- Women's Health
- Adolescent Medicine
Dr. Marjorie A Alvir has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 4 of 7
I happen to be a physician and went to her due to the other doctors being fully booked. Bad mistake. I have a family history of high cholesterol. My blood work came back as doubled the normal range, which is concerning to a 30 year old. Her solution was for me to go on a diet and workout. If she didn't look at her computer the entire time along with not obtaining a case history, she would know that I run 5-8 miles daily along with strength training for the last 8 years. I don't eat red meat and monitor all my nutrients. Very poor bedside manners. How is she even a physician?
It's ironic that Dr. Alvir is smiling in her photo because I've never actually seen her smile.In my experience she has been rude, has not listened at all, ordered tests for me that I did not need, but refused to order tests I requested based on a genetic condition. The last appointment she stared at her computer 90% of the time, and then abruptly announced, "I don't have time for this" and left the room to deal with other patients. I had to wait over 20 minutes for her to come back, on top of the original 20 minutes I had to wait just to see her initially.
Very insecure, short, uninformed. Would rather do nothing unless the issue is extreme and then she doesn't follow through with treatment. Inconsistent answers from one visit to another. Second guesses herself and bases decisions on partial information because she tunes out the patient. She even WALKED OUT of the room as I was asking her questions because she felt it was taking too long and instead of wrapping it up, she walked out.It is a fight just to get her to treat a condition. The wait is forever for such a short time you get with her. She even told me once that "I can only bring 2 issues up per visit!!"STAY AWAY from her and any other practitioner at hartland family care. it is a waste of money and time. Even the office staff makes you feel like they are doing YOU a favor when they do their job. They pass the buck any chance they can.
13 Years Experience
Michigan State University College Of Human Medicine
Graduated in 2005
Dr. Marjorie A Alvir accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna HMO Deductible Plan CA only
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
Blue Cross California
- BC CA California Care Small Group HMO
- Blue Cross CA California Care Large Group HMO
- Blue Cross CA PPO Prudent Buyer Large Group
- Blue Cross CA Pathway X PPO
- Blue Cross CA Select HMO
- Blue Cross CA Select PPO
- Blue Cross CA Select Plus HMO
- Blue Cross CA Vivity
Blue Shield California
- Blue Shield CA Access Plus HMO
- Blue Shield CA Access Plus Savenet
- Blue Shield CA Bronze Full PPO 4500
- Blue Shield CA Local Access Plus HMO
- Blue Shield CA PPO
- Blue Shield CA Platinum Access+ HMO 25
- Blue Shield CA Platinum Local Access + HMO 25
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- Cigna Southern CA Select
- First Health PPO
- Health Net CA HMO Employer Group
- Health Net CA HMO SmartCare
- Health Net CA HMO Whole Care Network
- Health Net CA Individual and Family PPO
- Health Net CA PPO
- Health Net SmartCare Large Group
- Health Net SmartCare Small Group
- Humana Choice POS
LA Care Health
- Multiplan PPO
- PHCS PPO
- PHCS PPO Kaiser
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsHealthcare Partners Medical Group, 450 E Huntington Dr, Arcadia, CA
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- HIV/AIDS The differences between HIV & AIDS; signs, symptoms & complications.
- Lupus Get the facts about lupus, including symptoms, risk factors, and the different types.
- Menopause Facts about menopause, including the stages, symptoms, and types.
- Shingles Facts about shingles, including symptoms & possible long-term effects.
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About Dr. Essam A Girgawy
Dr. Essam A Girgawy, MD is a Doctor primarily located in Kingwood, TX, with other offices in Houston, TX and Houston, TX . He has 38 years of experience. His specialties include Infectious Disease and Internal Medicine. Dr. Girgawy is affiliated with Memorial Hermann Northeast Hospital. Dr. Girgawy has received 1 award. He speaks English.
Dr. Essam A Girgawy has the following 2 specialties
- Infectious Disease
An infectious disease specialist has specialized training in the diagnosis and treatment of contagious diseases.
Infectious diseases, also known as contagious or transmissible diseases, are those that stem from pathogen from a host organism. These infections may spread to other carriers through physical touch, airborne inhalation, bodily fluids or contaminated foods.
Infectious disease specialists identify whether the disease is caused by bacteria, a virus, a fungus or a parasite often through blood tests and then determine what course of treatment, if any, is necessary.
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Essam A Girgawy has the following 8 expertise
- AIDS/HIV (Acquired Immunodeficiency Syndrome)
- Human Immunodeficiency Virus (HIV/AIDS)
- Hepatitis C
- HIV Infections
Dr. Essam A Girgawy has 0 board certified specialties
Showing 4 of 10
Dr Girgawy is the most special doc. He always puts the patient's welfare and feelings first. He carefully explains all procedures and options. He is extremely compassionate and caring. He consults in person and by phone for many patients in numerous hospitals and sees patients late into the evenings if necessary. His thorough knowledge has saved my husband's life.
My husband was billed for services that were unjust. When I questioned what services Dr. Girgawy had provided, I was told consultation fee. When I said he did not see him, I was told he may have gone in his room or looked at his files. This doctor charged over $100; my husband's GP does more and charges much less.
Patients' Choice Award (2014)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Dr. Girgawy is affiliated (can practice and admit patients) with the following hospital(s).
38 Years Experience
University Of Cairo
Graduated in 1980
University Of Texas Health Science Center
Dr. Essam A Girgawy accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS TX BlueChoice
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana HMO
- Humana HMO Premier
- Humana Houston HMOx
- Humana National HMO
- Humana National POS
- Humana Preferred PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Dr. Essam A Girgawy is similar to the following 3 Doctors near Kingwood, TX. | <urn:uuid:25ba8f65-2684-4300-8f3b-57c35ac8cc8c> | {
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
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About Dr. Valerie A Kimball
Dr. Valerie A Kimball, MD is a Doctor primarily located in Evanston, IL. Her specialties include Pediatrics. She speaks English.
Dr. Valerie A Kimball has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Valerie A Kimball has the following 9 expertise
- Pediatric Diabetes
- Child Development
- Newborn Medicine (Neonatology)
Dr. Valerie A Kimball has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Valerie A Kimball is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 1 of 6
Loyola University Medical Center
Dr. Valerie A Kimball accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL Blue Advantage HMO
- BCBS IL PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- HealthLink PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Multiplan PPO
- PHCS PPO
- PriorityHealth Priority PPO
- UHC Choice Plus POS
- UHC Options PPO
Locations & DirectionsTraismans Benuck Merens And Kimball, 1950 Dempster St, Evanston, IL
Take a minute to learn about Dr. Valerie A Kimball, MD - Pediatrics in Evanston, IL, in this video.
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Getting Started with Ubuntu 16.04 →
Getting Started with Ubuntu 16.04 →
1 Installation Getting Ubuntu Before you can get started with Ubuntu, you will need to obtain a copy of Many companies (such as Dell and System76) sell computers with Ubuntu preinstalled. If you already have Ubuntu installed on your computer, feel free to skip to Chapter 2: The Ubuntu Desktop. the Ubuntu installation image for dvd or usb. Some options for doing this are outlined below. Minimum system requirements If you are unsure whether it will work on your computer, the Live dvd is a great way to test things out first. Below is a list of hardware specifications that your computer should meet as a minimum requirement. ‣ 1 GHz x86 processor (Pentium 4 or better) ‣ 1 gb of system memory (ram) ‣ 8.6 gb of disk space (at least 15 gb is recommended) ‣ Video support capable of 1024×768 resolution ‣ Audio support (recommended, but not required) ‣ An Internet connection (highly recommended, but not required) Downloading Ubuntu The easiest and most common method for getting Ubuntu is to download the Ubuntu dvd image directly from http://www.ubuntu.com/download. Choose how you will install Ubuntu: ‣ Download and install ‣ Try it from a dvd or usb stick Download and Install / Try it from a DVD or USB stick For the Download and install, or Try it from a dvd or usb stick options, select whether you require the 32-bit or 64-bit version (see the following section if you are unsure), then click “Start download.” 32-bit versus 64-bit Ubuntu and its derivatives are available in two versions: 32-bit and 64-bit. This difference refers to the way computers process information. Comput- 32-bit and 64-bit are types of processor architectures. Most new desktop computers have a 64-bit capable processor. ers capable of running 64-bit software are able to process more information than computers running 32-bit software; however, 64-bit systems require more memory in order to do this. Nevertheless, these computers gain per- formance enhancements by running 64-bit software. ‣ If your computer has a 64-bit processor, install the 64-bit version. ‣ If your computer is older, a netbook, or you do not know the type of processor in the computer, install the 32-bit version. If your computer has a 64-bit processor, select the “64-bit” option before you click “Start download.”
10 getting started with ubuntu 16.04 Downloading Ubuntu as a torrent When a new version of Ubuntu is released, the download servers can get Torrents are a way of sharing files and informa- tion around the Internet via peer-to-peer file sharing. A file with the .torrent extension is made available to users, which is then opened with a compatible program such as uTorrent, Deluge, or Transmission. These programs download parts of the file from other people all around the world. “clogged” as large numbers of people try to download Ubuntu at the same time. If you are familiar with using torrents, you can download the torrent file by clicking “Alternative downloads,” and then “BitTorrent download.” Downloading via torrent may improve your download speed, and will also help to spread Ubuntu to other users worldwide. Burning the DVD image Once your download is complete, you will be left with a file called ubuntu- While the 64-bit version of Ubuntu is referred to as the “AMD64” version, it will work on Intel, AMD, and other compatible 64-bit processors. 16.04-desktop-i386.iso or similar (i386 here in the filename refers to the 32-bit version. If you downloaded the 64-bit version, the filename contains amd64 instead). This file is a dvd image—a snapshot of the contents of a dvd— which you will need to burn to a dvd. Creating a bootable USB drive If your pc is able to boot from a usb stick, you may prefer to use a usb memory stick instead of burning a dvd. Scroll down on the download webpage to the “Easy ways to switch to Ubuntu” section and you will find a link to instructions on how to create a bootable usb stick in your current operating system. If you select this option, your installation will be running from the usb memory stick. In this case, references to Live dvd, will refer to the usb memory stick. Trying out Ubuntu The Ubuntu dvd and usb stick function not only as installation media, but also allow you to test Ubuntu without making any permanent changes to your computer by running the entire operating system from the dvd or usb stick. Your computer reads information from a dvd at a much slower speed In some cases, your computer will not recognize that the Ubuntu DVD or USB is present as it starts up and will start your existing operating system instead. To run Ubuntu from the Live DVD or USB, we want the computer to look for information from the Live DVD or USB first. Changing your boot priority is usually handled by BIOS settings; this is beyond the scope of this guide. If you need assistance with changing the boot priority, see your computer manufacturer’s documentation for more information. than it can read information off of a hard drive. Running Ubuntu from the Live dvd also occupies a large portion of your computer’s memory, which would usually be available for applications to access when Ubuntu is running from your hard drive. The Live dvd/usb experience will therefore feel slightly slower than it does when Ubuntu is actually installed on your computer. Running Ubuntu from the dvd/usb is a great way to test things out and allows you to try the default applications, browse the Internet, and get a general feel for the operating system. It’s also useful for checking that your computer hardware works properly in Ubuntu and that there are no major compatibility issues. To try out Ubuntu using the Live dvd/usb stick, insert the Ubuntu dvd into your dvd drive, or connect the usb drive and restart your computer. After your computer finds the Live dvd/usb stick, and a quick load- ing screen, you will be presented with the “Welcome” screen. Using your mouse, select your language from the list on the left, then click the button labelled Try Ubuntu. Ubuntu will then start up, running directly from the Live dvd/usb drive. Once Ubuntu is up and running, you will see the default desktop. We will talk more about how to actually use Ubuntu in Chapter 2: The Ubuntu Desktop, but for now, feel free to test things out. Open some applications,
installation 11 Figure 1.1: The “Welcome” screen allows you to choose your language. change settings and generally explore—any changes you make will not be saved once you exit, so you don’t need to worry about accidentally breaking anything. When you are finished exploring, restart your computer by clicking Alternatively, you can also use your mouse to double-click the “Install Ubuntu 16.04” icon that is visible on the desktop when using the Live DVD. This will start the Ubuntu installer. the “Power” button in the top right corner of your screen (a circle with a line through the top) and then select Restart. Follow the prompts that appear on screen, including removing the Live dvd and pressing Enter when instructed, and then your computer will restart. As long as the Live dvd is no longer in the drive, your computer will return to its original state as though nothing ever happened! Installing Ubuntu—Getting started At least 8.6 gb of free space on your hard drive is required in order to install Clicking on the underlined “release notes” link will open a web page containing any important information regarding the current version of Ubuntu. Ubuntu. We recommend 15 gb or more. This will ensure that you will have plenty of room to install extra applications later on, as well as store your own documents, music, and photos. To get started, place the Ubuntu dvd in your dvd drive and restart your computer. Your computer should load Ubuntu from the dvd. When you first start from the dvd, you will be presented with a screen asking you whether you want to first try out Ubuntu or install it. Select the language you want to view the installer in and click on the Install Ubuntu button. This will start the installation process. If you have an Internet connection, the installer will ask you if you would like to “Download updates while installing Ubuntu.” We recommend you do so. The second option, “Install third-party software for graphics and Wi-Fi hardware, Flash, MP3, and other media” includes the Fluendo mp3 codec, and software required for some wireless hardware. If you are not connected to the Internet, the installer will help you set up a wireless connection. The “Preparing to install Ubuntu” screen will also let you know if you have enough disk space and if you are connected to a power source (in case you are installing Ubuntu on a laptop running on battery). Once you have selected your choices, click Continue.
12 getting started with ubuntu 16.04 Figure 1.2: Preparing to install. Internet connection If you are not connected to the Internet, the installer will ask you to choose a wireless network (if available). We recommend that you connect to the Internet during install, although updates and third-party software can be installed after installation completes. 1. Select Connect to this network, and then select your network from the list. 2. If the list does not appear immediately, wait until a triangle/arrow ap- pears next to the network adapter, and then click the arrow to see the available networks. 3. In the Password field, enter the network wep or wpa key (if necessary). 4. Click Connect to continue. Figure 1.3: Set up wireless. Allocate drive space The Ubuntu installer will automatically detect any existing operating sys- If you are installing on a new machine with no operating system, you will not get the first option. The upgrade option is only available if you are upgrading from a previous version of Ubuntu. tem installed on your machine, and present installation options suitable for your system. The options listed below depend on your specific system and may not all be available: ‣ Install alongside other operating systems ‣ Upgrade Ubuntu … to 16.04
installation 13 ‣ Erase … and install Ubuntu ‣ Something else Install alongside other operating systems. For more complicated dual-booting setups, you will need to configure the parti- tions manually. Figure 1.4: Choose where you would like to install Ubuntu. Upgrade Ubuntu … to 16.04 This option will keep all of your documents, music, pictures, and other personal files. Installed software will be kept when possible (not all of your currently installed software may be supported on the new version). System- wide settings will be cleared. Erase disk and install Ubuntu Use this option if you want to erase your entire disk. This will delete any existing operating systems that are installed on that disk, such as Microsoft Windows, and install Ubuntu in its place. This option is also useful if you have an empty hard drive, as Ubuntu will automatically create the neces- sary partitions for you. Formatting a partition will destroy any data currently on the partition. Be sure to back up any data you want to save before formatting. More information and detailed instructions on partitioning are available at: https://help.ubuntu.com/community/HowtoPartition. After you have chosen the installation type, click Continue, or Install Now. Confirm Partition choices and start install If you chose Something else, configure the partitions as you need. Once you are happy with the way the partitions are going to be set up, click the Install Now button at the bottom right to move on. To reduce the time required for installation, Ubuntu will continue the installation process in the background while you configure important user
14 getting started with ubuntu 16.04 details—like your username, password, keyboard settings and default time- zone. Where are you? Figure 1.5: Tell Ubuntu your location. The next screen will display a world map. Using your mouse, click your geographic location on the map to tell Ubuntu where you are. Alternatively, you can type your location in the field below the map. This allows Ubuntu to configure your system clock and other location-based features. Click Continue when you are ready to move on. Keyboard layout Figure 1.6: Verify that your keyboard layout is correct. Next, you need to tell Ubuntu what kind of keyboard you are using. In most cases, you will find the suggested option satisfactory. If you are unsure which keyboard option to select, you can click the Detect Keyboard Layout button to have Ubuntu determine the correct choice by asking you to press a series of keys. You can also manually choose your keyboard layout from the list of options. If you like, enter text into the box at the bottom of the window to ensure you are happy with your selection, then click Continue.
installation 15 Who are you? Ubuntu needs to know some information about you so it can set up the primary user account on your computer. When configured, your name will appear on the login screen as well as the user menu, which we discuss in Chapter 2: The Ubuntu Desktop. On this screen you will need to tell Ubuntu: ‣ your name ‣ what you want to call your computer ‣ your desired username ‣ your desired password ‣ how you want Ubuntu to log you in Figure 1.7: Setup your user account. Enter your full name under Your name. The next text field is the name your computer uses, for terminals and networks. You can change this to what you want, or keep the predetermined name. Next is your username, the name that is used for the user menu, your home folder, and behind the scenes. You will see this is automatically filled in for you with your first name. Most people find it easiest to stick with this. However, it can be changed if you prefer. Next, choose a password and enter it into both password fields. When both passwords match, a strength rating will appear to the right that will show you whether your password is “short,” “weak,” “fair,” or “good.” You will be able to continue the installation process regardless of your password strength, but for security reasons it is best to choose a strong one. This is best achieved by having a password that is at least nine characters long, with a mixture of uppercase and lowercase letters, as well as numbers and symbols. Avoid words that can be found in a dictionary and obvious passwords such as your birth date, spouse’s name, or the name of your pet. Login Options Finally, at the bottom of this screen you have two options regarding how you wish to log in to Ubuntu. You may also choose to have Ubuntu encrypt your home folder. ‣ Log in automatically ‣ Require my password to log in – Encrypt my home folder
16 getting started with ubuntu 16.04 Log in automatically Ubuntu will log in to your primary account automatically when you start up the computer so you won’t have to enter your username and password. This makes your login experience quicker and more convenient, but if privacy or security are important to you, we don’t recommend this option. Anyone who can physically access your computer will be able to turn it on and also access your files. Require my password to login This option is selected by default, as it will prevent unauthorized people from accessing your computer without knowing the password you cre- ated earlier. This is a good option for those who, for example, share their computer with other family members. Once the installation process has been completed, an additional login account can be created for each family member. Each person will then have their own login name and password, account preferences, Internet bookmarks, and personal storage space. Encrypt my home folder This option provides you with an added layer of security. Your home folder is where your personal files are stored. By selecting this option, Ubuntu will automatically enable encryption on your home folder, meaning that files and folders must be decrypted using your password before they can be accessed. Therefore if someone had physical access to your hard drive (for example, if your computer was stolen and the hard drive removed), they would not be able to see your files without knowing your password. If you choose this option, be careful not to enable automatic login at a later date. It will cause complications with your encrypted home folder, and will potentially lock you out of important files. Finishing Installation Ubuntu will now finish installing on your hard drive. As the installation progresses, a slideshow will give you an introduction to some of the default applications included with Ubuntu. These applications are covered in more detail in Chapter 3: Working with Ubuntu. The slideshow will also highlight the Ubuntu support options. After approximately twenty minutes, the installation will complete and you will be able to click Restart Now to restart your computer and start Ubuntu. The dvd will be ejected, so remove it from your dvd drive and press Enter to continue. Wait while your computer restarts, and you will then see the login win- dow (unless you selected automatic login). Login Screen After the installation has finished and your computer is restarted, you will be greeted by the login screen of Ubuntu. The login screen will present you with your username and you will have to enter the password to get past it. Click your username and enter your password. Once done, you may click the arrow or press Enter to get into the Ubuntu desktop. Ubuntu’s login
installation 17 Figure 1.8: Ubuntu community support options. Where to get help for Ubuntu. Figure 1.9: You are now ready to restart your computer. screen supports multiple users and also supports custom backgrounds for each user. In fact, Ubuntu automatically will pick up your current desktop wallpaper and set it as your login background. The login screen allows you to update your keyboard language, volume intensity and enable/disable accessibility settings before you log in to your desktop. It also displays date/time and battery power for laptops. You can also shut down or restart your system from the login screen. Figure 1.10: Login Screen.
2 The Ubuntu Desktop Understanding the Ubuntu desktop Initially, you may notice many similarities between Ubuntu and other op- erating systems, such as Microsoft Windows or Apple OS X. This is because they are all based on the concept of a graphical user interface (gui)—i.e., you use your mouse to navigate the desktop, open applications, move files, and perform most other tasks. In short, things are visually oriented. This chapter is designed to help you become familiar with various applications and menus in Ubuntu so that you become confident in using the Ubuntu gui. Figure 2.1: The Ubuntu 16.04 default desktop. Unity All gui-based operating systems use a desktop environment. Desktop envi- ronments contain many features, including (but not limited to): ‣ The look and feel of the system ‣ The organization of the desktop ‣ How the user navigates the desktop Ubuntu uses Unity as the default desktop environment. The Unity desk- To read more about other variants of Ubuntu, refer to Chapter 8: Learning More. top is comprised of the desktop background and two bars—a horizontal one located at the top of your desktop called the menu bar and a vertically oriented bar at the far left called the Launcher.
20 getting started with ubuntu 16.04 The desktop background Below the menu bar at the top of the screen is an image covering the entire desktop. This is the default desktop background, or wallpaper, belonging to the default Ubuntu 16.04 theme known as Ambiance. To learn more about customizing your desktop (including changing your desktop background), see the section on Customizing your desktop below. The menu bar The menu bar incorporates common functions used in Ubuntu. The icons on the far right of the menu bar are located in an area of the menu bar called the indicator area, or notification area. Each installation of Ubuntu may contain slightly different types and quantities of icons based on a number of factors, including the type of hardware and available on-board peripherals upon which the Ubuntu installation is based. Some programs add an icon to the indicator area automatically during installation. The most common indicators are: For more about: ‣ the Messaging indicator see Using instant messaging on page 59; ‣ the Network indicator see Getting online on page 39; ‣ the Session indicator see Session options on page 33. Network indicator ( or ) manages network connections, allowing you to connect quickly and easily to a wired or wireless network. Text entry settings ( ) shows the current keyboard layout (such as En, Fr, Ku, and so on) and, if more than one keyboard layout is chosen, allows you to select a keyboard layout. The keyboard indicator menu contains the following menu items: Character Map, Keyboard Layout Chart, and Text Entry Settings. Messaging indicator ( ) incorporates your social applications. From here, among others, you can access instant messenger and email clients. Sound indicator ( ) provides an easy way to adjust the sound volume as well as access your music player and sound settings. Clock displays the current time and provides a link to your calendar and time and date settings. Session indicator ( ) is a link to the system settings, Ubuntu Help, and session options (like locking your computer, user/guest session, logging out of a session, restarting the computer, or shutting down completely). Figure 2.2: The indicators of the menu bar. Every application has a menuing system where different actions can be executed in an application (like File, Edit, View, etc.); the menuing system for an application is appropriately called the application menu. It is located Note that some older applications may still display their menu within the application window. in the left area of the menu bar. By default in Unity, the application menu isn’t on the title bar of the application as is commonly the case in other gui environments. Figure 2.3: To show an application’s menu, just move your mouse to the desktop’s menu bar (at the top of the screen). To show an application’s menu, just move your mouse to the desktop’s menu bar (at the top of the screen). While your mouse is positioned here, the active application’s menu options will appear in the desktop’s menu bar, allowing you to use the application’s menuing options. When clicking on the desktop, the desktop’s menu bar reappears. This capability in Unity to display the application’s menu only when needed is especially beneficial for netbook and laptop users with limited viewable screen space. You can disable this feature via Session Indicator ‣ System Settings ‣ Appearance. In the Behavior tab, under Show the menus for a window, select In the window’s title bar.
the ubuntu desktop 21 The Launcher The vertical bar of icons on the left side of the desktop is called the Launcher. The Launcher provides easy access to applications, mounted devices, and the Trash. All running applications on your system will place an icon in the Launcher while the application is running. To change the Launcher icon size, go to Session Indicator ‣ System Settings ‣ Appearance, tab Look. Figure 2.4: The Ubuntu Launcher on the left with a sample of applications on it. The first icon at the top of the Launcher is the Dash, a component of Unity. We will explore the Dash in a later section of this chapter. By default, other applications appear in the Launcher, including the Files file manager, LibreOffice, Firefox, any mounted devices, and the Trash, which contains deleted folders and files, at the bottom of the Launcher. Holding the Super key, also known as the Windows key (Win key), located between the left Ctrl key and Alt key, will cause Ubuntu to super- impose a number onto the first ten applications in the Launcher and also display a screen full of useful shortcuts. You can launch an application with a number n on it by typing Super+n. If you open more applications than can be shown in the Launcher, the Launcher will “fold” the application icons at the bottom of the Launcher. Simply move your mouse to the bottom of the Launcher, and you’ll see the Launcher icons “slide” and the folded application icons unfold for easy access. Running applications To run an application from the Launcher (or cause an already-running application to appear), just click on the application’s icon. Applications that are currently running will have one or more triangles on the left side of the icon indicating the number of application windows open for this application. Running applications also have a back-lit icon on the Launcher. Some also refer to an application in the foreground as being in focus. Figure 2.5: The triangles on each side of the Firefox icon indicate Firefox is in the foreground and only one window is associated with Firefox at this time. The application in the foreground (i.e., the application that is on top of all other open application windows) is indicated by a single white triangle on the right side of its icon. You can also run an application through the Dash which will be explored in the upcoming The Dash section. Adding and removing applications from the Launcher There are two ways to add an application to the Launcher: ‣ Open the Dash, find the application you wish to add to the Launcher, and drag its icon to the Launcher. ‣ Run the application you want to add to the Launcher, right-click on the application’s icon on the Launcher, and select Lock to Launcher. To remove an application from the Launcher, right-click on the applica- tion’s icon, then select Unlock from Launcher. The Dash The Dash helps you quickly find applications and files on your computer. For more information about the Dash and its lenses, see https://wiki.ubuntu.com/Unity. If you’ve used Windows in the past, you’ll find the Dash to be similar to the Windows Start menu or the Start Screen in Windows 8. OS X users will find the Dash similar to Launchpad in the dock. If you’ve used a previous
22 getting started with ubuntu 16.04 version of Ubuntu or another gnome Linux distribution, the Dash serves as a replacement for the various gnome 2 menus. The Dash allows you to search for information both locally (installed applications, recent files, bookmarks, etc.) and remotely (Twitter, Google Docs, etc.). Figure 2.6: The Dash. To explore the Dash, click on the topmost icon on the Launcher; the icon contains the Ubuntu logo on it. After clicking the Dash icon, the desktop will be overlaid by a translucent window with a search bar on top as well as a grouping of recently accessed applications, files, and downloads. Ubuntu also includes results from popular web services. The search bar provides dynamic results as you enter your search terms. Lenses Lenses act as specialized search categories in the Dash: searching is accom- plished by utilizing one or more lenses, also known as scopes, and each lens is responsible for providing a category of search results through the Dash. The six lenses installed by default at the bottom are: Home lens Applications lens Files and Folders lens Videos lens Music lens and Photos lens Search for files and applications with the Dash The Dash is an extremely powerful tool allowing you to search your com- puter for applications and files. Find files/folders The Dash can help you find names of files or folders. Simply type a portion of the file or folder name. As you type, results will appear in the Dash. The Files and Folders lens will also assist in finding files or folders—showing you the most recently accessed files as well as the most recent downloads. You can use the filter results button in the top-right corner of the Dash to
the ubuntu desktop 23 filter results by attributes such as file or folder modification times, file type (.odt, .pdf, .doc, .txt, etc.), or size. Find applications A standard Ubuntu installation comes with many applications. Users can additionally download thousands of applications from the Ubuntu Software application. As you collect an arsenal of awesome applications (and get The Ubuntu Software application and software management will be discussed in detail at Chapter 5: Software Management. a bonus point for alliteration!), it may become difficult to remember the name of a particular application; the Applications lens on the Dash can assist with this search. This lens will automatically categorize installed applications under “Recently used,” “Installed,” or “Dash plugins.” You can If you are new to the world of Ubuntu, be sure to read Chapter 3: Working with Ubuntu. It will provide you with assistance in choosing application(s) to suit your needs. also enter the name of an application (or a part of it) into the search bar in the Dash, and the names of applications matching your search criteria will appear. Even if you don’t remember the name of the application at all, type a keyword that is relevant to that application, and the Dash will find it. For example, type music, and the Dash will show you the default music player and any music player you’ve used. Figure 2.7: You can see the default results when you press the Applications lens. External search results In addition to searching your local computer for applications and files, the Dash can also search various online resources (e.g., Amazon.com). Results pertinent to your search criteria are returned to you in the Dash. The online search results within the Dash are turned off by default during installation. If you want external search results, go to System Settings ‣ Security & Privacy ‣ Search and set the “Include online search results” switch to the On position.
24 getting started with ubuntu 16.04 Workspaces Workspaces are also known as virtual desktops. These separate views of your desktop allow you to group applications together, and by doing so, help to reduce clutter and improve desktop navigation. For example, you can open all of your media applications in one workspace, your office suite in another, and your web browser in a third workspace. Ubuntu has four workspaces by default. The workspaces feature is not activated by default in Ubuntu. To activate workspaces, click on Session Indicator ‣ System Settings ‣ Appearance then click on the Behavior tab and click on the Enable workspaces box. When this box is checked, you’ll notice that another icon is added to the bottom of the Launcher that looks like a window pane. This is the workspace switcher. Switching between workspaces Figure 2.8: The workspace switcher on the Launcher. If you’ve activated the workspace switcher as described above, you can switch between workspaces by clicking on the workspace switcher icon located on the Launcher. This utility allows you to toggle through the workspaces (whether they contain open applications or not) and choose the one you want to use. You can also launch the workspace switcher by typing Super+s and choose a workspace by using the keyboard arrows followed by RET (the Return / Enter key). Managing windows When opening a program in Ubuntu (such as a web browser or a text editor —see Chapter 3: Working with Ubuntu for more information on using appli- cations)—a window will appear on your desktop. Simply stated, a window is the box that appears on your screen when you start a program. In Ubuntu, the top part of a window (the title bar) will have the name of the applica- tion to the left (most often, the title will be the same as the application’s name). A window will also have three buttons in the top-left corner. From left to right, these buttons represent close window, minimize window, and maximize window. Other window management options are available by right-clicking anywhere on the title bar. Closing, maximizing, restoring, and minimizing windows To close a window, click on the close button ( ) in the upper-left corner of the window—the first button on the left-hand side. Figure 2.9: This is the top bar of a window, named title bar. The close, minimize, and maximize buttons are in the top-left corner of the window. The button immediately to the right of the close button is the minimize button which hides the window from view and minimizes it to the Launcher. When an application is minimized to the Launcher, the left-side of the icon in the Launcher will display an additional triangle. Clicking the icon of the minimized application will restore the window to its original position. Finally, the right-most button is the maximize button ( ) which causes the application to completely fill the desktop space. If a window is maxi- mized, its top-left buttons and menu are automatically hidden from view. To make them appear, just move your mouse to the menu bar. Clicking the maximize button again will return the window to its original size.
the ubuntu desktop 25 Moving and resizing windows To move a window around the workspace, place the mouse pointer over the window’s title bar, then click and drag the window while continuing to hold down the left mouse button. You can also move a window by holding the Alt key and then clicking and holding the left mouse button while pointing anywhere in the window and dragging the window to a new location. To resize a window, place the pointer on an edge or corner of the window so that the pointer turns into a larger, two-sided arrow (known as the resize icon). You can then click and drag to resize the window. Switching between open windows In Ubuntu, there are many ways to switch between open windows: ‣ If the window is visible on your screen, click any portion of it to raise it above all other windows. ‣ Use Alt+Tab to select the window you wish to work with. Hold down the Alt key, and keep pressing Tab until the window you’re looking for appears highlighted in the pop-up window. Then, release the Alt key, and the application highlighted in the pop-up will move to the foreground of your desktop. ‣ Click on the corresponding icon on the Launcher by moving your mouse to the left side of the screen and right-clicking on the application’s icon. If the application has multiple windows open, double-click on the icon in order to select the desired window. Press Ctrl+Super+D to hide all windows and display the desktop; the same works to restore all windows. Moving a window to a different workspace To move a window to a different workspace, verify that the window isn’t maximized. If it is maximized, click on the right-most button on the left side of the title bar to restore it to its original size. Then right-click on the window’s title bar and select: You can also use Shift+Control+Alt in combination with the arrow keys to move a window to a different workspace. ‣ Move to Workspace Left, to move the window to the left workspace ‣ Move to Workspace Right, to move the window to the right workspace ‣ Move to Workspace Down, to move the window to the bottom workspace ‣ Move to Another Workspace, and then choose the workspace to where you wish to move the window. Note that the options available when moving windows to different workspaces depends on which workspace contains the window you are moving. If the window exists in the lower-right workspace, you will not see a Move to Workspace Down because there is no workspace available below the lower-right quadrant of a four quadrant workspace. Window always on the top or on visible workspace At times, you may want to force a window to always be in the foreground so that it can be seen or monitored while you work with other applications. For example, you may want to browse the web and, at the same time, view and answer an incoming instant message. To keep a window always in the foreground, right-click on the window’s title bar, then select Always On Top. This window will now be on the top of all windows opened in
26 getting started with ubuntu 16.04 the current workspace. If you want to have a window always on the top regardless of the workspace, right-click on the window’s title bar, then select Always on Visible Workspace. This window will now be on top of all other windows across all workspaces. Unity’s keyboard shortcuts When you long-press the Super key (also known as the Win key) for a few seconds, Unity will display a list of useful keyboard shortcuts, some of which have been mentioned above. Figure 2.10: Common keyboard shortcuts as displayed by Unity. Browsing files on your computer There are two ways to locate files on your computer—search for them or access them directly from their directory. You can search for a file using the Dash or the Files file manager. You can also use the Dash or Files file manager to access commonly used directories (such as Documents, Music, Downloads) as well as the most recently accessed files. Your home directory The home directory is used to store all of your personal files (rather than The terms “directory” and “folder” are often used interchangeably. system files, such as applications). In Ubuntu, by default, the contents of your home directory are acces- sible for and can be read by other users who have an account on your PC. The name of your home directory matches your login name and is cre- ated when your user account is created. When opening your personal directory, you will see a collection of several directories, including Desk- top (which contains any files that are visible on the desktop), Documents, Downloads, Music, Pictures, Public, Templates, and Videos. These directo- ries are created automatically during the installation process. You can add more files and directories as needed.
the ubuntu desktop 27 Files file manager Just as Microsoft Windows has Windows Explorer and OS X has Finder to browse files and directories, Ubuntu uses the Files file manager by default. The Files file manager window When you select the Files shortcut in the Launcher, click on a directory in the Dash, or double-click a directory on the desktop, Ubuntu will open the Files file manager. The default window contains the following features: Figure 2.11: Files file manager displaying your home directory. menu bar The menu bar is located at the top of the screen. The Files menu allows you to modify the layout of the browser, show, browse and re- move bookmarks, open a Help document, open a new window, connect to a server, or quit. Choosing Enter Location will open the Locations text field where you can enter any location directly. title bar The title bar shows the name of the currently selected directory. It also contains the Close, Minimize, and Maximize buttons. toolbar The toolbar displays your directory browsing history (using two arrow buttons), your location in the file system, a search button, and options for your current directory view. Figure 2.12: The toolbar of the Files application while browsing the directory /var/log/apt/, with the Search functionality activated. - On the upper left corner of the toolbar, there are two arrow icons. These are similar to the “Back” and “Forward” history functionality in web browsers. The Files application keeps track of where you are and allows you to backtrack if necessary. As such, the buttons Previous visited location and Next visited location allow you to navigate through your directory browsing history. - In the middle of the toolbar, you will see a representation of your current directory location.
28 getting started with ubuntu 16.04 - Clicking on the Search icon opens a text field so you can search for a file or directory by name. - Clicking on the View items as a grid icon (the default setting) enables you to see the files and directories as icons. In this view, previews of photos and text files are also displayed. - Clicking on the View items as a list icon allows you to see a list of files and directories, along with their size, type, and date of last modification. You may customize what information is displayed by right-clicking on either Name, Size, Type, or Modified. This action will display a checklist of available options. left pane The left pane of the file browser has shortcuts to commonly used directories. You can also bookmark a directory through the menu bar by choosing Bookmarks ‣ Bookmark this Location. Once you have bookmarked the directory, it should appear in the left pane. Regardless of the directory you are currently browsing, the left pane will always contain the same directories. right pane The largest pane shows the files and directories within the directory you are currently browsing. To navigate to a directory in Files, click (or double-click) on its icon in the right pane, the left pane, or the toolbar. Opening files A file, in its simplest form, is data. Data can represent a text document, database information, or other media such as music or videos. To open a file, you can double-click on its icon. Ubuntu will try to find an appropriate application with which to open the selected file. In some cases, you may wish to open the file with a different application than the one Ubuntu se- lected. To select an application, right-click the icon and select one of the Open With options. Creating new directories To create a new directory from within the Files file manager, right-click in the blank area of the right pane and select New Folder from the pop- up menu (this action will also work on the desktop). Replace the default “Untitled Folder” title with your desired label (e.g., “Personal Finances”). You can also create a new directory by pressing Ctrl+Shift+N. Hidden files and directories If you wish to hide certain directories or files, place a dot (.) in front of the name (e.g., “.Personal Finances”). In some cases, it is impossible to hide files and directories without prefixing them with a dot. You can easily view hidden files by clicking View ‣ Show Hidden Files or by pressing Ctrl+H. Hiding files with a dot (.) is not a security measure—it is simply a way to help you organize your files. Copying and moving files and directories You can cut, copy, and paste files or directories in the Files file manager by right-clicking on the item and selecting the corresponding button from the pop-up menu. You can also use the keyboard shortcuts Ctrl+X, Ctrl+C, and Ctrl+V to cut, copy, and paste files and directories, respectively.
the ubuntu desktop 29 Multiple files can be selected by left-clicking in an empty space (i.e., not on a file or directory), holding the mouse button down, and dragging the cursor across the desired files or directories. This “click-drag” action is useful when you are selecting items that are grouped closely together. To select multiple files or directories that are not positioned next to each other, hold down the Ctrl key while clicking on each item individually. Once the desired files and/or directories are selected, right-click on any of the selected items to perform an action just like you would for a single item. When one or more items have been “copied,” navigate to the desired location, then right-click in an empty area of the window and select Paste to copy them to the new location. While the copy command can be used to make a duplicate of a file or directory in a new location, the cut command can be used to move files and directories. That is, a copy will be placed in a new location, and the original will be removed from its current location. Note that when you “cut” or “copy” a file or directory, nothing will happen until you “paste” it somewhere. Paste will only affect the most recent item(s) cut or copied. To move a file or directory, select the item to move, then click Edit ‣ Cut. Navigate to the desired location, then click Edit ‣ Paste. If you click on a file or directory, drag it, then hold down the Alt key and drop it to your destination directory, a menu will appear asking whether you want to copy, move, or link the item. As with the copy command above, you can also perform this action using the right-click menu, and it will work for multiple files or directories at once. An alternative way to move a file or directory is to click on the item, and then drag it to the new location. Using multiple tabs and multiple Files windows Opening multiple Files file manager windows can be useful for dragging files and directories between locations. You can also have multiple tabs to browse multiple locations at once. To open a second window when browsing a directory in Files, select File ‣ New Window or press Ctrl+N. This will open a new window, allowing you to drag files and/or directories between two locations. To open a new tab, click File ‣ New Tab or press Ctrl+T. A new row will appear above the space used for browsing your files containing two tabs—both will display the directory you were originally browsing. You can click these tabs to switch between them and click and drag files or directories between tabs the same as you would between windows. When dragging items between Files windows or tabs, a small symbol will appear over the mouse cursor to let you know which action will be performed when you release the mouse button. A plus sign (+) indicates you are about to copy the item, whereas a small arrow means the item will be moved. The default action will depend on the directories you are using. Searching for files and folders on your computer You can search for files and folders using the Dash or the Files file manager. Search for files and folders quickly by pressing Ctrl+F in Files and then typing what you want to find. Search using the Dash In the Dash, simply type your search terms in the search bar at the top of the Dash.
30 getting started with ubuntu 16.04 Alternatively, you may use the Applications or Files & Folders lenses; here you can use a filter to narrow down your search. Open the drop-down menu on the right side of the search bar. If you’ve selected Applications, you will be able to filter by application type. If you’ve chosen Files & Fold- ers, you can filter by a host of options, including Last modified, Type (e.g., Documents), or Size. It is sufficient to type the first few letters of the file or folder for which you are searching. Search using Files file manager In Files file manager, click on the magnifying glass button or press Ctrl+F. This opens the search field where you can type the name of the file or folder you want to find. Customizing your desktop Figure 2.13: You can change most of your system’s settings here. Most customizations can be reached via the Session Indicator and then selecting System Settings to open the System Settings application window. The Dash, desktop appearance, themes, wallpapers, accessibility, and other configuration settings are available here. For more information see Session options. Appearance The Look tab In the Look tab you can change the background, window theme, and Launcher icon size to further modify the look and feel of your desktop. To begin, open Appearance by either right-clicking on your background and selecting Change Desktop Background or selecting Session Indicator ‣ System Settings… ‣ Appearance. Select the Look tab. Theme The “Appearance” window will display the current selected back- ground wallpaper and theme. Themes control the appearance of your win- dows, buttons, scroll bars, panels, icons, and other parts of the desktop. The Ambiance theme is used by default, but there are other themes from which
the ubuntu desktop 31 Figure 2.14: You can change the theme in the Look tab of the “Appearance” window. you can choose. Just click once on any of the listed themes to give a new theme a try. The theme will change your desktop appearance immediately. Desktop background To change the Background, either select Wallpapers, Pictures Folder, or Colors and Gradients from the drop-down list. When Wallpapers is selected, you will see Ubuntu’s default selection of back- grounds. To change the background, simply click the picture you would like to use. You’re not limited to this selection. To use one of your own pictures, click the + button and navigate to the image you would like to use. Then click the Open button, and the change will take effect immediately. This image will then be added to your list of available backgrounds. Selecting Pictures Folder opens your Pictures folder where you can choose a picture for the background. The Colors and Gradients button allows you to set the background to a solid or gradient color. Click on the Solid Color but- ton, then the Pick a Color to choose a solid color. The Vertical Gradient and Horizontal Gradient buttons bring up two Pick a Color buttons. Just choose any two colors you like and see if you have achieved the desired result. Launcher icon size At the bottom of the Look tab you find a slider to change the size of icons on the Launcher. You may choose from a range between 32 and 64 pixels. The Behavior tab In the behavior tab you find several options to change the behavior of your desktop. Auto-hide the Launcher Switch the Auto-hide the Launcher to either show the Launcher or reveal it when moving the pointer to the defined hot spot. When turned on, you can choose the reveal location—Left side or Top left corner—and the reveal sensitivity. Enable workspaces By default, workspaces are not enabled. You can enable workspaces by checking this option.
32 getting started with ubuntu 16.04 Add show desktop icon to the launcher Check this option if you want to show the desktop icon on the Launcher. Show the menus for a window Here you can choose if you want menus to show in the menu bar or in the window’s title bar. Menus visibility You can change the visibility of your application menus between two options. The first is Displayed on mouse hovering, which will show application menus when the mouse hovers over the application window. The second option is Always displayed, which allows application menus to always be displayed when possible. You can restore the behavior settings by clicking the Restore Behavior Settings button. Accessibility Ubuntu has built-in tools that make using the computer easier for people with disabilities. You can find these tools by opening the Dash and search- ing for “Universal Access,” or by selecting Session Indicator ‣ System Set- tings… ‣ Universal Access. Use the Seeing tab to manage the text size, the contrast of the interfaces, enable a zoom tool, a virtual keyboard, a screen reader, and so on. Selecting high-contrast themes and larger on-screen fonts can assist those with vision difficulties. You can activate “Visual Alerts” through the Hearing tab if you have hearing impairment. You can also adjust keyboard and mouse settings to suit your needs through the Typ- ing and Pointing and Clicking tabs, respectively. The Profiles tab will allow you to enable the Accessibility Profiles Indicator with which you may switch between the following profiles: Minor Motor Difficulties, Screen reader with speech, High Contrast, Braille, and On-screen Keyboard. Figure 2.15: Universal Access allows you to enable extra features to make it easier to use your computer. Once you have finished toggling the settings to your needs, you may need to log out of the computer and log back in for the changes to take effect. Screen reader (Orca) Orca is a useful tool for people who have difficulties with their vision. It comes preinstalled with Ubuntu and provides the “Screen Reader” function- ality in Universal Access.
the ubuntu desktop 33 The screen reader can be activated by using one of the following meth- ods: ‣ Using the keyboard shortcut ALT-Super-s (in that order), or ‣ Using Session Indicator ‣ System Settings… ‣ Universal Access ‣ Screen Reader ‣ ON/OFF, or ‣ Clicking on Dash and launching Orca. Session options When you have finished working on your computer, you can choose to log out, suspend, restart, or shut down through the Session Indicator on the far right side of the top panel. Logging out Logging out will leave the computer running but return the desktop to the login screen. This is useful for switching between users, such as when a different person wishes to log in to their account or if you are ever in- structed to “log out and back in again.” You can also log out by pressing Ctrl+Alt+Del. Before logging out, always verify that you have saved your work in any open application. Suspending To save energy, you can put your computer into suspend mode which will save the current opened applications to internal memory (RAM), power off most of the internal devices and hardware, and allow you to start back up more quickly. Unlike hibernation (which is not officially supported or enabled in Ubuntu/Unity since 14.04 but can be enabled through other means), while in a suspended state the computer will continue operating using minimal electricity. Note that if the power goes out during this state, unsaved changes will be lost and data loss may also occur. To put your computer in suspend mode, select Suspend from the “Session Indicator”. Rebooting To reboot your computer, select Shut Down… from the “Session Indicator,” then click the Restart icon. Shutting down To totally power down your computer, select Shut Down… from the “Ses- sion Indicator,” then click the Shut Down icon. Other options From the “Session Indicator”, select Lock/Switch Account… to either lock the screen of the current user or switch user accounts. You can lock your screen quickly by using the keyboard shortcut Ctrl+Alt+L. Locking your screen is recommended if you are away from your computer for any amount of time.
34 getting started with ubuntu 16.04 Getting help General Help Figure 2.16: The built-in system help, accessible via the keyboard shortcut F1, provides topic- based help for Ubuntu. Like with many other operating systems, Ubuntu has a built-in help reference called the Ubuntu Desktop Guide (Figure 2.16 on page 34). To access it, click on the Dash and type Help. Alternatively, you can press F1 while on the desktop, or select Ubuntu Help from the Help menu in the menu bar. Many applications have their own help section which can be accessed by clicking the Help menu within the application window. Online Help If you can’t find an answer to your question in this manual or in the Ubuntu Desktop Guide, you can ask for assistance from other Ubuntu users using the Ubuntu Forums (http://ubuntuforums.org). To best assist you in solv- ing the issue, it is best to provide as much information as possible when submitting your query, such as: ‣ System information (e.g. Ubuntu version, PC make and model) ‣ The full text of any error messages you have encountered, ‣ What you were doing at the time, ‣ What were you trying to achieve / what you were expecting to happen… Many Ubuntu users open an account on the forums to receive help and in turn provide support to others as they gain more knowledge. Another useful resource is the Ubuntu Wiki (https://wiki.ubuntu.com/community), a website maintained by the Ubuntu community. You can additionally find the Official Ubuntu Documentation, prepared by Ubuntu developers, at https://help.ubuntu.com. Last but not least, one other helpful resource for online help and assis- tance is Ask Ubuntu (https://askubuntu.com/). Ask Ubuntu is provided by Stack Overflow and can be a helpful resource in addition to the previously- mentioned ones.
the ubuntu desktop 35 Heads-Up Display help Figure 2.17: The HUD (Heads-Up Display) shows application-specific information and options based on your general input. The hud (Heads-Up Display) is a keyboard-friendly utility to help you find commands, features, and preferences embedded deep within the stacked menu structure of an application. Activate the hud by tapping the Alt key on the keyboard. For example, if you want to add music in Rhythmbox (the default music player in Ubuntu) you can open the application, press Alt, and begin typing add music. The options available in Rhythmbox will begin to appear as you type, meaning you usually do not have to type many characters to obtain useful results. You can use the Down/Up Arrow keys to navigate these results and press the Enter key to active the selected option. While the hud is primarily of use within applications, particularly those with deep menus such as LibreOffice or GIMP, it may also be used on the Unity desktop itself with no applications opened or given focus. With the hud, you can often easily perform within a few keystrokes something that would otherwise require navigating various menus and sub-menus.
3 Working with Ubuntu All the applications you need Because Ubuntu is a separate operating system, some applications that are available for other operating systems (such as FreeBSD, Windows, or OS X) may not be available for Ubuntu and vice versa. This is especially true for closed source (i.e., proprietary) software released by makers of closed source operating systems. If you are migrating from a Windows or Mac platform, some of the Most of the applications listed in this section can be installed via the Ubuntu Software application, are open source, and are freely available. Those followed by an asterisk (*) can be downloaded directly from their respective official websites. programs you were using have native Linux versions. For those that lack compatibility, there are well established free software alternatives that will cover your needs. This section will recommend some of these free software applications that are known to work well on Ubuntu. Office Suites In Ubuntu you may choose among many office suites. The most popular suite is LibreOffice (formerly OpenOffice). Included in the suite: ‣ Writer: word processor ‣ Calc: spreadsheet ‣ Impress: presentation manager ‣ Draw: drawing program ‣ Base: database ‣ Math: equation editor The LibreOffice Suite comes pre-installed with Ubuntu by default. Note that Base is not installed by default but can be installed through Ubuntu Software. Other office productivity applications that you might want to try out are KOffice, Gnome Office (for older Ubuntu versions), Gnumeric (spreadsheet application), Kexi (database application), and so on. Email Applications As with office suites, there are multiple options for email applications. One very popular email application is Mozilla Thunderbird, which is also available for Windows. Thunderbird is the default email application in Ubuntu. Other options include Evolution and KMail. Web Browsers The default web browser in Ubuntu is Firefox. Other browsers you may want to try out include Epiphany, Midori, Chromium, Opera*, and Google Chrome*. PDF Readers Evince is the default pdf reader in Ubuntu. Others include Okular and Adobe Reader*.
38 getting started with ubuntu 16.04 Multimedia Players For multimedia, Ubuntu users have a wide variety of options for high qual- ity players. While VLC is a perennial favorite among videophiles, the classic and user-friendly Totem is the default media player in Ubuntu. Other media players, most of which can be installed through Ubuntu Software, are: Me- dia Player, SMPlayer, Parole Media Player, mpv Media Player, Tomahawk, Internet DJ Console, KMPlayer, Banshee (an all-round media player), and Kaffeine (KDE). Music Players and Podcatchers There are several options for listening to music with Ubuntu: Rhythmbox (installed by default), Amarok, Audacity (also a sound editor), Miro (also a video player), VLC, and so on. These applications allow you to listen to music and to your favorite podcasts. Amarok is similar to Winamp. Miro may be of use especially to those who watch video podcasts and tv shows from the Internet. VLC is well known for its ability to play a very wide range of multimedia file formats. CD/DVD Burning There are several popular disk burning applications such as Gnome-baker, Brasero, SimpleBurn, cd burner, Xfburn, and K3b. These CD/DVD creation tools are powerful and offer user-friendly interfaces and numerous features. Photo Management You can view and manage your favorite photos with Shotwell, Ubuntu’s default photo manager, gThumb, Gwenview, or F-Spot, among others. Graphics Editors gimp is a very powerful graphics editor. You can create your own graphics, taper your photographs, and modify your pictures. Another useful Graphics Editor is Inkscape, which allows you to create and edit Scalable Vector Graphics images. Both gimp and Inkscape can be installed through Ubuntu Software. Instant Messaging You can use Pidgin, Empathy, or Kopete to communicate over most proto- cols including: aim, msn, Google Talk, irc, Jabber/xmpp, Facebook, Yahoo!, and icq. This means that you need only one application to communicate with all of your friends. Note that some of these clients have limited video support. VoIP Applications voip technologies allow you to talk to people over the Internet. The most popular application is Skype, which is available for Ubuntu. An open-source alternative, Ekiga, supports voice communication using the sip protocol. Skype uses a proprietary protocol and is thus incompatible.
working with ubuntu 39 BitTorrent Clients There are a number of BitTorrent clients for Ubuntu: Transmission, Ubuntu’s default client, is simple and light-weight. Deluge, Vuze, and KTorrent offer many features and can satisfy the most advanced users. Getting online This section of the manual will help you to check your connection to the Internet and help you configure it where needed. Ubuntu can connect to the Internet using a wired, wireless, or dialup connection. Ubuntu also supports more advanced connection methods, which will be briefly discussed at the end of this section. A wired connection is when your computer connects to the Internet using an Ethernet cable. This is usually connected to a wall socket or a networking device—like a switch or a router. A wireless connection is when your computer connects to the Internet using a wireless radio network—usually known as Wi-Fi. Most routers now come with wireless capability, as do most laptops and netbooks. Because of this, Wi-Fi is the most common connection type for these types of devices. Wireless connectivity makes laptops and netbooks more portable when moving to different rooms of a house and while travelling. A dialup connection is when your computer uses a modem to connect to the Internet through a telephone line. NetworkManager Networking in Ubuntu is by default managed with the NetworkManager utility. NetworkManager allows you to turn network connections on or off, manage wired and wireless networks, and make other network connections, such as dialup, mobile broadband, and vpns. (a) (b) (c) Figure 3.1: The network connection states: (a) disconnected, (b) wired, and (c) wireless. You can access NetworkManager by using its icon found in the top panel. This icon may look different depending on your current connection state. Clicking this icon will reveal a list of available network connections. The current connections (if any) will have the word “disconnect” underneath. You can click on “disconnect” to manually disconnect from that network. This menu also allows you to view technical details about your current connection or edit all connection settings. Figure 3.2: Here you can see the currently active connection is “Wired connection 1.” In the image to the right, you will see a check mark next to “Enable Net- working.” Deselect “Enable Networking” to disable all network connections. Select “Enable Networking” to enable networking again. This can be very useful when you are required to turn off all wireless communications, like in an airplane. Establishing a wired connection If you are already online at this point as indicated by the NetworkManager icon in the top panel showing a connection, then you may have successfully connected during the Ubuntu setup process. You can also simply open a browser and see if you have access to the Internet. If so, you do not need to do anything for the rest of this section. If not, then continue reading. If you have an Ethernet cable running from a wall socket or networking device, such as a switch or router, then you will want to setup a wired connection in Ubuntu.
40 getting started with ubuntu 16.04 In order to connect to the Internet with a wired connection, you need to know whether your network supports dhcp (Dynamic Host Configuration Protocol). dhcp is a way for your computer to automatically be configured to access your network and/or Internet connection. dhcp is usually auto- matically configured on your router. This is usually the quickest and easiest way of establishing a connection to the Internet. If you are unsure whether your router is setup to use dhcp, you may wish to contact your isp’s (In- ternet Service Provider) customer service line to check. If your router isn’t configured to use dhcp then they will also be able to tell you what configu- ration settings you need in order to get online. If you are connected to your office LAN, you should contact your network administrator. Automatic connections with DHCP Figure 3.3: This window displays your IP address and other connection information. If your network supports dhcp, then you may already be set up for on- line access. To check this, click on the NetworkManager icon. There should be an “Ethernet Network” heading in the menu. If either “Wired connec- tion 1” or “Auto Ethernet” appears directly underneath, then your machine is currently connected and probably setup for dhcp. If “Disconnected” ap- pears in gray underneath the wired network section, look below to see if an option labeled “Wired connection 1” appears in the list. If so, click on it to attempt to establish a wired connection. An IP (Internet Protocol) address is a unique number assigned to your machine so that your router can identify you on the network. Think of it like a phone number for your computer. Having this unique address allows the router to speak to your computer, and therefore send/receive data. If you are still not online after following these steps, you may need to try setting up your network connection manually using a static ip address. To check if you are online, look for the NetworkManager icon in the top panel. If the icon shows , then your computer was not successfully assigned connection information through dhcp. If the icon shows either or , then it is likely that your dhcp connection to the router was successful. To test your Internet connection, you may want to open the Firefox web browser to try loading a web page. More information on using Firefox can be found later in this chapter. Manual configuration with static address If your network does not support dhcp, then you need to know a few items of information before you can get online. If you do not know any of this information, then you call your isp.
working with ubuntu 41 ‣ An ip address—This is a unique address used for identifying your com- puter on the network. An ip address is always given in four numbered groups, separated by dots, for example, 192.168.100.10. When connect- ing using dhcp, this address will periodically change (hence, the name “dynamic”). However, if you have configured a static ip address, your ip address will never change. ‣ A network mask—This tells your computer the size of the network to which it is being connected. It is formatted the same way as the ip ad- dress, but usually looks something like 255.255.255.0. ‣ A gateway—This is the ip address of the device that your machine looks to for access to the Internet. Usually, this will be the router’s ip address. ‣ dns server—This is the ip address of the dns (Domain Name Service) server. dns is what your computer uses to resolve ip addresses to domain names. For example http://www.ubuntu.com resolves to 22.214.171.124. This is the ip address of the Ubuntu website on the Internet. dns is used so you don’t have to remember ip addresses. Domain names (like ubuntu.com) are much easier to remember. You will need at least one dns server address but you can enter up to three addresses in case one server is unavailable. If you do not know your isp’s dns server addresses, Google has dns servers that anyone in the world can use for free. The addresses of these servers are: Primary—126.96.36.199 Secondary—188.8.131.52. To manually configure a wired connection, click on the NetworkManager icon and select Edit Connections. Make sure you are looking at the Wired tab inside the “Network Connections” window. The list may already have an entry, such as “Wired connection 1” or a similar name. If a connection is listed, select it and click the Edit button. If no connection is listed, click the Add button. If you are adding a connection, you need to provide a name for the connection. This will distinguish the connection being added from any other connections added in future. In the “Connection Name” field, choose a name such as “Wired Home.” Figure 3.4: In this window you can manually edit a connection. To setup the connection: 1. Make sure that the Connect automatically option is selected under the connection name. 2. Switch to the ipv4 Settings tab. 3. Change the Method to “Manual.” 4. Click on the Add button next to the empty list of addresses. 5. Enter your ip address in the field below the Address header.
42 getting started with ubuntu 16.04 6. Click to the right of the ip address, directly below the Netmask header and enter your network mask. If you are unsure, “255.255.255.0” is the most common. 7. Click on the right of the network mask directly below the Gateway header and enter the address of your gateway. 8. In the dns Servers field below, enter the address of your dns server(s). If you are entering more than one, separate them with commas—for example, “184.108.40.206, 220.127.116.11”. 9. Click Save to save your changes. A mac address is a hardware address for your computer’s network card. Entering this information is sometimes important when using a cable modem connection. If you know the mac address of your network card, this can be entered in the appropriate text field in the Wired tab of the editing window. To find the mac addresses for all installed networking devices, open a terminal window, and at the command line prompt, type ifconfig. This will display a lot of informa- tion about each of the network devices installed on the computer. The wired devices will begin with one of the four possible prefixes, and that prefix is en, for Ethernet devices. wl is for Wireless (or Wireless Lan), sl is for Serial Line IP (slip), and ww is for WWAN. When you have returned to the Network Connections screen, your newly added connection should now be listed. Click Close to return to the desktop. If your connection was configured correctly, the NetworkManager icon should have changed to show an active wired connection. To test if your connection is properly set up, simply open a web browser. If you can access the Internet, then you are connected! Wireless If your computer is equipped with a wireless (Wi-Fi) card and you have a wireless network nearby, you should be able to set up a wireless connection in Ubuntu. Connecting to a wireless network for the first time If your computer has a wireless network card, you can connect to a wireless network. Most laptops and netbooks have a built-in wireless networking card. Ubuntu is usually able to detect any wireless network in range of your computer. To see a list of wireless networks, click on the NetworkMan- ager icon. Under the “Wireless Networks” heading you should see a list of available wireless networks. Each network will be shown by its name and a signal meter to the left showing its relative signal strength. The signal meter looks like a set of bars similar to what is seen when viewing signal strength of a cell phone. Simply put, the more bars, the stronger the signal. To im- prove speed and reliability of your wireless connection, try moving closer to your router or wireless access point. A wireless network can be open to anyone, or it can be protected with a password. A small padlock will be displayed alongside the signal bar if any wireless networks within range are password-protected. You will need to know the correct password in order to connect to these secured wireless networks. To connect to a wireless network, select the desired network by clicking on its name within the list. This will be the name that was used during the
working with ubuntu 43 installation of the wireless router or access point. Most isps provide pre- configured routers with a sticker on them detailing the current wireless network name and password. Most publicly accessible wireless networks will be easily identifiable by the name used for the wireless network—for example “Starbucks-Wireless.” If the network is unprotected (i.e., the signal meter does not show a pad- lock), a connection should be established within a few seconds—and with- out a password required. The NetworkManager icon in the top panel will animate as Ubuntu attempts to connect to the network. If the connection is successful, the icon will change to display a signal meter. An on-screen notification message will also appear informing you that the connection was successful. If the network is password-protected, Ubuntu will display a window called “Wi-Fi Network Authentication Required” as it tries to make a con- nection. This means that a valid password is required to make a connection. This is what the screen should look like: Figure 3.5: Enter your wireless network password. If you know the password, enter it in the Password field and then click on the Connect button. As you type the password, it will be obscured from view to prevent others from reading the password as you type it. To verify the characters you are entering for the password, you can view the pass- word by selecting the Show Password check box. Then, you can make the password obscure again by deselecting the Show password check box. Once the password is entered, click on the Connect button. The Network- Manager icon in the top panel will animate as Ubuntu attempts to connect to the network. If the connection is successful, the icon will change to dis- play a signal meter. An on-screen notification message will also appear informing you that the connection was successful. If you entered the password incorrectly, or if it doesn’t match the cor- rect password (for example if it has recently been changed and you have forgotten), NetworkManager will make another attempt to connect to the network, and the “Wi-Fi Network Authentication Required” window will re-appear so that you can re-type the password. You can hit the Cancel but- ton to abort the connection. If you do not know the correct password, you may need to call your isp’s customer support line or contact your network administrator. Once you have successfully established a wireless connection, Ubuntu will store these settings (including the password) to make it easier to con- nect to this same wireless network in the future. You may also be prompted to select a keyring password here. The keyring stores passwords in one place so you can access them all in the future by remembering just the keyring password.
44 getting started with ubuntu 16.04 Connecting to a saved wireless network Ubuntu will automatically try to connect to a wireless network in range if it has the settings saved. This works on both open and secure wireless networks. If you have numerous wireless networks in range that are saved on your computer, Ubuntu may choose to connect to one network while you may want to connect to another network. To remedy this action, click on the NetworkManager icon. A list of wireless networks will appear along with their signal meters. Simply click on the network to which you wish to connect, and Ubuntu will disconnect from the current network and attempt to connect to the one you have selected. If the network is secure and Ubuntu has the details for this network saved, Ubuntu will automatically connect. If the details for this network connection are not saved, are incorrect, or have changed, then you will be prompted to enter the network password again. If the network is open (no password required), all of this will happen automatically and the connection will be established. Connecting to a hidden wireless network In some environments, you may need to connect to a hidden wireless net- work. These hidden networks do not broadcast their names, and, therefore, their names will not appear in the list of available wireless networks even if they are in range. In order to connect to a hidden wireless network, you will need to get its name and security details from your network adminis- trator or isp. To connect to a hidden wireless network: 1. Click on NetworkManager in the top panel. 2. Select Connect to a hidden wireless network. Ubuntu will then open the “Connect to Hidden Wireless Network” window. 3. In the Network name field, enter the name of the network. This is also known as the ssid (Service Set Identifier). You must enter the name ex- actly how it was given to you. For example, if the name is “Ubuntu- Wireless,” entering “ubuntu-wireless” will not work as the “U” and “W” are both uppercase in the correct name. 4. In the Wireless security field, select one of the options. If the network is an open network, leave the field set to “None.” If you do not know the correct setting for the field, you will not be able to connect to the hidden network. 5. Click the Connect button. If the network is secure, you will be prompted for the password. Provided you have entered all of the details correctly, the network should then connect, and you will receive an on-screen notification informing you that the connection was a success. As is the case with visible wireless networks, hidden wireless network settings will be saved once a connection is made, and the wireless network will then appear in the list of saved connections. Disabling and enabling your wireless card By default, wireless access is enabled if you have a wireless card installed in your computer. In certain environments (like on airplanes), you may need to temporarily disable your wireless card.
working with ubuntu 45 To disable your wireless card, click on the NetworkManager icon and deselect the Enable Wireless option. Your wireless radio will now be turned off, and your computer will no longer search for wireless networks. To reactivate your wireless card, simply select the Enable Wireless op- tion. Ubuntu will then begin to search for wireless networks automatically. If you are in range of a saved network, you will automatically be connected. Many modern laptops also have a physical switch/button built into the chassis that provides a way to quickly enable/disable the wireless card. Changing an existing wireless network At times you may want to change the settings of a saved wireless network —for example, when the wireless password gets changed. To edit a saved wireless network connection: 1. Click on the NetworkManager icon and select Edit Connections… 2. A “Network Connections” window will open. Click on the Wireless tab. 3. By default, saved networks are in chronological order with the most recently connected at the top. Find the network you want to edit, select it, and click on the Edit button. 4. Ubuntu will now open a window called “Editing 〈connection name〉”, where 〈connection name〉 is the name of the connection you are editing. This window will display a number of tabs. 5. Above the tabs, there is a field called Connection name where you can change the name of the connection to give it a more recognizable name. 6. If the Connect automatically option is not selected, Ubuntu will detect the wireless network but will not attempt a connection until it is se- lected from the NetworkManager menu. Select or deselect this option as needed. 7. On the Wireless tab, you may need to edit the ssid field. A ssid is the wireless connection’s network name. If this field isn’t set correctly, Ubuntu will not be able to connect to the wireless network in question. 8. Below the ssid is a Mode field. The “Infrastructure” mode means that you would be connecting to a wireless router or Access Point. The “ad- hoc” mode is for a computer-to-computer connection (where one com- puter shares another’s connection) and is often only used in advanced cases. 9. On the Wireless Security tab, you can change the Security field. A selection of “None” means that you are using an open network that doesn’t require a password. Other selections in this tab may require additional information: wep 40/128-bit Key is an older security setting still in use by some older wireless devices. If your network uses this method of security, you will need to enter a key in the Key field that will appear when this mode is selected. wep 128-bit Passphrase is the same older security as above. However, instead of having a key, your network administrator should have provided you with a passphrase to connect to the network. wpa & wpa2 Personal is the most common security mode for wireless networking. Once you select this mode, you will need to enter a password in the Password field. If your network administrator requires leap, Dynamic wep or wpa & wpa2 Enterprise then you will need to have the administrator help you with those modes.
46 getting started with ubuntu 16.04 10. In the ipv4 Settings tab, you can change the Method field from “Auto- matic (dhcp)” to “Manual” or one of the other methods. For setting up manual settings (also known as a static address), please see the section above on manual setup for wired network connections. 11. When you finish making changes to the connection, click Apply to save your changes and close the window. You can click Cancel at any time to close the window without saving any changes. 12. Finally, click Close on the “Network Connections” window to return to the desktop. After clicking Apply, any changes made to the network connection will take effect immediately. Connecting to a mobile broadband network If you have a mobile device capable of tethering, such as an Android tablet or phone, then you may be able to utilize the mobile network connection on your computer through the device. The steps to enable tethering on any device can vary widely, but once you have enabled tethering on the device and connected it to your computer (usually through usb) then it will show up on the list of available and current connections in the NetworkManager applet, located in the top panel. Be aware that doing this will send your network traffic over the carrier provider’s mobile network and data rates may apply (and add up quickly!). Many standard desktop applications do not yet either detect mobile connections and restrict bandwidth usage or allow you to change a setting in the application to have it do so. Other connection methods There are other ways to get connected with Ubuntu: ‣ With NetworkManager, you can connect to digital subscriber line (dsl) networks, a method of connecting to the Internet through your phone line via a modem. ‣ It is possible for NetworkManager to establish a virtual private network (vpn) connection. These are most commonly used to create a secure connection to a workplace network. The instructions for making connections using dsl, or creating and establishing vpn connections, are beyond the scope of this guide. Browsing the web Once you have connected to the Internet, you should be able to browse the web. Mozilla Firefox is the default application for this in Ubuntu. Starting Firefox There are several ways to start Firefox. By default Ubuntu has the Firefox icon within the Launcher (the vertical bar down the left side of the screen). Select this icon to open Firefox. Or, open the Dash (the top-most icon in the Launcher) and search for firefox using the search box. If your keyboard has a “www” button, you can press that button to start Firefox.
working with ubuntu 47 Figure 3.6: The default Ubuntu home page for the Firefox web browser. Navigating web pages Viewing your homepage When you start Firefox, you will see your home page. By default, this is the Ubuntu Start Page. To quickly go to your home page, press Alt+Home on your keyboard or press on the home icon in Firefox. Navigating to another page To navigate to a new web page, you need to enter its Internet address (also URL stands for uniform resource locator, which tells the computer how to find something on the Internet—such as a document, web page or an email address. WWW stands for World Wide Web, which means the web pages by which most people interact with the Internet. known as a url) into the Location Bar. urls normally begin with “http://” followed by one or more names that identify the address. One example is “http://www.ubuntu.com/.” (Normally, you can omit the “http://” part. Firefox will fill it in for you.) Figure 3.7: You can enter a web address or search the Internet by typing in the location bar. To navigate: 1. Double-click in the Location Bar, or press Ctrl+L, to highlight the url that is already there. 2. Enter the url of the page you want to visit. The url you type replaces any text already in the Location Bar. 3. Press Enter. If you don’t know the url that you need, type a search term into the Search Bar to the right of the Location bar. Your preferred search engine —Google by default—will return a list of websites for you to choose from. (You can also enter your query directly into the Location Bar).
48 getting started with ubuntu 16.04 Selecting a link Most web pages contain links that you can select. These are known as “hyperlinks.” A hyperlink can let you move to another page, download a document, change the content of the page, and more. To select a link: 1. Move the mouse pointer until it changes to a pointing finger. This hap- pens whenever the pointer is over a link. Most links are underlined text, but buttons and pictures on a web page can also be links. 2. Click the link once. While Firefox locates the link’s page, status mes- sages will appear at the bottom of the window. Retracing your steps If you want to visit a page you have viewed before, there are several ways To go backwards and forwards you can also use Alt+Left and Alt+Right respectively. to do so. ‣ To go back or forward one page, press the Back or Forward button by the left side of the Location Bar. ‣ To go back or forward more than one page, click-and-hold on the re- spective button. You will see a list of pages you have recently visited. To return to a page, select it from the list. ‣ To see a list of any urls you have entered into the Location Bar, press the down arrow at the right end of the Location Bar. Choose a page from the list. ‣ To choose from pages you have visited during the current session, open the History menu and choose from the list in the lower section of the menu. ‣ To choose from pages you have visited over the past few months, open the History ‣ Show All History (or press Ctrl+Shift+H). Firefox opens a “Library” window showing a list of folders, the first of which is “History.” Select a suitable sub-folder, or enter a search term in the search bar (at the top right), to find pages you have viewed before. Double-click a result to open the page. Stopping and reloading If a page is loading too slowly or you no longer wish to view a page, press The Reload button is at the right end of the Location Bar. Esc to cancel it. To reload the current page if it might have changed since you loaded it, press on the Reload button or press Ctrl+R. Opening new windows At times, you may want to have more than one browser window open. This may help you to organize your browsing session better, or to separate web pages that you are viewing for different reasons. There are four ways to create a new window: ‣ On the top bar, select File ‣ New Window. ‣ Press Ctrl+N. ‣ Right-click on Firefox’s icon on the Launcher and select Open New Window. ‣ Click on Firefox’s icon on the Launcher using your middle mouse button. Once a new window has opened, you can use it exactly the same as the first window—including navigation and opening tabs. You can open multiple windows.
working with ubuntu 49 Opening a link in a new window Sometimes, you may want to click a link to navigate to another web page, but do not want the original to close. To do this, you can open the link in its own independent window. There are two ways to open a link in its own window: ‣ Right-click a link and select Open Link in New Window. ‣ Press-and-hold the Shift key while clicking a link. Tabbed browsing An alternative to opening new windows is to use Tabbed Browsing instead. Tabbed browsing lets you open several web pages within a single Firefox A new tab is independent of other tabs in the same way that new windows are independent of other windows. You can even mix-and-match —for example, one window may contain tabs for your emails, while another window has tabs for your work. window, each independent of the other. This frees space on your desktop as you do not have to open a separate window for each new web page. You can open, close, and reload web pages in one place without having to switch to another window. You can alternate quickly between different tabs by using the keyboard shortcut Ctrl+Tab. Opening a new blank tab There are three ways to create a new blank tab: ‣ Click on the Open new tab button (a green plus-sign) on the right side of the last tab. ‣ On the top bar, open File ‣ New Tab. ‣ Press Ctrl+T. When you create a new tab, it contains a blank page with the Location Bar focused. Type a web address (url) or other search term to open a web- site in the new tab. Opening a link in its own tab Sometimes, you may want to click a link to navigate to another web page, but do not want the original to close. To do this, you can open the link in its own tab. There are several ways to open a link in its own tab. A tab always opens “in the background”—in other words, the focus remains on the original tab. The last method (Ctrl+Shift) is an exception; it focuses the new tab immediately. ‣ Right-click a link and select Open Link in New Tab. ‣ Press-and-hold the Ctrl key while clicking a link. ‣ Click the link using either the middle mouse button or both left and right mouse buttons simultaneously. ‣ Drag the link to a blank space on the tab bar or onto the Open new tab button. ‣ Press-and-hold Ctrl+Shift while clicking a link. Closing a tab Once you have finished viewing a web page in a tab, you have various ways to close it: ‣ Click on the Close button on the right side of the tab. ‣ Click the tab with the middle mouse button or the mouse wheel. ‣ Press Ctrl+W. ‣ Right-click the tab and select Close Tab.
50 getting started with ubuntu 16.04 Restoring a closed tab Sometimes, you may close the wrong tab by accident, or want to bring back a tab that you have recently closed. Bring back a tab in one of the following two ways: ‣ Press Ctrl+Shift+T to re-open the most recently closed tab. ‣ Select History ‣ Recently Closed Tabs, and choose the name of the tab to restore. Changing the tab order Move a tab to a different location on the tab bar by dragging it to a new location using your mouse. While you are dragging the tab, Firefox displays a small indicator to show the tab’s new location. Moving a tab between windows You can move a tab into a new Firefox window or, if one is already open, into a different Firefox window. Drag a tab away from the tab bar, and it will open into a new window. Drag it from the tab bar into the tab bar of another open Firefox window, and it will move there instead. Searching You can search the web from within Firefox without first visiting the home page of the search engine. By default, Firefox will search the web using the Google search engine. Searching the web To search the web in Firefox, type a few words into the Firefox search Bar. For example, if you want to find information about Ubuntu: 1. Move your cursor to the Search Bar using your mouse or press Ctrl+K. 2. Type the phrase Ubuntu. Your typing replaces any text currently in the Search Bar. 3. Press the magnifying glass or Enter to search. Search results from Google for “Ubuntu” will appear in the Firefox win- dow. Selecting search engines Figure 3.8: These are the other search engines you can use—by default—from the Firefox search bar. If you do not want to use Google as your search engine in the Search Bar, you can change the search engine that Firefox uses. To change your preferred search engine, press the search logo (at the left of your Search Bar—Google by default) and choose the search engine of your choice. Some search engines, such as Bing, Google and Yahoo, search the whole web; others, such as Amazon and Wikipedia, search only specific sites. Searching the web for words selected in a web page Sometimes, you may want to search for a phrase that you see on a web page. You can copy and paste the phrase into the Search Bar, but there is a quicker way.
working with ubuntu 51 1. Highlight the word or phrase in a web page using your left mouse but- ton. 2. Right-click the highlighted text and select Search [Search Engine] for [your selected words]. Firefox passes the highlighted text to the search engine, and opens a new tab with the results. Searching within a page Figure 3.9: You can search within web pages using the Find Toolbar. You may want to look for specific text within the web page you are viewing. To find text within the current page in Firefox: 1. Choose Edit ‣ Find or press Ctrl+F to open the Find Toolbar at the bottom of Firefox. 2. Enter your search query into the Find field in the Find Toolbar. The search automatically begins as soon as you type something into the field. 3. Once some text has been matched on the web page, you can: ‣ Click on Next to find text in the page that is below the current cursor position. ‣ Click on Previous to find text that is above the current cursor posi- tion. ‣ Click on Highlight all to highlight all occurrences of your search words in the current page. ‣ Select the Match case option to limit the search to text that has the same capitalization as your search words. To quickly find the same word or phrase again, press F3. You can skip opening the Find Toolbar altogether. 1. Turn on the relevant Accessibility option with Edit ‣ Preferences ‣ Advanced ‣ General ‣ Accessibility ‣ Search for text when I start typ- ing ‣ Close. 2. Now, provided your cursor is not within a text field, when you start typing, it will automatically start searching for text. Viewing web pages full screen To display more web content on the screen, you can use Full Screen mode. Full Screen mode hides everything but the main content. To enable Full Screen mode, choose View ‣ Full Screen or press F11. While in full-screen mode, move your mouse to the top of the screen to reveal the url and search bars. Press F11 to return to normal mode. Copying and saving pages With Firefox, you can copy part of a page so that you can paste it elsewhere, or save the page or part of a page as a file on your computer.
52 getting started with ubuntu 16.04 Copying part of a page To copy text, links or images from a page: 1. Highlight the text and images with your mouse. 2. Right-click the highlighted text and select Copy, or press Ctrl+C. To copy just a single image, it is not necessary to highlight it. Just right- click the image and select Copy. You can paste the results into another application, such as LibreOffice. Copying a link To copy a text or image link (url) from a page: 1. Position the pointer over the text, link or image. Your mouse pointer changes to a pointing finger. 2. Right-click the link or image to open a pop-up menu. 3. Select Copy Link Location. You can paste the link into other applications or into Firefox’s Location Bar. Saving all or part of a page To save an entire page in Firefox: 1. Choose File ‣ Save Page As from the top bar, or press Ctrl+S. Firefox opens the “Save As” window. 2. Choose a location for the saved page. 3. Type a file name for the page. 4. Press Save. To save an image from a page: 1. Position the mouse pointer over the image. 2. Right-click the image and select Save Image As. Firefox opens the “Save Image” window. 3. Choose a location for the saved image. 4. Enter a file name for the image. 5. Press Save. Changing your home page Firefox shows the home page when it opens. By default, this is the Ubuntu Start Page. You can change your default home page to a new one, or even to several new ones. To change your home page: 1. Navigate to the page that you would like to become your new home page. If you want Firefox to open more than one tab when it starts, open a new tab and navigate to the extra page as many times as you would like. The home page can also be set by entering the addresses that should be open in the Home Page, with a pipe ) separating pages to be opened in separate tabs. 2. Choose Edit ‣ Preferences ‣ General ‣ Startup ‣ Use Current Pages ‣ Close.
working with ubuntu 53 Figure 3.10: Change Firefox settings in this tab. Download settings In Edit ‣ Preferences ‣ General ‣ Downloads, you can tell Firefox where to The Downloads folder in the Library lists files downloaded in the past. It can be used to open or re-download files. place downloaded files, and whether or not to ask where each time. Bookmarks When browsing the web you may want to come back to certain web pages again without having to remember the url. To do this, you bookmark each page. These bookmarks are saved in the web browser, and you can use them to re-open to those web pages. Bookmarking a page After navigating to a web page you can save its location by bookmarking it. There are two ways to bookmark a page: ‣ From the top bar, choose Bookmarks ‣ Bookmark This Page, or press Ctrl+D. A window opens, allowing you to provide a descriptive name for the bookmark and a location (within the browser’s bookmarks) to save it. Press Done to save. ‣ Press the star on the right-hand side in the Location Bar. It turns blue. This saves the page in the Unsorted Bookmarks folder. Navigating to a bookmarked page To navigate to a bookmarked page, open the Bookmarks menu from the top bar, and choose your bookmark. Firefox opens the bookmark in the current tab. You can reveal the bookmarks, including the Unsorted Bookmarks, in a sidebar on the left of the browser window. Select View ‣ Sidebar ‣ Bookmarks, or press Ctrl+B. Repeat, or press the close button at its top, to hide the sidebar.
54 getting started with ubuntu 16.04 Deleting or editing a bookmark To delete or edit a bookmark, do one of the following: ‣ If you are viewing the page already, the star in the Location Bar will be blue. Press it. Firefox opens a small pop-up window, where you can either Remove Bookmark or edit the bookmark. ‣ Select Bookmarks ‣ Show All Bookmarks or press Shift+Ctrl+O. In the window that opens, you can navigate to bookmarks. Select the one you would like to change. To delete, right-click and choose Delete or press Delete on your keyboard. To edit, change the details shown at the bottom of the window. History Whenever you are browsing the web, Firefox saves your browsing history. This allows you to come back to a web page that you have recently visited without needing to remember or bookmark the page’s url. To see your most recent history, open the History menu from the top bar. The menu displays several of the most recent web pages that you have viewed. Choose one of the pages to return to it. To view the complete history, either: ‣ Select View ‣ Sidebar ‣ History or press Ctrl+H to view the history in a sidebar; this replaces the bookmarks sidebar if it is open. (Repeat, or press the close button at its top, to hide the sidebar.) ‣ Select History ‣ Show All History or press Shift+Ctrl+H to view the history in a pop-up window. Your browsing history is categorized as “Today,” “Yesterday,” “Last 7 days,” “This month,” the previous five months by name, and finally “Older than 6 months.” If the history for a category does not exist, that category will not be listed. Select one of the date categories in the sidebar to expand it and reveal the pages that you visited during that time. Once you find the page you want, select it to re-display it. You can also search for a page by its title or url. Enter a few letters from one or more words or, optionally, the url in the Search field at the top of the history sidebar. The sidebar displays a list of web pages matching your search words. Select the page you want. (You can even do this in the Location Bar, saving you from having to open the History sidebar or pop-up window.) Clearing private data Firefox stores all its data only on your computer. Nevertheless, if you share your computer, you may at times want to delete all private data. Select History ‣ Clear Recent History… or press Shift+Ctrl+Delete. Choose your Time range to clear, and under Details which items to clear, and press Clear Now. Preventing Firefox from recording private data You can start a “private browsing” session during which Firefox will not record anything permanently. This lasts until you disable private browsing or restart Firefox.
working with ubuntu 55 Choose File ‣ New Private Window or press Shift+Ctrl+P. As long as you remain in this mode, Firefox will not record browsing, download, form or search history, or cookies, nor will it cache files. However, if you bookmark anything or download files, these will be retained. To end private browsing, just close the private browsing window by clicking on its close button or pressing Shift+Ctrl+W, or restart Firefox. Using a different web browser Figure 3.11: The Default Applications where you can change your preferred browser. If you choose to install a different web browser on your computer, you may want to use it as the default browser when you click links from emails, instant messages, and other places. Canonical supports Firefox and Chromium (Google’s open-source version of Chrome), but there are several others that you can install. To change your preferred web browser, open Session Indicator from the top panel on the far right-hand side, and open System Settings… ‣ Details ‣ Default Applications. Choose your preferred web browser from the drop- down menu Web. Reading and composing email Introduction to Thunderbird Thunderbird is an email client developed by Mozilla and is easy to setup and use. It is free, fast, and comes packed full of useful features. Even if you are new to Ubuntu and Thunderbird, you will be up and running in no time, checking your email and staying in touch with friends and family. Setting up Thunderbird In the top right corner of the Ubuntu desktop you will see an envelope icon in the notification area. This is the messaging menu. From here, you can launch Thunderbird by clicking Set up Mail. Alternatively, you can click the Ubuntu button in the top left corner of the screen at the top of the Launcher to bring up the Dash and type thunderbird into the search box. Once Thunderbird opens, you will be greeted by a pop-up box prompting you to setup your email account. Before a valid email account is set up in Thunderbird, the first screen to appear will be an introductory message from Mozilla inviting you to set up an email account through a local service provider in your area. For the
56 getting started with ubuntu 16.04 Figure 3.12: Setting up Thunderbird purposes of these instructions, we will assume you already have an email address, so you can click on the button in the lower right corner of the screen that says Skip this and use my existing email. On the next screen titled Mail Account Setup, enter your name in the first text box, your email address in the second text box (for example, user- email@example.com), and your email password in the third text box. Once completed, click the Continue button. Thunderbird will auto- If Thunderbird fails to create the account, you may need to configure it manually, using the parameters that were sent to you by your email address provider and your ISP. If you are still unable to set up your account, you can get help from community members at http://ubuntuforums.org. matically set up your email account for you. When Thunderbird finishes detecting your email settings, click Create Account and Thunderbird will do the rest. You can also set Thunderbird as your default news and rss reader by checking the boxes in the pop-up box that appear after you click Create Account. If you don’t want to see this message box every time you start Thunderbird, simply deselect Always perform this check when starting Thunderbird. You are now ready to start using Thunderbird. Around the Thunderbird workspace Now that you have your email account set up, let’s get to know the Thun- derbird workspace. Thunderbird is designed to be very user-friendly and easy to navigate. When you open the application, you will see the main workspace with your email folders (all folders pane) on the left. On the right of the screen, you will see two panes. The top-right pane displays a list of your received email, and the bottom-right pane displays the current email you are viewing. The size of these panes can be easily resized to suit your viewing environment. To resize the panes, simply left-click and hold the dividing bar that separates two panes and drag it to the desired position. The All Folders pane is where you can see your mail folders. This pane can also include: Inbox Where your email is stored and accessed Email address folder You will see one of these folders for each of the ac- counts you have setup Drafts Where your draft emails are stored Sent mail Where the emails you have sent are stored Spam This is where suspected spam email is stored so you can check them to make sure you haven’t lost any important emails Trash This is where messages you’ve deleted are stored so you can double check to make sure you haven’t accidentally deleted an important email (also one of the local folders) Important This is where emails you have marked as important are stored Starred This is where emails you have marked with a star are stored
working with ubuntu 57 Personal This is where emails you have marked as personal are stored Receipts You can move important receipts to this folder. Travel You can use this folder to store travel emails such as flight times and bookings Work You can store work emails in this folder to keep them separate from your personal email Outbox Where the emails you are in the process of sending are stored (also one of the local folders) Across the top of the Thunderbird workspace, you will see at least four control buttons, Get Mail, Write, Address Book, and Tag. These are used to get your mail, write your mail, access your address book, and tag your email messages. At the top-right of the All Folders pane, you will see a set of quick filter buttons, Unread, Starred, Contact, Tags, and Attachment. You can use these buttons to filter your email messages so that you only see your unread mail, your favorite mail (starred), mail from people in your address book, mail you have tagged, and mail that includes attachments. If you are accustomed to a more traditional desktop and you have Thun- derbird maximized to full screen, you might be wondering where the menus are located. They are still there, and if you want to access them, move your mouse to the top of the screen and you will see the familiar menus: File, Edit, View, Go, Message, Tools, and Help. At the top of the pane that displays your email, you can see six action buttons, Reply, Reply All, Forward, Archive, Junk, and Delete. You will find these very useful for quickly replying to email, forwarding your email to another person, archiving (backing up) your email, marking an email as junk mail, and quickly deleting an email. To the left of these quick action buttons, you will see information about the email you are viewing that includes the sender’s name, the subject of the email, the reply address, and the recipient of the email. Using your address book At the top of the main workspace, you will see the Address Book button. Click this button to access your address book. The address book opens in a new window. From here, you can easily organize your contacts. At the top of the address book window, you will see five buttons, New Contact, New List, Properties, Write, and Delete. They function in the following ways: New Contact This button allows you to add a new contact and add as much detail as you wish to save, including name, nickname, address, email, additional email, screen name, work number, home number, fax, pager and mobile/cell number. New List This button allows you to add lists for your contacts such as family, friends, acquaintances, etc. Properties This button allows you to rename your address book name. The default name is personal address book, but you can change the name as you see fit. Write This button allows you to quickly send an email to a selected contact without needing to go back to the main Thunderbird workspace. Simply select a contact from your contacts list and click the Write button to send them an email. Delete This button allows you to quickly delete a contact from your address
58 getting started with ubuntu 16.04 book. Just select the contact you want to delete and press Delete to remove the contact from your address book. Checking and reading messages Thunderbird will automatically check your email account for new mes- sages every ten minutes, but if you need to manually check for new mes- sages at any time, left-click the Get Mail button in the top left corner of the workspace. Thunderbird will then check your email account for new messages and download them. As they are downloaded, you will see the new email appear in the mes- sage pane on the right side of the workspace. When you click on one of your emails, it will appear in the pane below your email list. If you want to view your email in a full window, double-left-click your chosen email, and Thunderbird will display the email in a full window in its own tab. At the top of the open email, you will see information about the email Remote content represent parts of an email that may be hosted elsewhere. Remote content might consist of video or audio, but most often is graphics or HTML content. For security purposes, Thunderbird will ask you if you wish to view this remote content. and the five quick action buttons, Reply, Forward, Archive, Junk and Delete as previously discussed. If an email has remote content, you will see a message asking if you want to display the email or not. You may want to sort out your emails from time to time; this is easily done with Thunderbird. When you have an email selected and you want to tag the email, simply click the Tag button and a drop-down list will be displayed. In this drop-down list, you have the options to Remove All Tags or Mark as…, Important, Work, Personal, To Do, Later. You can also create a New Tag more suited to your own personal requirements. Composing Messages To compose a new email message, click the Write button in the top left of the workspace. This will bring up a new window where you can compose your new email. In the To: field, enter the email address of the destination —the contact to whom you are sending this email. If there is more than one contact to whom you are writing, separate multiple recipients with commas. If a contact that you are addressing is in your address book, you can address them by name. Start typing the name of the contact; Thunderbird will display the list of mailing contacts below your text. Once you see the contact you intend to address, click on their email address or use the down arrow key and then press Enter to select the address. If you would like to carbon-copy (Cc) some contacts, click the To: field and select Cc:. Contacts who are listed on the To: and Cc: lines will receive the email, and will see the rest of the contacts to whom an email was sent. If you would like to send an email to some contacts without disclosing to whom your email was sent, you can send a blind carbon-copy, or Bcc. To enable Bcc, select Bcc: by clicking the To: field and selecting Bcc:. Any contacts entered in the Bcc: field will receive the message, but none of the recipients will see the names or emails of contacts on the Bcc: line. Instead of typing the email addresses or names of the contacts you are addressing in the message, you can select the contacts from your address book. Start typing a few letters from your contact’s first or last name in the To: field to filter the list to only show mailing contacts. Once you identify the contact you would like to address, click on their name in the list. If you’ve added the contact in error, delete their address and enter the correct address. You may enter a subject for your email in the Subject field. Messages
working with ubuntu 59 should have a subject to help the recipient identify the general contents of the email while glancing at their message list. Enter the contents of your If you do not include a subject in your email, Thunderbird will warn you about this omission. message in the big text field below the subject. There is no practical limit on the amount of text you can include in your message. By default, Thunderbird will auto-detect the correct format for your email but you can change this by clicking Options then mouse over De- livery Format and select your preferred option from the list. You have a choice of Auto-Detect, Plain Text Only, Rich Text (HTML) Only, and Plain and Rich (HTML) Text. When you have finished composing your email, click on the Send button on the window’s toolbar. Your message will be placed in the Outbox, and will be sent to your desired recipient. Attaching files At times, you may want to send files to your contacts. To send files, you will need to attach them to your email message. To attach a file to an email You can attach quite a few different file types to emails, but be careful about the size of the attachments! If they are too big, some email systems will reject the email you are sending, and your recipient will never receive it! you are composing, click on the Attach button. When the new window opens, select the file you want to send and click Open. The file you selected will then be attached to the email when you click send. Replying to Messages In addition to composing new messages, you may want to reply to messages that you receive. There are three types of email replies: Reply or Reply to Sender sends your reply only to the sender of the message to whom you are replying. Reply to All sends your reply to the sender of the message as well as any address in To: or Cc: lines. Forward allows you to send the message, with any additional comments you may add, to some other contacts. To use any of these methods, click on the message to which you want to reply and then click the Reply, Reply to All, or Forward button on the message toolbar. Thunderbird will open the reply window. This window should look much like the window for composing new messages, but the To:, Cc:, Subject:, and main message content fields should be filled in from the message to which you are replying. Edit the To:, Cc:, Bcc:, Subject: or main body as you see fit. When your reply is finished, click on the Send button on the toolbar. Your message will be placed in the Outbox and will be sent. Using instant messaging To communicate with people online in real time, you will first need to install an instant messaging application such as Empathy, which lets you connect to many instant messaging networks (such as Google Talk, Salut, Jabber, Yahoo!, and aim). To install Empathy, open the Dash, search for Terminal and hit Enter or click on the icon labeled “Terminal”. Once inside the terminal, type sudo apt install empathy and hit Enter. Running Empathy for the first time Figure 3.13: This is the icon that Empathy displays in the launcher. To run Empathy for the first time, you need to start it from the Dash (see The Dash) by searching for Empathy and hitting Enter. Altenately, you can
60 getting started with ubuntu 16.04 click on its icon, shown in 3.13. After Empathy launches, you should see a window similar to that in figure 3.14. At this time, Empathy does not know about any of your instant messaging accounts. Figure 3.14: You should see a window like this the first time you open Empathy. Adding accounts You must have existing chat accounts that are compatible with Empathy. If you do not have an existing account, you will need to create one before continuing. Be aware that when you Add or Remove accounts using the Online Accounts manager you will be adding or removing those accounts to or from all the applications that they integrate with, not just Empathy. On the first run, the Online Accounts manager will appear, allowing you to add accounts to be used with Empathy. You can return to this dialog at any time by navigating to Empathy ‣ Accounts. You should see a dialog similar to that in figure 3.15. Figure 3.15: Add your existing chat accounts for use in Empathy using the Online Accounts manager. Click Add account… on the left-hand side of the window if it is not already selected. At the top of the window, where it says Show accounts that integrate with:, select Empathy from the drop-down menu. Now click on the name of the chat service with which you have an account. Shown in figure 3.16, we have selected a Google account. You must now enter your login credentials and authorize Ubuntu to access your account. When you have authorized Ubuntu to access your account, you are shown all the applications that integrate with the account, including Em- pathy. All the applications have an ON/OFF button to control their inte- gration with the account. Make sure the ON/OFF button is set to ON for
working with ubuntu 61 Figure 3.16: You must enter your account credentials and authorize Ubuntu to use your account. Empathy. There is also an Options button for you to edit details used by Empathy. The details shown are specific to each application. After adding your accounts, you can now use Empathy to chat with all of your friends, right from your Ubuntu desktop! Communicating with contacts Text To communicate with a contact, select the contact in Empathy’s main win- dow and double-click their name. Empathy should open a new window where you can type messages to your contact and see a record of previously exchanged messages. Figure 3.17: Chatting with friends in Empathy. To send a message to the contact, enter your message in the text field below the conversation history. When you have typed your message press the Enter key to send the message to your contact. When the person you are chatting with is typing to you, a small keyboard icon will appear next to their name in the chat window. If you are communicating with more than one person, then all of the conversations will be shown either in tabs in your Empathy window or in
62 getting started with ubuntu 16.04 separate windows, depending on the option you have chosen in the menu item Empathy ‣ Preferences. Audio and Video Calling You also can use Empathy to chat with your friends using audio and video. To start an audio or video call, right click on the contact name, then select Audio Call or Video Call, as shown in figure 3.18. This will notify the person you are trying to call, and they will be asked if they would like to answer the call. Figure 3.18: Right-clicking a contact exposes many ways to communicate. If the person you are calling accepts your call request, you will be con- nected, and you can begin talking. If the person you are calling cannot see or hear you, your webcam or microphone may not be properly configured; see the sections on Sound and Using a webcam, respectively. You can end the call by clicking on the red telephone button in the chat window. Sending and receiving files Sending a file When you are in a conversation with a contact and you would like to send them a file, right-click the contact in the contact list—as in figure 3.18— and select Send File. Empathy should open the “Select file” window. Find the file you wish to send, and click on the Send button. A “File Transfers” window will open showing the file and its transfer progress. When the file transfer is complete, you can close the “File Transfers” window. Changing your status You can use your status to show your contacts how busy you are or what you are doing. Your contacts see your status next to your name when they chat with you. You can use the standard statuses, which are: ‣ Available ‣ Busy ‣ Away ‣ Invisible ‣ Offline Two of these statuses have additional functionality. The Invisible status lets you see which of your contacts are online, but does not allow them to see that you are online. The Offline status logs you out entirely; you will not be able to see which of your contacts are online, nor can they see you or chat with you. Figure 3.19: Change your Empathy status from the drop-down list at the top of the main window. You can change your status from the drop-down list at the top of the main Empathy window, as shown in figure 3.19. This same drop-down list lets you set a custom status by choosing “Custom Message…” next to the icon that matches your status. Enter what you would like your status to say, and click on the green check mark. Desktop Sharing Desktop sharing is a very nice feature available with Ubuntu. It can be used for a lot of purposes, like troubleshooting, online meetings, or just showing off your cool desktop to your friend. It is very easy to get remote desktop sharing working between two Ubuntu machines.
working with ubuntu 63 To share your screen, you will first have to set up Desktop Sharing. Open the Desktop Sharing application from the Dash (see The Dash). Next, select Allow other users to view your desktop; you may want to deselect Allow other users to control your desktop. After you have Desktop Sharing configured, open Empathy. To begin sharing your desktop, right-click on the contact you wish to share your desktop with, and select Share my desktop. It should be noted that the other user will obviously be able to see the information displayed on your screen. Please be sure to keep this in mind if you have documents or files that are of a private nature open on your desktop. Changing account settings If you need to add more accounts after the initial launch of Empathy, open the Empathy menu on the menu bar, then select Accounts. Empathy will then display the Online Accounts manager window. Editing an account You might need to edit the details of an account. Select the account you want to change on the left side of the Online Accounts window then click the Options button for Empathy. The Online Accounts manager should show the current information for the account. Once you have made your changes, click Done. Removing an account from Empathy To stop an account from showing in Empathy, select the account on the left hand side of the Online Accounts manager window. Then click on the ON/OFF button for Empathy and set it to OFF. Editing contacts Adding a contact To add a contact open Empathy ‣ Contacts ‣ Add contacts.. from the menu bar. Empathy opens the “New Contact” window. In the Account drop-down list, choose the account you want to add contacts for. When creating a contact you must select the service that matches the service your contact is using. After choosing the account you wish to add the contact to, enter their login id, their username, their screen name, or their email address in the Identifier text field. Next, in the Alias text field, enter the name you want to see in your contact list. Click Add to add the contact to your list of contacts. Removing a contact Right click on the contact that you want to remove, then select Remove. This will open the “Removing contact” window. Click on the Delete button to confirm that you want to remove this contact, or click Cancel to keep the contact.
64 getting started with ubuntu 16.04 Microblogging There is no longer a default microblogging client included within the core of Ubuntu/Unity, and so you will need to first install an appropriate applica- tion for whatever service you intend to use. Corebird is a modern GTK+ based Twitter client that, while not installed by default, is available in the default repositories. Install Corebird with sudo apt install corebird in a terminal. When you first start Corebird, it will give you a chance to request a token from Twitter in your web browser. This token will log you in to your Twitter account in Corebird. Figure 3.20: Corebird is a modern GTK+ client for Twitter Choqok, from an ancient Persian word for Sparrow, is a well-maintained and fully-featured client for Twitter.com, Pump.io (Formerly known as Identi.ca), and OpenDesktop.org services. It uses the Qt toolkit, is a part of the KDE Project, and also has ties to the Ubuntu community project Kubuntu. Figure 3.21: Choqok is a powerful microblog- ging client for Twitter.com, Pump.io, and OpenDesktop.org services. Install Choqok with sudo apt install choqok in a terminal. The startup wizard will authorize the client to utilize your Twitter account via a gen-
working with ubuntu 65 erated token you will retrieve in your web browser, which by default in Ubuntu is Mozilla Firefox. Viewing and editing photos Shotwell Photo Manager is the default photo application in Ubuntu. This application allows you to view, tag, edit, and share photos. To start Shotwell Photo Manager, click on the Dash near the top-left of the screen, then select the Shotwell Photo Manager icon labeled View Photos. If you do not see Shotwell Photo Manager, simply type Shotwell in the search bar at the top of the Dash and then select the Shotwell Photo Manager application. Figure 3.22: Manage your photo collection, enhance your photos while keeping the original, and share your memories online using Shotwell Photo Manager. Importing Photos When you launch Shotwell Photo Manager for the first time, you will be greeted with the “Welcome!” window which provides instructions on how to import photos. Click OK. You can now import photos by dragging photos into the Shotwell Photo Manager window or by connecting your camera or external storage device to the computer. From a digital camera Connect your camera to the computer using the data cable, and power on your camera. If your camera is properly detected, you will see a new window prompting you to launch an application. Select Shotwell Photo Manager in the drop-down menu, then click OK. Your camera will be listed in the Shotwell Photo Manager sidebar. Select your camera in the sidebar. You will see a preview of the contents stored in the camera’s memory. Select individual photos by pressing and holding Ctrl and clicking on each photo you want to import, and then click Import Selected on the bottom bar of the window. Or, you can choose to import all photos by clicking Import All. From your computer You can import photos into Shotwell Photo Manager by dragging photos from the file browser into the Shotwell Photo Manager
66 getting started with ubuntu 16.04 window. Alternatively, you can click File ‣ Import From Folder, then select the folder containing the photos you want to import. From external hard drive, usb flash drive, or cd/dvd Importing photos from external storage is similar to importing from your computer. Your external storage device may also appear under the Camera label on the Shotwell Photo Manager sidebar. Follow the instructions for importing from a camera or computer. Choosing where Shotwell Photo Manager saves photos The default location for the Shotwell Photo Manager Library is your Pic- tures folder in your home directory. When importing pictures using the “Import” window, you will be given the option to copy the files to your Library or keep the files in place. If you have your photos stored on your computer, the option Import in Place will be suitable. This will prevent photos from being duplicated. If you are importing photos from an external source, such as a portable hard drive, usb flash drive, or cd/dvd, you should select Copy into Library so the photos are copied to your computer—otherwise the photos won’t appear when you remove the external source. Viewing photos Choose Library or any collection in the sidebar to display photos from your selection. Use the slider on the bottom bar to adjust the size of the thumbnails. To view a full-window image, double-click an individual photo. In the full-window view, you can navigate through the collection using the backward and forward arrows, zoom in on the image using the slider, pan by clicking and dragging the image, and exit the full-window view by double-clicking the image. To view the collection in full-screen mode, press F11 or go to View ‣ Fullscreen. You can navigate through the collection using the toolbar by moving your mouse to the bottom of the screen. To view a slideshow pre- sentation of the collection, press F5 or go to View ‣ Slideshow. Press the Esc key to exit the Fullscreen or Slideshow views. Organizing photos Shotwell Photo Manager makes finding photos of the same type easier by using tags. You can apply as many tags to a photo as you like. To apply tags to photos, first select the photos. Then right-click on the photos and select Add Tags. Enter the tags you want into the text field, separated by commas. If you are adding new tags, these will appear in the side bar on the right under the Tags label. Editing images You may want to edit some of the photos you import into Shotwell Photo Manager. For example, you may want to remove something at the edge, adjust the color, reduce the red-eye effect, or straighten the image. To edit a photo, double-click on the photo you want to edit, and then click on one of the following buttons:
working with ubuntu 67 Rotate Click Rotate to rotate the image 90° clockwise. You can click the button more than once and it will rotate the image clockwise in 90° intervals. Crop Click Crop to change the framing of the photo. The image will darken and a selection will appear. Adjust the selection to your desired crop by dragging a corner or side. If you want to choose a specific aspect ratio, use the drop- down menu to select one of the preset ratios or enter your own custom ratio. A pivot button is provided to change your selection from landscape to portrait and vice versa. Once you are happy with the selection, click OK to apply the crop or Cancel to discard it. Red-eye reduction If you have taken a photo and the flash has caused the subject to have red eyes, you can fix this problem in Shotwell Photo Manager using the following process. 1. Click the Red-eye button. A circle will appear. 2. Drag this circle over one of the subjects eyes and then use the slider to adjust the circle size. 3. When the circle is over the eye, click Apply to fix the red eye. You will need to repeat this for each individual eye. Use caution when adjusting the size of the circle. A circle too large that covers the skin may cause discoloration when applying the red-eye reduction. Adjust Clicking Adjust will bring up a window that lets you edit a few things: Level Similar to contrast. Exposure How bright the image is. Saturation How colorful the image is. Tint The overall color. Temperature Whether the image is warm (more yellow) or cool (more blue). Shadows How dark the shadows are. To change these values, drag the sliders until you are satisfied with the image. Click OK to apply the changes, Reset to undo the changes and start over, or Cancel to discard the changes. Auto-adjustment with Enhance Click Enhance to let Shotwell Photo Manager automatically adjust the color, levels, exposure, contrast, and temperature to create a more pleasing image. Reverting an edited photo to the original When you edit a photo in Shotwell Photo Manager, your original image re- mains untouched. You can undo all of the changes and revert to the original version by right-clicking on the photo, then selecting Revert to Original. This option is only available for edited photos.
68 getting started with ubuntu 16.04 Sharing your photos You can easily share your photos on the web using Shotwell Photo Man- agers’s Publish feature. Select the photos you want to share, then go to the top menu and click File ‣ Publish. A new window will appear asking where the photos are to be published. Choose Facebook, Flickr, or Picasa Web Al- bums in the upper right-hand drop-down menu. Some services may require you to authorize Shotwell Photo Manager before allowing the application to publish photos. Follow the instructions in the window, select your desired options, and click Publish to upload your images to the web. Further information We’ve only just touched on the features of Shotwell Photo Manager. To get more help, select Help ‣ Contents. This will load the online manual, where you can get more detailed instructions on how to use Shotwell Photo Manager effectively. Watching videos and movies To watch videos and dvds in Ubuntu, you can use the Videos application. To start Videos, click on the Dash, then search for “Videos” and select it. This will open the “Videos” window. Figure 3.23: The “Videos” (commonly called “Totem”) application plays videos as well as music. Codecs Watching most commercial dvds and some video files may require you DRM, or Digital Restrictions Management, is the practice of imposing technological restrictions that control what users can do with digital media. When a program is designed to prevent you from copying or sharing a song, reading an ebook on another device, or playing a single- player game without an Internet connection, you are being restricted by DRM. to install additional software. You will need “codecs” for Ubuntu to de- code proprietary music and video files as well as for music and video files encumbered by drm. You will need “unscrambling software” to access com- mercial dvds encrypted by drm. Legal Notice: Patent and copyright laws differ depending on which country you are in. Please obtain legal advice if you are unsure whether a particular patent or restriction applies to a media format you wish to use in your country. To install these additional codecs, open the Terminal either through the Dash or the Launcher. When the “Terminal” window opens, use apt to install the following packages via sudo apt install: ‣ ubuntu-restricted-extras
working with ubuntu 69 ‣ libdvdread4 ‣ libdvdnav4 Double-click each item above and then click the Install button. This may open an “Authenticate” window. If so, enter your administrative pass- word, then click Authenticate to start the installation process. The ubuntu- restricted-extras meta-package includes most if not all restricted codecs as well as the Adobe Flash Player npapi plugin and Microsoft corefonts. Playing videos from file Open the Movie menu in the Videos application, then select Open Local Video… or Open Web Video… which will open the “Add Videos” or “Add Web Video” window, respectively. Find the file or files that you want to play and click on the Add button. The video or videos will now be available for viewing in the Videos tab, along with any other videos already located in an indexed folder such as your Videos folder in your user home directory. Playing a DVD When you insert a dvd in the computer, Ubuntu should open the “You have just inserted a Video dvd. Choose what application to launch.” window. Make sure that Videos is chosen in the drop-down list and then click OK. The “Movie Player” window will open and the movie will begin. You can also choose to always perform the action you just specified when another Video dvd is inserted. If the “Videos” window is already open, then open the Videos tab, and select the dvd title that should now appear in the list as a tile. Listening to audio and music Ubuntu comes with the Rhythmbox Music Player for listening to your mu- sic, streaming Internet radio and managing playlists and podcasts. Rhythm- box (Figure 3.24) can also help you find and purchase music, along with managing subscriptions to your favorite rss feeds. Starting Rhythmbox There are several ways to start Rhythmbox. ‣ Open the Dash, type Rhythmbox or Music and click on the Rhythmbox Music Player icon. ‣ Ubuntu comes with an indicator menu in the top bar for sound-related applications and devices After you’ve opened Rhythmbox the first time, a link to start Rhythmbox and basic controls will be placed under this indicator. If you close Rhythmbox by pressing Alt+F4, or CTRL+W, or clicking the red close button it will disappear from view but continue to play in the background. You can still control music playback or reopen the application from the sound indicator as shown in Figure 3.25. Playing music To play music, you can either double-click on your music file or, alterna- tively, import your music into your library. To do the latter, choose File ‣
70 getting started with ubuntu 16.04 Figure 3.24: Rhythmbox Music Player Figure 3.25: Rhythmbox controls as displayed under the sound indicator. The applica- tion is currently playing Hexenritt, from Humperdinck’s opera Hänsel Und Gretel. Add Music… or press Ctrl+O on your keyboard to import a folder contain- ing audio files. You can use the dropdown box to select the folder where your music resides or click the Other… option to find an alternate folder. The Rhythmbox toolbar contains most of the controls that you will use for browsing and playing your music. If you want to play a song, double- click a track; or click it and press the Play button on the toolbar, choose Control ‣ Play from the menu bar, or press Ctrl+Space. When a song is playing, the Play button will become a Pause button. Use this button, Con- trol ‣ Play, or Ctrl+Space to toggle between playing and pausing the track. Next and Previous buttons are next to the Play/Pause button. Click on these buttons to play the next and previous songs in your library or playlist. Rhythmbox also has options to toggle repeat mode (Repeat, Control ‣ Repeat or Ctrl+R) and shuffle mode (Shuffle, Control ‣ Shuffle or Ctrl+U). Playing Audio CDs When you insert an audio cd in the computer, Ubuntu should open the “You have just inserted an Audio cd. Choose what application to launch.” window. Make sure that Rhythmbox is chosen in the drop-down list and then click OK. The “Rhythmbox” window will open. You can also choose to always perform the action you just specified when another Video dvd is inserted. To play your cd once in Rhythmbox you can use the audio controls in
working with ubuntu 71 the Rhythmbox toolbar. Adding the music to your library, or ”Ripping” the audio, is covered below and available in this same window. Importing (“Ripping”) Audio CDs Begin by inserting a cd. Rhythmbox will automatically detect it and add it to the side menu. If you have an active Internet connection, Rhythmbox will try to find the album details via the web. Click the cd. Uncheck any tracks you don’t want imported. Press the Extract button, located at the upper-left corner of the right panel. Rhythmbox will begin importing the cd. As it finishes each track, it will appear in your Music Library. Listening to streaming audio Rhythmbox is pre-configured to enable you to stream audio from various Streaming audio stations are “radio stations” that broadcast over the Internet. Some of these are real radio stations that also stream over the Internet, and others broadcast only over the Internet. sources. These include Internet broadcast stations (Radio from the Side Pane), Last.fm and Libre.fm. To listen to an Internet radio station, click on the Radio icon in the Side Pane for a list of pre-configured stations. You can filter by genre in the middle pane. To add a new radio station, select Add and enter the radio station url. You can browse a selected list of radio stations at http://en.wikipedia.org/wiki/List_of_ Internet_stations or you can use your browser to search for “Internet radio stations.” Connect digital audio players Rhythmbox can connect with many popular digital media players. Con- nected players will appear in the Devices list. Features will vary depending on the player (and often the player’s popularity), but common tasks like transferring songs and playlists should be supported. If your device isn’t shown on the Devices list, try searching for it by clicking on the + button ‣ Check for New Devices in the bottom-left corner. Figure 3.26: Rhythmbox connected to an Android device Listen to shared music If you are on the same network as other Rhythmbox users (or most other DAAP stands for “Digital Audio Access Proto- col,” and is a method designed by Apple to let software share media across a network. music player software), you can share your music and listen to their shared
72 getting started with ubuntu 16.04 music. To do this, click File ‣ Connect to DAAP Share… Then enter the ip address and the port number. Click OK. Clicking a shared library will enable you to browse and play songs from other computers. Manage podcasts Rhythmbox can manage all of your favorite podcasts. Select Podcasts from the Side Pane to view all added podcasts. The toolbar will display additional options to Browse, View All, Add and Update. Choose Add on the toolbar and enter the url of the podcasts to save it to Rhythmbox. You can also search for podcasts to find here to add to Rhythmbox. Podcasts will be automatically downloaded at regular intervals or you can manually update feeds. Select an episode and click Play. You can also delete episodes. Rhythmbox preferences The default configuration of Rhythmbox may not be exactly what you want. Choose Edit ‣ Preferences to alter the application settings. The Preferences tool is broken into four main areas: general, playback, music, and Podcasts. General includes how you want Rhythmbox to display artist and track information. You can adjust the columns visible in your library and how the toolbar icons are displayed. Playback options allow you to enable crossfading and the duration of the fade between tracks. Music includes where you would like to place your music files and the library structure for new tracks added to Rhythmbox. You can also set your preferred audio format. Podcasts designates where podcasts are stored on your computer along with the ability to change how often podcast information is updated. Plugins Rhythmbox supports a wide array of plugins, which add functionality to Rhythmbox. Many of the plugins provide basic audio playback, and you may check a few more boxes, for example, to access Soundcloud or to provide a consistent playback volume (ReplayGain). To view or change the activated plugins, use the global menu bar (Tools ‣ Plugins). Managing your music Rhythmbox supports creating playlists. Playlists can be either static lists of songs to be played in order or smart playlists based on filter criteria. Playlists do not contain the actual songs, but only provide references to them. Thus, if you remove a song from a playlist (right-click on the song ‣ Remove from Playlist), the song will remain in your library and on your hard drive. To create a playlist, choose File ‣ Playlist ‣ New Playlist… or + button ‣ New Playlist in the bottom-left corner, or press Ctrl+N. It appears in the sidebar as “New Playlist.” Select the new playlist in the sidebar on the left and then press F2 to give the new playlist a name of your choosing. Drag songs from your library to the new playlist in the side pane or right-click on songs and select Add to Playlist and pick the playlist. Automatic Playlists are created in a similar way. Choose File ‣ Playlist ‣ New Automatic Playlist… or + button ‣ New Automatic Playlist in the
working with ubuntu 73 bottom-left corner. Define the filter criteria. You can add multiple filter rules and select a name. Save. You can update any playlist (including the predefined ones) by first selecting it on the sidebar and then selecting the Playlist button and selecting Edit…. Rhythmbox supports song ratings. Right-click a song in your library ‣ Properties ‣ Details and click on the number of stars. To remove a rating, select zero stars. Other song information such as Title, Artist and Album can be changed. Right-click a song in your library ‣ Properties ‣ Basic. To remove a song, right-click ‣ Remove. To delete a song from your hard drive entirely, right-click ‣ Move to the Rubbish Bin. If you ever want to move a song, highlight the song (or group of songs) from your library and drag it to a folder or to your desktop. This will make a copy of the audio file in the new location. Audio codecs Different audio files (mp3, wav, aac, ogg, etc.) require unique tools to de- code them and play the contents. These tools are called codecs. Rhythmbox attempts to detect any missing codecs on your system so you can play all of your audio files. If a codec is missing, it automatically tries to find the codec online and guides you through its installation. Rhythmbox support Rhythmbox is used by many users throughout the world. There are a vari- ety of support resources available in many languages. ‣ Help ‣ Contents or F1 for the main help. ‣ Help ‣ Get Help Online to ask questions and report bugs. ‣ The Rhythmbox website at http://www.rhythmbox.org/. ‣ The Multimedia & Video category of Ubuntu Forums at http://ubuntuforums. org/forumdisplay.php?f=334. Burning CDs and DVDs To create a cd or dvd, you will need to first install a burning application such as Brasero (The GNOME default) or K3b (A powerful utility built with the Qt toolkit). For the purposes of the Manual we will install and use Brasero. To do this, click the Ubuntu Software icon on the launcher, located to the left by default but it may also be on the bottom of the screen. Once Ubuntu Software opens search for Brasero using the top search bar in the “Ubuntu Software” window. Press ”Install” and enter your password. Ubuntu Software will now create an icon for Brasero on your launcher. Click on this icon. This opens the Brasero Disc Burner application. The burning options (Figure 3.27) appearing within Brasero are explained below.
74 getting started with ubuntu 16.04 If you only need to burn a disc image such as an ISO file, you can do this from the Files application’s context menu when you right-click on a disk image file. After right-clicking the ISO file in Files, select ”Open With ‣ Disk Image Writer”. At this point, do not select one of your hard disks in the window that appears unless you are certain you intend to wipe that device! Select a destination (such as your optical drive with blank media inserted) and click ”Start Restoring…”. This uses the GNOME Disks component/utility, which is included within the base Ubuntu/Unity system. A burning application such as Brasero or K3b is only nec- essary if you plan on creating your own disc images, or ”projects”, or if you prefer greater control over the burning process. Figure 3.27: Brasero burns music, video, data DVDs and CDs. Getting Started Before you can use Brasero, you need to Create a new project. There are three types of media projects available: Audio Project, Data Project, and Video Project. There are also two utility projects available: Disc Copy and Burn Image. Make your selection based on your requirements. At this current time, Brasero does not support Blu-Ray. The following options apply for all projects except Disc Copy and Burn Image. Adding files to a project To add files to the list, click the + button. This button will open the “Select Files” window. Navigate to the file you want to add, click the desired file, then click the Add button. Repeat this process for each file until all desired files have been added. Removing files If you want to remove a file from the project, click the file in the list and click on the - button. To remove all the files in the list click on the Broom shaped button.
working with ubuntu 75 Saving a project To save an unfinished project, choose Project ‣ Save. The “Save Current Project” window will be opened. Choose where you would like to save the project. In the Name: text field, enter a name for the project. Click the Save button, and your unfinished project will be saved. When saving a project, you are only saving the parameters of the project; you’ve burned nothing to the disc at this time. Burning the disc When you click the Burn… button, you will see the “Properties of …” win- dow. You can specify the burning speed in the Burning speed drop-down. It is safest to choose the slowest speed to prevent a corrupted CD / DVD disc. To burn your project directly to the disc, select the Burn the image directly without saving it to disc option. With this option selected, no image file is created, and no files are saved to the hard disk. All data is saved to the blank cd or dvd. Note that Brasero only burns information onto standard CDs and DVDs; Brasero does not burn data onto Blu-Ray DVDs at this time. The Simulate before burning option is useful if you encounter problems burning discs. Selecting this option allows you to simulate the disc burning process without actually writing data to a disc—a wasteful process if your computer isn’t writing data correctly. If the simulation is successful, Brasero will burn the disc after a ten second pause. During those ten seconds, you have the option to cancel the burning process. Blanking a disk Some CDs and DVDs have an rw marking on them. rw simply indicates the disc is Re-Writable, meaning the current data on the disc can be com- pletely erased and new data can be written to it. To erase a disc, open the Tools menu, then select Blank. The “Disc Blanking” window will be open. In the Select a disc drop-down choose the disc that you would like to erase. You can enable the Fast blank option if you would like to shorten the amount of time to perform the blanking process. However, selecting this option will not fully remove the files; if you have any sensitive data on your disc, it would be best not to enable the Fast blank option. Once the disc is erased (blank), you will see The disc was successfully blanked. Click the Close button to finish. Audio project If you record your own music, then you may want to transfer this music onto an audio cd so your friends and family can listen. You can start an audio project by clicking Project ‣ New Project ‣ New Audio Project. When burning a music cd, it is important to remember that commercial music cds usually contains a two-second gap between the songs. To ensure your music has this same gap between songs, click the file and then click the pause button. You can slice files into parts by clicking the Knife button. This opens a “Split Track” window. The Method drop-down gives you four options; each option lets you split the track in a different way. Once you have split the track, click OK.
76 getting started with ubuntu 16.04 In the drop-down list at the bottom of the main “Brasero” window, make sure that you have selected the disc where you want to burn the files. Then click the Burn button. Data project If you want to, for instance, make a back up of your documents or photos, it would be best to make a data project. You can start a data project by clicking Project ‣ New Project ‣ New Data Project. If you want to add a folder, click the Folder picture, then enter the name of the folder. In the drop-down list at the bottom of the main “Brasero” window, be sure to select the disc where you want to burn the files. Then click the Burn button. Video project If you want to, for instance, make a dvd of your family videos, it would be best to make a video project. You can start a video project by clicking Project ‣ New Project ‣ New Video Project. In the drop-down list at the bottom of the main “Brasero” window, be sure to select the disc where you want to burn the files. Then click the Burn button. Disc copy You can make a copy of an existing disc by clicking Project ‣ New Project ‣ Disc copy. This opens the “Copy cd/dvd” window. If you have only one drive, you will need to first make a disc image and then burn it to a blank disc. If you have two cd/dvd drives, you can copy a disc from one to the other directly, assuming that the source disc is in one drive and the destination disc (the blank media) is in the other drive. In the Select disc to copy drop-down choose the disc to copy. In the Select a disc to write to drop-down either choose image file or the disc that you want to copy to. Disc image You can make an image file of your data as well. An “image,” in this context, is a single-file representation of the contents of the disk. The file usually has an .iso or .img extension. An image file is similar to a set of zipped files. Change where the image file is saved by clicking Burn…. This shows the “Location for Image File”. You can edit the name of the file in the Name: text field. The default location to save the image file is your home folder, but you can change the location by clicking the + button next to Browse for other folders. Once you have chosen where you want to save the photo or image, click Close. Returning to the “Copy cd/dvd” window, click Create Image. Brasero will open the “Creating Image” window and will display the job progress. When the process is complete, click Close.
working with ubuntu 77 Burn image “Burning” an image to a disc should not be confused with copying an image file to a disc. When burnt, the contents of the image file are copied over to the disc, rather than the image file itself. To burn an image, that is, to transfer the contents inside an image file to a blank disc, open the Project ‣ New Project ‣ Burn Image. Brasero will open the “Image Burning Setup” window. Click on the Click here to select a disc image drop-down and the “Select Disc Image” window will appear. Navigate your way to the image you wish to burn, click on it, and then click Open. In the Select a disc to write to drop-down menu, click on the disc to which you’d like to write, then click Create Image. Working with documents, spreadsheets, and presentations LibreOffice Suite is the default office suite when working with documents, spreadsheets, and slide presentations. Working with documents If you need to work with documents, you can use the LibreOffice Word Pro- The LibreOffice Word Processor is known as LibreOffice Writer. LibreOffice Spreadsheet is known as Calc, and LibreOffice Presentation is known as Impress. cessor. Writer has all the features you need from a modern, full-featured word processing and desktop publishing tool including a built-in PDF cre- ator. It also has the ability to save documents in several common formats, such as “.doc” or “.txt” files. It’s simple enough for a quick memo, and yet powerful enough to create complete books with contents, diagrams, in- dexes, and more. You’re free to concentrate on your message, while Writer will make it look great. To start the word processor, open the Dash and search for LibreOffice Writer. Then select LibreOffice Writer. Working with spreadsheets If you need to work with spreadsheets, you can use LibreOffice Spreadsheet (Calc). Calc is the spreadsheet program you’ve always needed. Newcomers find it intuitive and easy to learn. Professional data miners and number crunchers will appreciate the comprehensive range of advanced func- tions. To start the spreadsheet application, open the Dash and search for LibreOffice Calc. Then select LibreOffice Calc. Working with presentations If you need to work with slides for a presentation, you can use LibreOffice Impress. Impress is a truly outstanding tool for creating effective multi- media presentations. Your presentations can be enhanced with 2D and 3D clip art, special effects and transition styles, animations, and high-impact drawings. To start the presentation application, open the Dash and search for LibreOffice Impress. Then select LibreOffice Impress. Getting more help Each of these applications come with a comprehensive set of help screens. If you are looking for more assistance with these applications, press the F1 key after starting the application.
4 Hardware Using your devices Ubuntu supports a wide range of hardware, and support for new hardware improves with every release. Hardware identification There are various ways to identify your hardware in Ubuntu. The easiest would be to install an application from the Ubuntu Software application, called Sysinfo. Firstly, open the “Ubuntu Software” application, then use the search box at the top of the window to search for sysinfo. Select the Application, click Install. Enter your password when prompted, to install the application. To run the application, search for Sysinfo at the Dash search bar. Click on the program once you find it. The Sysinfo program will open a window that displays information about the hardware in your system. Displays Hardware drivers A driver is a piece of software which tells your computer how to communi- cate with a piece of hardware. Every component in a computer requires a driver to function, whether it’s the printer, dvd player, hard disk, or graph- ics card. The majority of graphics cards are manufactured by three well-known Your graphics card is the component in your computer which outputs to the display. Whether you are watching videos on YouTube, viewing DVDs, or simply enjoying the smooth transition effects when you maximize/minimize your windows, your graphics device is doing the hard work behind the scenes. companies: Intel, amd/ati, and nvidia Corp. You can find your video card manufacturer by referring to your computer’s manual, by looking for the specifications of your computer’s model on the Internet, by opening an application such as Sysinfo, or by using the command lspci in a terminal. The Ubuntu Software application houses a number of applications that can tell you detailed system information. SysInfo, see the previous section, is one such program that you can use to find relevant information about your System devices. Ubuntu comes with support for graphics devices manufactured by the above companies, and many others, out of the box. That means you don’t have to find and install any drivers yourself, Ubuntu takes care of it all. Keeping in line with Ubuntu’s philosophy, the drivers that are used by default for powering graphics devices are open source. This means that the drivers can be modified by the Ubuntu developers and problems with them can be fixed. However, in some cases a proprietary driver (restricted driver) provided by the company may provide better performance or features that are not present in the open source driver. In other cases, your particular device may not be supported by any open source drivers yet. In those scenarios, you may want to install the restricted driver provided by the manufacturer. For both philosophical and practical reasons, Ubuntu does not install restricted drivers by default but allows the user to make an informed choice. Remember that restricted drivers, unlike the open source drivers for your
80 getting started with ubuntu 16.04 device, are not maintained by Ubuntu. Problems caused by those drivers will be resolved only when the manufacturer wishes to address them. To see if restricted drivers are available for your system, go to System Settings, then open Software and Updates and go to the Additional Drivers tab. If a driver is provided by the company for your particular device, it will be listed there. You can choose the proprietary driver for your graphics card, then click on the Apply Changes button to enable the driver. This process requires an active Internet connection and it will ask for your password. Once installation is complete you may have to reboot your computer to finish activating the driver. The Ubuntu developers prefer open source drivers because they allow Another useful resource is the official online documentation (http://help.ubuntu.com), which contains detailed information about various graphics drivers and known problems. This same documentation can be found by searching for Help in the Dash search bar or by pressing F1 on your keyboard. any problem to be identified and fixed by anyone with knowledge within the community. Ubuntu development is extremely fast and it is likely that your device will be supported by open source drivers. You can use the Ubuntu Live dvd to check your device’s compatibility with Ubuntu before installing, or go online to the Ubuntu forums or to http://www.askubuntu. com to ask about your particular device. Setting up your screen resolution One of the most common display related tasks is setting the correct screen resolution for your desktop monitor or laptop. Ubuntu correctly identifies your native screen resolution by itself and Displays are made up of thousands of tiny pixels. Each pixel displays a different color, and when combined they all display the image that you see. The native screen resolution is a measure of the amount of actual pixels on your display. sets it for you. However, due to a wide variety of devices available, some- times it can’t properly identify your resolution. To set or check your screen resolution, go to System Settings ‣ Displays. The “Displays” window automatically detects the type of display and shows your display’s name and size. The screen resolution and refresh rate is set to the recommended value by Ubuntu. If the recommended settings are not to your liking, you can change them here. For example, to change the resolution click on the triangle in the Resolution drop-down and choose the resolution you want. Ubuntu 16.04 now includes HiDPI settings in the System Settings Display module. You can now scale menu and title bars according to your viewing needs. Adding an extra display Sometimes, you may want to add more than one display device to your desktop, or you may want to add an external monitor to your laptop. Doing this is quite simple. Whether it’s an extra monitor, lcd tv, or a projector, Ubuntu can handle it all. Ubuntu supports the addition of multiple displays by default, which is as easy as plug and play. Ubuntu recognizes almost all the latest monitors, tvs and projectors by default. Sometimes it may happen that your additional display is not detected when you connect it to the machine. To resolve this, go to Sys- tem Settings ‣ Displays and click on Detect Displays. This will detect the monitors connected to the machine. This menu can also be found from the Power Off menu on the top panel. You can also search for Displays at the Dash search bar. Now, there are two modes which you can enable for your displays. One option is to spread your desktop across two or more monitors. This is par- ticularly useful if you are working on multiple projects and need to keep an eye on each of them at the same time. You can configure the screen to be on any side of your primary screen i.e. to your right, your left or on the
hardware 81 top (particularly nice if you are working on a large screen i.e. a big monitor or a TV connected to your 12-13 inch laptop); just move the screen on the Displays settings to the side of your choice. The second option is to mirror the desktop onto each of the displays. This is useful when you are using a laptop to display something on a larger screen e.g. projector. To enable this option just check the box beside Mir- ror displays and click Apply to save the settings. You will get a pop-up notification asking if you want to keep the current setting or revert to the previous setting. Click to keep the current setting. Starting from Ubuntu 12.04, you can also select whether you want the Unity Launcher in both the displays or only in the primary display. Ubuntu 16.04 LTS inherited better multi-monitor support for higher resolutions introduced in Ubuntu 13.04. Connecting and using your printer Ubuntu supports most new printers. You can add, remove, and change printer properties by navigating to System Settings ‣ Printers. You can also search for Printers from the Dash search bar. Opening Printers will display the “Printers-localhost” window. When you want to add a printer, you will need to make sure that it is switched on, and plugged into your computer with a usb cable or connected to your network. Adding a local printer If you have a printer that is connected to your computer with a usb cable then this is termed a local printer. You can add a printer by clicking on the Add Printer button. In the left hand pane of the “New Printer” window any printers that you can install will be listed. Select the printer that you would like to install and click Forward. You can now specify the printer name, description and location. Each of If your printer can automatically do double sided printing, it will probably have a duplexer. Please refer to the instructions that came with the printer if you are unsure. If you do have a duplexer, make sure the Duplexer Installed option is checked and then click the Forward button. these should remind you of that particular printer so that you can choose the right one to use when printing. Finally, click Apply. Adding a network printer Make sure that your printer is connected to your network either with an Ethernet cable or via wireless, and that it is turned on. You can add a printer by opening Printers, and then clicking the Add button. The “New Printer” window will open. Click on the small triangle next to Network Printer. If your printer is found automatically it will appear under Network Printer. Click the printer name and then click Forward. In the text fields you can now specify the printer name, description and location. Each of these should remind you of that particular printer so that you can choose the right one to use when printing. Finally click Apply. You can also add your network printer by entering the ip address of the The default printer is the one that is automat- ically selected when you print a file. To set a printer as default, right-click the printer that you want to set as default and then click Set As Default. printer. Select “Find Network Printer,” enter the ip address of the printer in the box that reads Host: and press the Find button. Ubuntu will find the printer and add it. Most printers are detected by Ubuntu automatically. If Ubuntu cannot detect the printer automatically, it will ask you to enter the make and model number of the printer.
82 getting started with ubuntu 16.04 Changing printer options Printer options allow you to change the printing quality, paper size and media type. They can be changed by right-clicking a printer and choosing Properties. The “Printer Properties” window will show; in the left pane, select Printer Options. You can now specify settings by changing the drop-down entries. Some of the options that you might see are explained. Media size This is the size of the paper that you put into your printer tray. Media source This is the tray that the paper comes from. Color Model This is very useful if you want to print in Grayscale to save on ink, or to print in Color, or Inverted Grayscale. Media type Depending on the printer you can change between: ‣ Plain Paper ‣ Automatic ‣ Photo Paper ‣ Transparency Film ‣ cd or dvd Media Print quality This specifies how much ink is used when printing, Fast Draft using the least ink and High-Resolution Photo using the most ink. Sound Ubuntu usually detects the audio hardware automatically during installa- tion. Audio in Ubuntu is provided by a sound server named PulseAudio. The audio preferences are easily configurable with the help of a very easy to use gui which comes preinstalled with Ubuntu. Volume indicator and sound preferences A volume icon is present on the top panel which provides quick access to a number of audio related functions. When you click on the volume icon you are greeted with four options: A mute option at the very top, a slider but- ton which you can move horizontally to increase/decrease volume, another slider button to increase/decrease the volume of the microphone, a shortcut to the default music player, Rhythmbox, and an option for accessing the Sound Settings. Selecting Sound Settings… opens up another window, which provides access to options for changing input and output hardware prefer- ences for speakers, microphones and headphones. It also provides options for setting the volume level for each application. Sound Settings can also be found from System Settings…. It is known as Sound.
hardware 83 Output The Output tab will have a list of all the sound cards available By default, the volume in Ubuntu is set to maximum during installation. in your system. Usually there is only one listed; however, if you have a graphics card which supports hdmi audio, it will also show up in the list. The Output tab is used for configuring the output of audio. You can in- If you change your sound output device, it will remain as default. crease/decrease and mute/unmute output volume and select your preferred output device. If you have more than one output device, it will be listed in the section which reads “Choose a device for sound output.” The default output hardware, which is automatically detected by Ubuntu during instal- lation will be selected. This section also allows you to change the balance of sound on the left and right speakers of your desktop/laptop. A new op- tion introduced in Ubuntu 14.04 LTS will allow you to increase the output volume past 100. You need to check the box ”Allow louder than 100%”. Input The second tab is for configuring audio Input. You will be able to A microphone is used for making audio/video calls which are supported by applications like Skype or Empathy. It can also be used for sound recording. You should note that by default in any Ubuntu installation, the input sound for mic is either very low or muted. You will have to manually increase the volume or unmute the input to enable your microphone to record sound or use it during audio/video calls. use this section when you have an in-built microphone in your system or if you’ve plugged in an external microphone. You can also add a Bluetooth headset to your input devices which can serve as a microphone. You can increase/decrease and mute/unmute input volume from this tab. If there is more than one input device, you will see them listed in the white box which reads Choose a device for sound input. If you run VoIP applications such as Skype, you will find the microphone slider just below the volume slider in the top panel sound menu during a voice or video call. Sound Effects The third tab is Sound Effects. You can enable, disable, or change the existing sound theme from this section. You can also change the alert sounds for different events. Applications The Applications tab is for changing the volume for running applications. This comes in handy if you have multiple audio applications running, for example, if you have Rhythmbox, Totem Movie Player and a web-based video playing at the same time. In this situation, you will be able to increase/decrease, mute/unmute volume for each application from this tab. More functionality The icon can control various aspects of the system, application volume and music players like Rhythmbox, Banshee, Clementine and Spotify. The volume indicator icon can now be easily referred to as the sound menu, given the diverse functionality of the icon. Media controls available include You can start and control the default music player, Rhythmbox, by simply left clicking on the sound menu and selecting Rhythmbox from the list. Clicking the play button also starts the player. play/pause, previous track, and next track. You can also switch between different playlists from the Choose Playlist option. If the current playing song has album art, it will show up beside the name of the current track, otherwise you will see only the details of the song. It displays the track name, the artist name and the album name of the current track. Using a webcam Webcams often come built into laptops and netbooks. Some desktops, such as Apple iMacs, have webcams built into their displays. If you purchase a webcam because your computer doesn’t have its own, it will most likely have a usb connection. To use a usb webcam, plug it into any empty usb port of your desktop.
84 getting started with ubuntu 16.04 Almost all new webcams are detected by Ubuntu automatically. You can There are several applications which are useful if you have a webcam. Cheese can capture pictures with your webcam and VLC media player can capture video from your webcam. You can install these from the Ubuntu Software application. configure webcams for individual applications such as Skype and Empathy from the application’s setup menu. For webcams which do not work right away with Ubuntu, visit https://wiki.ubuntu.com/Webcam for help. Scanning text and images Scanning a document or an image is very simple in Ubuntu. Scanning is handled by the application Simple Scan. Most of the time, Ubuntu will simply detect your scanner and you should just be able to use it. To scan a document, follow these steps: 1. Place what you want to scan on the scanner. 2. Click to open the Dash and enter scan. 3. Click on Simple Scan. 4. Click to choose between Text or Photo from Document ‣ Scan ‣ Text. 5. Click Scan. 6. Click the Paper Icon to add another page. 7. Click Save to save. You can save the scanned documents and pictures in jpeg. You can also save in pdf format to enable opening in Acrobat Reader. To do that, add the extension .pdf at the end of the filename. Troubleshooting your scanner If your scanner is not detected, Ubuntu may give you a “No scanners de- tected” message when trying to scan. There may be a reason why Ubuntu cannot find your scanner. ‣ Simply unplug the scanner and plug it back in. If it is a newer usb scan- ner, it is likely that it will just work. ‣ The driver for your scanner is not being automatically loaded. Restart your system. It might help! ‣ Try restarting the scanner service. Open a terminal from the Dash and type in sudo /etc/init.d/saned restart ‣ Your scanner is not supported in Ubuntu. The most common type of scanner not supported is old parallel port or Lexmark All-in-One printer/scanner/faxes. ‣ sane project listing of supported scanners. The sane (Scanner Access Now Easy) project provides most of the back-ends to the scanning soft- ware on Ubuntu. ‣ Check https://wiki.ubuntu.com/HardwareSupportComponentsS canners to find out which scanners work with Ubuntu. Keyboard and mouse The keyboard and mouse are essential input devices for a large number of computer users today. There are many different makes and models of keyboards and mice, including lots of keyboards with support for different languages. In this section we will look at the different settings for your keyboard and mouse. This will be of great use to international users.
hardware 85 Keyboard The keyboard is likely to be one of the main ways that you interact with your computer. Unfortunately not all keyboards are uniform in design; they can differ by country, by language or appearance. In Ubuntu 16.04, the default language set for the keyboard now appears as an applet menu right next to the Network Manager icon. Clicking on the keyboard applet menu will show you what is the default language set for the keyboard and also enable you to access three options: 1. Character Map 2. Keyboard Layout 3. Text Entry Settings…. Figure 4.1: Keyboard applet menu. Mouse and Touchpad A mouse is another mode of input and goes hand in hand with the key- board. Ubuntu supports all types of plug and play mice, including touch- pads and trackballs. If you are planning to use a mouse with your laptop, just plug it in and Ubuntu will recognize it instantly. There is a settings menu under System Settings ‣ Mouse and Touch- pad where you can change the mouse settings such as double-click speed, pointer speed and left handed or right handed clicks. If you are using touch- pad on your laptop/netbook you can also increase the sensitivity of your touchpad. You can also enable horizontal, edge scrolling and two finger scrolling on your laptop/netbook. Multitouch and gesture support Ubuntu has full support for multitouch gestures. This means that anyone with a touch-enabled device or interface can use the multitouch features. Once triggered, resizing and moving windows in touch-friendly devices can be done using three fingered tap on an application window. Ubuntu also supports two-finger scrolling similar to OS X laptops and desktops. This setting can be enabled from System Setting ‣ Mouse and Touchpad ‣ Touchpad. Select “Two-finger scrolling” from the Scrolling options. You can also search for Mouse and Touchpad from the Dash search bar and enable the option. Please note that enabling two finger scrolling will disable edge scrolling. Other devices USB usb ports are available as standard on almost all computers available now. They are used to connect a multitude of devices to your computer. These could include portable hard drives, flash drives, removable cd/dvd/Blu-ray drives, printers, scanners and mobile phones. When connected, flash drives and portable hard drives are automatically detected—the file manager will open and display the contents of the drive. You can then use the drives for copying data to and from the computer. All new cameras, camcorders and mobile phone sd cards are automati- cally detected by Ubuntu. These sd cards have different types of data, so a window will appear with a drop-down menu to choose between video, au- dio import and the file manager—you can choose your desired action from this menu.
86 getting started with ubuntu 16.04 Firewire Firewire is a connection on some computers that allows you to transfer data Firewire is officially known as IEEE 1394. It is also known as the Sony i.LINK and Texas Instruments Lynx. from devices. This port is generally used by camcorders and digital cameras. If you want to import video from your camcorder you can do so by connecting your camcorder to the Firewire port. You will need to install a To find out more about Kino, visit http://www. kinodv.org/. program called Kino which is available in Ubuntu Software. Bluetooth Bluetooth is a wireless technology that is widely used by different types of devices to connect to each other. It is common to see a mouse or a keyboard that supports Bluetooth. You can also find gps devices, mobile phones, headsets, music players and many other devices that can connect to your desktops or laptop and let you transfer data, listen to music, or play games as an example. If your computer has Bluetooth support then you should be able to see a Bluetooth icon on the top panel, usually on the left side of the volume icon. If you click on the Bluetooth icon it will open a drop down menu with choices to Turn on/off Bluetooth, to Turn on/off visibility of the device, setup access to a Bluetooth device and also access Bluetooth settings. Figure 4.2: The Bluetooth applet menu. The Bluetooth preferences can also be accessed from System Settings ‣ Bluetooth. If you want to connect (pair) a new device—for example, to have a mobile phone send pictures or videos to your computer—click on the Bluetooth icon on the top panel and select Setup new device…. Ubuntu will open a window for new device setup. When you click For- ward, Ubuntu will show you how many Bluetooth devices are present near your computer. The list of available devices might take a minute or so to appear on the screen as your system scans for these devices. Each device will be displayed as soon as it is found by Ubuntu. Once a device you’d like to connect with appears in the list, click on it. Then, choose a pin number by selecting PIN options. Three predefined pin numbers are available, but you can also create a When you pair two Bluetooth devices, you are letting each device trust the other one. After you pair two devices, they will automatically connect to each other in the future without requiring a PIN. custom pin. You will need to enter this pin on the device you will be pairing with Ubuntu. Once the device has been paired, Ubuntu will open the “Setup com- pleted” window. In Ubuntu, your computer is hidden by default for security reasons. This means that your Ubuntu system can search other Bluetooth devices, but others cannot find your Ubuntu system when they perform a search on their own computer. If you would like to let another device find your computer, you will have to explicitly allow your computer to be found. To allow your computer to be found by other bluetooth devices, turn ’on’ the “Visibility of yourcomputername” from System Settings ‣ Bluetooth. You can also click on the Bluetooth icon and click on Visible to turn on visibility which will make your computer discoverable. You can also add a fancy name for your Bluetooth-enabled Ubuntu sys- tem by changing the text under Friendly Name. Another feature present in the Bluetooth icon menu is “Send files to Android devices need to be paired at all times, even while transferring files. device.” Use this option to send a file to a mobile phone without pairing with the computer.
5 Software Management Software management in Ubuntu Installing software in Ubuntu extends the functionality and usability of this operating system. This chapter describes the way Ubuntu manages software installation and how it keeps all software current. Package management system Ubuntu and various other Linux variants use a collection of software tools called a package management system, or package manager. A package man- ager is a collection of tools that make installing, deleting, upgrading, and configuring software easy. A package management system has a database of software called a repository where individual software is arranged into a collection called a package. These packages, apart from the software, contain important information about the software itself, such as the soft- ware’s name, description, version, name of the vendor, and a list of various dependencies upon which the software relies for proper installation. Most other operating systems require a user to purchase commercial software (online or through a physical store) or search the Internet for a free alternative (if one is available). The correct installation file must then be verified for integrity, downloaded, and located on the computer, followed by the user proceeding through a number of installation prompts and options. A package management system removes the user interaction from these steps and automates most, if not all, of the installation process. Ubuntu comes with a package management system called Advanced Packaging Tool or apt. As discussed in Chapter 3: Working with Ubuntu, Ubuntu offers a wide range of applications for your daily work. Ubuntu comes with a basic set of applications for common tasks, like surfing the Internet, checking email, listening to music, and organizing photos and videos. At times, you may need an extra level of specialization. For example, you may want to retouch your photos, run software for your business, or play new games. In each of these cases, you can search for an application, install it, and use it—usually with no extra cost. Figure 5.1: Software Center icon By default, Ubuntu provides a centralized point with two different ways to browse the repositories for searching, installing, and removing software. ‣ The Ubuntu Software application ‣ Command line apt-get Ubuntu Software makes searching, installing, and/or removing appli- cations easy and convenient; it is most often the application management system used by both beginning and expert Ubuntu users. We highly recom- mend Ubuntu Software for searching, installing, and removing applications, although you can still use the command-line application apt-get or install and use the advanced application Synaptic Package Manager. Since soft- ware in Ubuntu is delivered in the form of packages, software installation becomes a one-click, one-step process when using the Ubuntu Software application.
88 getting started with ubuntu 16.04 Using Software Center There are numerous ways to install software on an operating system. In Ubuntu, the quickest and easiest way to find and install new applications is through Ubuntu Software. Ubuntu Software is your very own store- In Ubuntu 16.04, Ubuntu Software Center is replaced by GNOME Software which has been renamed as Ubuntu Software. Ubuntu Software Center can still be installed optionally via Ubuntu Software. front and gives you instant access to thousands of great applications. Some of these applications are free to download whereas others are available commercially. Each application within Ubuntu Software comes with ratings and reviews making it easier for you to decide which of the applications you want to install. To start Ubuntu Software, click on its icon in the Launcher, or click on the Dash and search for Ubuntu Software. Figure 5.2: You can install and remove appli- cations from your computer using Ubuntu Software. Ubuntu Software can be used to install applications available in the of- ficial Ubuntu repositories. The Ubuntu Software window has four sections —Featured Application, Editor’s Picks, Recommended Applications and Categories. Clicking on a category will take you to a list of related applica- tions. For example, the Internet category contains the Firefox web browser application. At the top of the window there are three buttons. Click the All button to go to Ubuntu Software’s main page, click the Installed button to see a list of software already installed on your computer, or click Updates to see available updates. Find your application If you are looking for an application, you may already know its specific name (for example, vlc Media Player). Just type the name of the applica- tion in the search box at the top of the window and Ubuntu Software will show the application in the main window. Or you may just have a general category in mind (for example, the Audio category includes a number of different software applications, such as audio editors and music players). To help you find the right application, you can browse the Ubuntu Soft- ware catalog by clicking on the category reflecting the type of software you
software management 89 seek. When you select a category, you will be shown a list of applications. Most categories have sub-categories—for example, the Games category has sub-categories such as Simulation, Action, Adventure, Card Games. To go to a sub-category, select one in the left pane; Ubuntu Software will show all available applications in this category in the main window. Figure 5.3: Searching for an application in Ubuntu Software. Installing software Once you have found an application you would like to try, installing it is just one click away. To install software: 1. Click the Install button. 2. After clicking Install, enter your password into the authentication win- dow. This is the same password you use to log in to your account. You are required to enter your password whenever installing or removing software in order to prevent someone without administrator access from making unauthorized changes to your computer. If you receive an Au- thentication Failure message after typing in your password, check that you typed it correctly and try again. 3. Wait until the package is finished installing. During the installation of programs, you will see an animated icon of the application in the Launcher. This animated icon shows the Progress of the installation. If you like, you can go back to the main browsing window and choose additional software packages to be installed by following the steps above. Once Ubuntu Software has finished installing an application, it is ready to be used. You can start the newly installed application by going to the Dash and typing the name of the application in the search bar. Removing software Removing applications is very similar to installing software. First, find the installed software in Ubuntu Software. You can click on the Installed button
90 getting started with ubuntu 16.04 Figure 5.4: Here, clicking on “Install” will download and install the package “Stellarium.” to see all installed software listed in alphabetic order. Scroll down to the application you wish to remove, then click on the Remove button. Before actually removing the application, you get a dialog asking you if you are sure you want to remove it. In this dialog you see two buttons, Cancel and Remove. This way you can decide whether you really want to remove the application, or cancel the action. Figure 5.5: Here, clicking on “Remove” will remove the package “SuperTuxKart.” To remove software: 1. Click the Remove button to the right of the application you want to remove. 2. Enter your password into the authentication window. Similar to in- stalling software, removing software requires your password to help
software management 91 protect your computer against unauthorized changes. After confirming the remove action, the package will be removed. Removing a package will also update your menus accordingly. Software Recommendations On its main page Ubuntu Software shows recommended software in The “Recommended” section. The content of this section changes regularly. Figure 5.6: Software Recommendations. Managing additional software Although Ubuntu Software provides a large library of applications from which to choose, you may be interested in a particular application not avail- able in these repositories. It is important to understand alternative methods for accessing and installing software in Ubuntu, such as downloading an installation file manually from the Internet, or adding extra repositories. First, we will look at how to manage your repositories through Software & Updates. Software Sources Ubuntu Software lists only those applications that are available in your enabled repositories. Repositories can be added or removed through the Software & Updates application. To open Software & Updates, simply open System Settings and click on Software & Updates in the System section. Figure 5.7: The Software & Updates program enables you to add, remove and manage package repositories. Managing the official repositories When you open Software & Updates, you will see the Ubuntu Software tab where the first four options are enabled by default. Canonical-supported free and open-source software (main) This repository contains all the open-source packages maintained by Canonical.
92 getting started with ubuntu 16.04 Community-maintained free and open-source software (universe) This reposi- tory contains all the open-source packages developed and maintained by the Ubuntu community. Proprietary drivers for devices (restricted) This repository contains propri- etary drivers which may be required to utilize the full capabilities of some of your devices or hardware. Figure 5.8: Drivers can be installed or removed via the Additional Drivers application. Software restricted by copyright or legal issues (multiverse) This repository contains software possibly protected from use in some states or countries by copyright or licensing laws. By using this repository, you assume responsibility for the usage of any packages that you install. Source code This repository contains the source code used to build software packages from some of the other repositories. Building applications from source is an advanced process for creating packages, and usually only concerns developers. The Source code option should not be selected unless you have experience with building applications from source. Selecting the best software server To distribute applications and software, Ubuntu grants permission to many servers all across the world to act as official mirrors to host an exact copy of all the files contained in the official Ubuntu repositories. When selecting a server, you may want to consider the following: Distance to server. This will affect the speed you can achieve with the file server—the closer the server to your location, the faster the potential connection. Internet Service Provider. Some Internet service providers offer low-cost or unlimited free downloads from their own servers. Quality of server. Some servers may only offer downloads at a capped speed, limiting the rate at which you can install and update software on your computer. Ubuntu will automatically choose an appropriate server while installing. It is recommended these settings not be changed unless your physical loca- tion significantly changes or if you feel a higher speed should be achieved by your Internet connection. The guide below will help in choosing an optimal server. Ubuntu provides a tool for selecting the server that provides the fastest connection with your computer. 1. Click the dropdown box next to “Download from:” in the Software & Updates window.
software management 93 Figure 5.9: You can use automatic selection or choose a server manually. 2. Select “Other…” from the list. 3. In the “Choose a Download Server” window, click the Select Best Server button in the upper-right. Your computer will now attempt a connection with all the available servers, then select the one with the fastest speed. If you are happy with the automatic selection, click Choose Server to return to the Software & Updates window. If you are not happy with the automatic selection or prefer not to use the tool, the fastest server is often the closest server to you geographically. In this case, simply choose “Other” then find the nearest location to your location. When you are happy with the selection, click Choose Server to return to the Software & Updates window. If you do not have a working Internet connection, updates and programs can be installed from the installation media itself by inserting your media and clicking the box under “Installable from cd-rom/dvd.” Once this box is checked, the media within the cd-rom/dvd drive will function as an online repository, and the software on the media will be installable from Ubuntu Software. Adding more software repositories Ubuntu makes it easy to add additional third-party repositories to your list of software sources. The most common repositories added to Ubuntu are called ppas. A ppa is a Personal Package Archive. These are online reposito- ries used to host the latest versions of software packages, digital projects, and other applications. ppas allow you to install software packages that are not available in the official repositories. ppas also allow you to automati- cally be notified whenever updates for these packages are available. If you know the web address of a ppa’s Launchpad site, adding it to your list of software sources is relatively simple. To do so, you will need to use the Other Software tab in the “Software & Updates” window. On the Launchpad site for a ppa, you will see a heading to the left called “Adding this PPA to your system.” Underneath will be a short paragraph containing a unique url in the form of ppa:test-ppa/example. Highlight this url by selecting it with your mouse, then right-click and select Copy. Return to the “Software & Updates” window, and in the Other Software tab, click Add… at the bottom. A new window will appear, and you will see the words “Apt line:” followed by a text field. Right-click on the empty space in this text field and select Paste. You should see appear the url you copied from the ppa’s Launchpad site earlier. Click Add Source to return to the “Software & Updates” window. You will see a new entry has been added to the list of sources in this window with a selected check box in front (meaning it is enabled).
94 getting started with ubuntu 16.04 Figure 5.10: This is an example of the Launch- pad page for the Sublime Text PPA. Sublime Text is an application that is not available in the official Ubuntu repositories. However, by adding this PPA to your list of software sources, it will be easy to install and update this application through the Ubuntu Software application. If you click Close in the bottom right corner of this window, a message will appear informing you that “The information about available software is out-of-date.” This is because you have just added a new repository to Ubuntu, and it now needs to connect to that repository and download a list of the packages it provides. Click Reload, and wait while Ubuntu refreshes all of your enabled repositories (including this new one you just added). When it has finished, the window will close automatically. Congratulations, you have just added a ppa to your list of software sources. You can now open Ubuntu Software and install applications from this ppa in the same way you previously installed applications from the default Ubuntu repositories. Manual software installation Although Ubuntu has extensive software available, you may want to man- ually install a software package not available in the repositories. If no ppa exists for the software, you will need to install it manually. Before you choose to do so, make sure you trust the package and its maintainer. Packages in Ubuntu have a .deb extension. Double-clicking a package will open an overview page in Ubuntu Software which will give you more information about that package. The overview provides technical information about that package, a website link (if applicable), and the option to install. Clicking Install will install the package just like any other installation in Ubuntu Software. Updates and upgrades Ubuntu also allows you to decide how to manage package updates through the Updates tab in the Software & Updates window.
software management 95 Figure 5.11: Installing .deb files manually using Ubuntu Software. Ubuntu updates In this section, you are able to specify the kinds of updates you wish to install on your system. The type of update usually depends upon your preferences with regards to system stability versus having access to the latest developments. Figure 5.12: You can update installed software by using the Software Updater application in Ubuntu. Important security updates (xenial-security) These updates are highly rec- ommended to ensure your system remains as secure as possible. These updates are enabled by default. Recommended updates (xenial-updates) These updates are not as important in keeping your system secure. Rather, updates listed in this section will keep your software updated with the most recent bug fixes or minor updates that have been tested and approved. This option is also enabled by default. Unsupported updates (xenial-backports) These are updates that have not yet been fully tested and reviewed by Canonical. Some bugs may occur when using these updates, and so this option is also not enabled by default.
96 getting started with ubuntu 16.04 An additional option “Pre-released updates (xenial-proposed)” has been moved to a separate tab Developer Options. This option is for those who would rather remain up-to-date with the very latest releases of applications at the risk of in- stalling an update that has unresolved bugs or conflicts. Note that it is possible you will encounter problems with these updated applications, therefore, this option is not enabled by default. Automatic updates The middle section of this window allows you to customize how your sys- tem manages updates, such as the frequency with which it checks for new packages, as well as whether it should install important updates right away (without asking for your permission), download them only, or just notify you about them. Release upgrade At the bottom of the Updates tab in the Software & Updates window, you will see a dropdown box labeled Notify me of a new Ubuntu version:. This option allows you to tell Ubuntu how you would like to handle release updates. This dropdown box contains the following options for notification: Never Choose this option if you would rather not be notified about any new Ubuntu releases. For any new version Choose this option if you always want to have the latest Ubuntu release, regardless of whether it is a long-term support release or not. This option is recommended for normal home users. For long-term support versions Choose this option if you need a release that will be more stable and have support for a longer time. If you use Ubuntu for business purposes, you may want to consider selecting this option. Canonical will release a new version of the Ubuntu operating system ev- ery six months. Almost every release is a normal release. However, every fourth release—or every 2 years—Canonical releases a long-term support (lts) version of the operating system. Long-term support releases are intended to be the most stable releases available and are supported for a longer period of time. Ubuntu 16.04 is an LTS release. Ubuntu 16.10 will be a normal release.
6 Advanced Topics Ubuntu for advanced users To this point, we’ve provided detailed instructions on getting the most from Ubuntu’s basic features. In this chapter, we’ll detail some of Ubuntu’s more advanced features—like the terminal, a powerful utility that can help you accomplish tasks without the need for a graphical user interface (gui). We’ll also discuss some advanced security measures you can implement to make your computer even safer. This chapter has been written with advanced users in mind. If you’re new to Ubuntu, don’t feel as though you’ll need to master these topics to get the most out of your new software (you can easily skip to the next chap- ter without any adverse impact to your experience with Ubuntu). However, if you’re looking to expand your knowledge of Ubuntu, we encourage you to keep reading. Introduction to the terminal Throughout this manual, we have focused primarily on the GUI. In order to fully realize the power of Ubuntu, you will need to learn how to use the terminal. What is the terminal? Most operating systems, including Ubuntu, have two types of user inter- faces. The first is a GUI. This is the desktop, windows, menus, and toolbars you click to get things done. The second, much older type of interface is the command-line interface (cli). The terminal is Ubuntu’s CLI. It is a method of controlling some aspects of Ubuntu using only commands that you type on the keyboard. Why would I want to use the terminal? You can perform most day-to-day activities without ever needing to open the terminal. However, the terminal is a powerful and invaluable tool that can be used to perform many useful tasks you might not be able to accom- plish with a GUI. For example: ‣ Troubleshooting any difficulties that may arise when using Ubuntu sometimes requires you to use the terminal. ‣ A command-line interface is sometimes a faster way to accomplish a task. For example, it is often easier to perform operations on many files concurrently using the terminal. ‣ Learning the command-line interface is the first step towards more advanced troubleshooting, system administration, and software develop- ment skills. If you are interested in becoming a developer or an advanced Ubuntu user, knowledge of the command-line is essential.
98 getting started with ubuntu 16.04 Opening the terminal You can open the terminal by clicking Dash then searching for word “term”. You’ll see an application named terminal. Click on this application to open a terminal. Alternatively, you can open the terminal by hitting Ctrl+Alt+T simultaneously. The terminal gives you access to what is called a shell. When you type a command in the terminal, the shell interprets this command, resulting in the desired action. Different types of shells accept slightly different com- mands. The most popular is called “bash,” and is the default shell in Ubuntu. When the terminal window opens, it will be largely blank with the excep- tion of some text at the top left of the screen, followed by a blinking block, known as a cursor. This text is your prompt—it displays, by default, your login name and your computer’s name, followed by the current directory. The tilde (~) means that the current directory is your home directory. Fi- nally, the blinking block is called the cursor—this marks where text will be entered as you type. To test a terminal command, type pwd and press Enter. The terminal should display /home/yourusername. This text is called the “output.” You have just used the pwd (print working directory) command, which outputs (displays) the current directory. Figure 6.1: The default terminal window allows you to run hundreds of useful commands. All commands in the terminal follow the same approach: Type a com- mand, possibly followed by some parameters, and press Enter to perform the specified action. Parameters (also called switches) are extra segments of text, usually added at the end of a command, that change how the com- mand itself is interpreted. These usually take the form of -h or --help, for example. In fact, --help can be added to most commands to display a short description of the command, as well as a list of any other parameters that can be used with that command. Often, some type of output will be displayed confirming the action was completed successfully, although this can depend on the command being executed. For example, using the cd command to change your current direc- tory (see above) will change the prompt but will not display any output. The rest of this chapter covers some very common uses of the termi- nal. Throughout the second part of this manual, we will continue to refer to the command line, particularly when discussing steps involved in trou- bleshooting as well as when describing more advanced management of your computer.
advanced topics 99 Ubuntu file system structure Ubuntu uses the Linux file system, which is based on a series of folders in the root directory. These folders contain important system files that cannot be modified unless you are running as the root user or use sudo. This restriction exists for both security and safety reasons; computer viruses will not be able to change the core system files, and ordinary users should not be able to accidentally damage anything vital. Figure 6.2: Some of the most important directories in the root file system. We begin our discussion of the Ubuntu file system structure at the top —also known as the root directory—as denoted by /. The root directory contains all other directories and files on your system. Below the root directory are the following essential directories: /bin and /sbin Many essential system applications (equivalent to C:\Windows). /etc System-wide configuration files. /home Each user will have a subdirectory to store personal files (for example, /home/yourusername) which is equivalent to C:\Users or C:\Documents and Settings in Microsoft Windows. /lib Library files, similar to .dll files on Windows. /media Removable media (cd-roms and usb drives) will be mounted in this directory. /root This contains the root user’s files (not to be confused with the root directory). /usr Pronounced “user,” it contains most program files (not to be con- fused with each user’s home directory). This is equivalent to C:\Program Files in Microsoft Windows. /var/log Contains log files written by many applications. Every directory has a path. The path is a directory’s full name—it de- scribes a way to navigate the directory from anywhere in the system. For example, the directory /home/yourusername/Desktop contains all the files that are on your Ubuntu desktop. It can be broken down into a handful of key pieces —indicates that the path starts at the root directory ‣ home/—from the root directory, the path goes into the home directory ‣ yourusername/—from the home directory, the path goes into the you- rusername directory ‣ Desktop—from the yourusername directory, the path ends up in the Desktop directory
100 getting started with ubuntu 16.04 Every directory in Ubuntu has a complete path that starts with the / (the root directory) and ends in the directory’s own name. Directories and files that begin with a period are hidden. These are usually only visible with a special command or by selecting a specific op- tion. In the Files file manager, you can show hidden files and directories by selecting the Show Hidden Files option in the View menu. Hidden files can also be shown by simply pressing Ctrl+H in the Files file manager. If you are using the terminal, then you would type ls -a and press Enter to see the hidden files and directories. There are many hidden directo- ries in your home folder used to store program preferences. For example, /home/yourusername/.thunderbird stores preferences used by the Thun- derbird mail application. Mounting and unmounting removable devices Any time you add storage media to your computer—an internal or external hard drive, a usb flash drive, a cd-rom—it needs to be mounted before it is accessible. Mounting a device means to associate a directory name with the device, allowing you to navigate to the directory to access the device’s files. When a device, such as a usb flash drive or a media player, is mounted in Ubuntu, a folder is automatically created for it in the media/yourusername directory, and you are given the appropriate permissions to be able to read and write to the device. Most file managers will automatically add a shortcut to the mounted device in the side bar of your home folder or as a shortcut directly on the desktop so that the device is easily accessible. You shouldn’t have to physi- cally navigate to the media directory in Ubuntu unless you choose to do so from the command line. When you’ve finished using a device, you can unmount it. Unmounting a device disassociates the device from its directory, allowing you to eject it. If you disconnect or remove a storage device before unmounting it, you may lose data. Securing Ubuntu Now that you know a bit more about using the command line, we can use it to make your computer more secure. The following sections discuss various security concepts, along with procedures for keeping your Ubuntu running smoothly, safely, and securely. Why Ubuntu is safe Ubuntu is secure by default for a number of reasons: ‣ Ubuntu clearly distinguishes between normal users and administrative users. ‣ Software for Ubuntu is kept in a secure online repository containing no false or malicious software. ‣ Open-source software like Ubuntu allows security flaws to be easily detected. ‣ Security patches for open-source software like Ubuntu are often released quickly. ‣ Many viruses designed to primarily target Windows-based systems do not affect Ubuntu systems.
advanced topics 101 Just because Ubuntu implements strong security model by default doesn’t mean the user can “throw caution to the wind.” Care should always be taken when downloading files, opening email, and browsing the Internet. Using a good antivirus program is warranted as well. Basic security concepts The following sections discuss basic security concepts—like file permissions, passwords, and user accounts. Understanding these concepts will help you in securing your computer. Permissions In Ubuntu, files and folders can be set up so that only specific users can view, modify, or run them. For instance, you might wish to share an impor- tant file with other users, but do not want those users to be able to edit the file. Ubuntu controls access to files on your computer through a system of “permissions.” Permissions are settings configured to control exactly how files on your computer are accessed and used. To learn more about modifying permissions, visit https://help.ubuntu. com/community/FilePermissions. Passwords You should use a strong password to increase the security of your computer. Your password should not contain names, common words, or common phrases. By default, the minimum length of a password in Ubuntu is four characters. We recommend a password with more than the minimum num- ber of characters. A password with a minimum of eight characters which includes both upper and lower case letters, numbers, and symbols is consid- ered strong. Locking the screen When you leave your computer unattended, you may want to lock the screen. Locking your screen prevents another user from using your com- puter until your password is entered. To lock the screen: ‣ Click the session menu icon in the right corner of the top panel, then select Lock/Switch Account…, or ‣ Press Ctrl+Alt+L to lock the screen. This keyboard shortcut can be changed by going to Session Indicator ‣ System Settings… ‣ Keyboard ‣ Shortcuts and then selecting System from the list in the left column and clicking on Lock Screen in the right column. Users and groups User accounts When Ubuntu is installed, it is automatically configured for use by a single user. If more than one person will use the computer, each person should have his or her own user account. This way, each user can have separate settings, documents, and other files. If necessary, you can also protect files from being viewed or modified by users without administrative privileges.
102 getting started with ubuntu 16.04 Like most operating systems, Ubuntu allows you to create separate user accounts for each person. Ubuntu also supports user groups, which allows you to administer permissions for multiple users at the same time. Every user in Ubuntu is a member of at least one group. At a bare min- imum, the user of the computer has permissions in a group with the same name as the user. A user can also be a member of additional groups. You can configure some files and folders to be accessible only by a user and a group. By default, a user’s files are only accessible by that user, and system files are only accessible by the root user. Figure 6.3: Add, remove and change the user accounts. Managing users If the account you are using is an administrator account, you can manage users and groups using the Users and Groups administration application. To find this application, click Session Indicator ‣ System Settings… ‣ User Accounts. Then click the Unlock button and enter your password to unlock the user settings. Next, select the user that you want to modify from the list. Then click on the element that you want to change. Adding a user Click the + button underneath the list of the current user accounts. A window will appear with three fields. The Account Type field contains a list of user account types. Take care in determining what type of account to assign a user. An Administrator has full access to all areas of Ubuntu, whereas the Standard account type is more limited. The Full Name field contains a friendly display name. The Username field is for the actual username. As you enter the user’s full name, the Username field will automatically fill with a lowercase, no space version of the user’s full name. If you prefer to use a different username for this user, highlight the existing username and type in the username of your choice. Once all fields are filled in, click Add. The new user will be added to the list of user accounts. New accounts are disabled by default. To enable an account, click the Account disabled field next to the Password label. A new window will appear allowing you to set the password for the new user. At the top of the new window is a dropdown menu next to the label Action. By default, the “set a password now” option will be automatically selected. You may also choose “log in without a password”, however, this is not advised as the account will be available to anyone. The final option, “enable this account” is available once a password has been set. Using this option allows an administrator to enable or disable an account without losing the password.
advanced topics 103 Ubuntu provides a way to create a secure password by clicking the gears button located inside of the New password field. A random sequence of numbers, letters, and symbols will be entered into this field. You can also simply enter a password of your choosing by entering it into the New password field. Then, re-enter this same password into the space next to Confirm password. Ubuntu enforces the password policies on this screen, so pay attention to the status information located between the New password and Confirm password fields for information about the password you’re setting. If there are problems with the password, Ubuntu will tell you what is wrong with the password and will prevent you from entering the same password into the Confirm password field until the new password meets the requirements. Modifying a user Click on the name of a user in the list of users, then click on the text entry next to any of the following options: ‣ Account type: ‣ Language: ‣ Password: ‣ Automatic Login: You may also change the username by clicking on the username at the top and entering a new name. Deleting a user Select a user from the list and click -. Ubuntu will deacti- vate the user’s account, and you can choose whether to remove the user’s home folder or leave it in place. If a user is removed and the user’s files re- main, the only user who can access the files are the root user—also known as the superuser—or anyone associated with the file’s group. Managing groups Group management is accomplished through the command line (Terminal) or by adding third-party applications (the latter is beyond the scope of this manual). You will find more information in the section below titled “Using the command line”. Adding a group To add a group, type sudo addgroup groupname and press Enter, replacing groupname with the name of the group you wish to add. For example, sudo addgroup ubuntuusers will add the group ubuntuusers to the list of groups. Modifying a group To alter the users in an existing group, type sudo adduser username groupname to add a user, or sudo deluser username groupname to remove a user, and press Enter, replacing username and groupname in these commands with the actual user and group name with which you’re working. Deleting a group To delete a group, type sudo delgroup groupname and press Enter, replacing groupname with the name of the group you wish to delete.
104 getting started with ubuntu 16.04 Applying groups to files and folders To change the group associated with a file or folder, open the Files file man- ager and navigate to the appropriate file or folder. Then, either select the menu Files and choose Properties, or right-click on the file or folder and select Properties. In the Properties dialog window, click on the Permissions tab and select the desired group from the Groups drop-down list. Then close the window. Using the command line You can also modify user and group settings via the command line, but we recommend you use the graphical method above unless you have a good reason to use the command line. For more information on using the command line to modify users and groups, see the Ubuntu Server Guide at https://help.ubuntu.com/13.04/serverguide/user-man agement.html. System updates Good security happens with an up-to-date system. Ubuntu provides free software and security updates. You should apply these updates regularly. See Updates and upgrades to learn how to update your Ubuntu computer with the latest security updates and patches. Trusting third party sources Normally, you will add applications to your computer via Ubuntu Software which downloads software from the Ubuntu repositories as described in Chapter 5: Software Management. However, it is occasionally necessary to add software from other sources. For example, you may need to do this when an application is not available in the Ubuntu repositories or when you need a version of software newer than what is currently in the Ubuntu repositories. Additional repositories are available from sites such as http://www. getdeb.net and Launchpad ppas which can be added as described in Soft- ware Sources. You can download the deb packages for some applications from their respective project sites on the Internet. Alternatively, you can build applications from their source code. Using only recognized sources, such as a project’s site, ppa or various community repositories (such as http://www.getdeb.net), is more secure than downloading applications from an arbitrary (and perhaps less rep- utable) source. When using a third party source, consider its trustworthi- ness, and be sure you know exactly what you’re installing on your com- puter. Firewall A firewall is an application that protects your computer against unautho- rized access by people on the Internet or your local network. Firewalls block connections to your computer from unknown sources. This helps prevent security breaches. Uncomplicated Firewall (ufw) is the standard firewall configuration pro- gram in Ubuntu. It runs from the command line, but a program called Gufw allows you to use it with a graphical user interface gui. See Chapter 5: Software Management to learn more about installing the Gufw package.
advanced topics 105 Once Gufw is installed, start Gufw by clicking Dash ‣ Applications ‣ Firewall configuration. To enable the firewall, select the Enable option. By default, all incoming connections are denied. This setting should be suitable for most users. If you are running server software on your Ubuntu system (such as a web server, or an ftp server), then you will need to open the ports these services use. If you have no need to run any server applications or services, you will likely not need to open any additional ports. To open a port click on the Add button. For most purposes, the Precon- figured tab is sufficient. Select Allow from the first box and then select the program or service required. The Simple tab can be used to allow access on a single port, and the Advanced tab can be used to allow access on a range of ports. Encryption You may wish to protect your sensitive personal data—for instance, finan- cial records—by encrypting it. Encrypting a file or folder essentially “locks” that file or folder by encoding it with an algorithm that keeps it scrambled until it is properly decoded with a password. Encrypting your personal data ensures that no one can open your personal folders or read your private data without your authorization through the use of a private key. Ubuntu includes a number of tools to encrypt files and folders. This chapter will discuss two of them. For further information on using en- cryption with either single files or email, see Ubuntu Community Help documents at https://help.ubuntu.com/community. Home folder When installing Ubuntu, it is possible to encrypt a user’s home folder. See Chapter 1: Installation for more on encrypting the home folder. Private folder If you have not chosen to encrypt a user’s entire home folder, it is possible to encrypt a single folder—called Private—in a user’s home folder. To do this, follow these steps: 1. In the terminal, install the ecryptfs-utils software package using the command sudo apt install ecryptfs-utils. 2. Use the terminal to run ecryptfs-setup-private to set up the private folder. 3. Enter your account’s password when prompted. 4. Either choose a mount passphrase or generate one. 5. Record both passphrases in a safe location. These are required if you ever have to recover your data manually. 6. Log out and log back in to mount the encrypted folder. After the Private folder has been set up, any files or folders in it will automatically be encrypted. If you need to recover your encrypted files manually see https://help. ubuntu.com/community/EncryptedPrivateDirectory.
106 getting started with ubuntu 16.04 Running Windows Programs on Ubuntu As many Windows users will know, some programs that you can use on a Windows system cease to work on Ubuntu. For example, LibreOffice works on both Windows and Ubuntu systems, but Microsoft Office works only on a Windows system. Since many Windows users who use Ubuntu want all of their Windows programs back, many programmers have worked together to create Wine. Wine is an acronym for “Wine Is Not an Emulator”. This section will discuss what Wine is, and how to use it on your Ubuntu installation. For recent information about Wine, please visit the official Wine website at http://www.winehq.org. What is Wine? Wine is a background application that allows Linux and OS X users to install and run Windows programs on their system. While not every Win- dows program is compatible with Wine, many programs seem to be com- pletely compatible with Wine while running on Linux or OS X. For example, Microsoft Office may not be compatible without installing additional com- ponents (such as Microsoft.NET Framework 4.0). The current stable version of Wine is 1.8.2, and the most recent development version is 1.9.8. Installing Wine To install Wine Version 1.8.2, follow the following steps: If you have a previous version of Wine installed, uninstall Wine before continuing using the command, sudo apt remove --purge wine1.* winetricks && sudo apt-get autoremove 1. Open the terminal and type: sudo apt-add-repository ppa:ubuntu- wine/ppa. This will install the Official Wine ppa. 2. After the terminal has finished installing the Wine ppa, type: sudo apt update. This will update the ppa list. 3. Once the terminal has finished refreshing the ppa list, type: sudo apt install -y wine1.8 winetricks. This will install Wine 1.8.2 and Winet- ricks. Winetricks is a software center for Wine, and is, in most cases, optional. Figure 6.4: The Terminal showing the installa- tion of the Wine PPA. During the installation of Wine and Winetricks, you will have to ac- cept the Microsoft End User License Agreement and the Microsoft Core
advanced topics 107 Fonts License Agreement so that the Microsoft fonts and native files can be installed. Figure 6.5: The Microsoft Core Fonts EULA dialog opened in the Terminal. When accepting the Microsoft Core Fonts License Agreement, the Ok button is not highlighted. To highlight and accept the Microsoft EULA, press the Tab key and then the Enter key. The Microsoft End User License Agreement will be shown after you accept the Microsoft Core Fonts EULA. By default, the No button is highlighted. To highlight the Yes button and accept the Microsoft EULA, press the Tab key and then the Enter key. Figure 6.6: The Microsoft Core Fonts EULA dialog opened in the Terminal. Please Note: It is recommended to reboot your system after installing Wine and Winetricks, although this is not always required. Configuring Wine Wine 1.8.2 contains many features that will change the look and feel of the Windows applications you are trying to run. For example, you can change the theme of the Windows interface, and what version of Windows you would like to run (from Windows 2.0 to Windows 8). To change these settings, open the Dash and search for Configure Wine. Then, open the application. You may see a dialog asking you to install the packages Mono and Wine Gecko. You can either press the Install button, or go to the Wine website for details. Application Tab In the Application tab, you can change the way Wine runs applications. Some Windows programs work only for specific versions of Windows. This feature allows you to change the version of Windows Wine will run as for a specific application, or for all of them to run under one version.
108 getting started with ubuntu 16.04 Figure 6.7: The Wine configuration open to the Application Tab. Libraries Tab In the Libraries tab, you can change core Windows files, to suit your needs. Many Windows programs install dll files, or Dynamic Link Libraries. These files contain all of the information needed for an application to work on a Windows system. Many dll files are needed for a Windows system to run, and are different between versions of Windows. In this feature, you may edit or replace existing dll files. This allows you to change the Windows System files, to suit you needs. These files should not be edited. These are core files needed for Wine to run correctly. Only edit these files if you have to. Graphics Tab In the Graphics tab, you can change the look and feel of how Wine runs. You can make Wine emulate a Virtual Desktop (this feature opens a new window that will contain any Windows application that is currently running while this option is in effect), how the applications look, and what resolution to run the application in. Desktop Integration Tab In the Desktop Integration tab, you can change the way buttons, menus, and other elements appear in an application. Each version of Windows has brought its own unique visual style for its ap- plications. In this feature, you can install and change the applied theme. In this tab, you can also change major file folders. For example, while using Ubuntu, your picture folder is located at /home/user/Pictures/ but in Windows, your picture folder is located at C:\Documents and Set- tings\User\My Documents\My Pictures\ or C:\Users\User\My Pictures\. This feature allows you tell Wine where your folders are, for quick refer- ence. Drives Tab In the Drives tab, you can manage the connected drives that Wine will be able to access. Unlike Ubuntu, Windows applies a Drive Letter to each drive. This letter identifies the drive. For example, on every Win- dows system, the C: drive is the core drive. It contains all of the needed files for the operating system to work. The C: drive is the equivalent to root (File System, or / ) in Ubuntu. This feature allows you to change the drive letters for any drive, or add a drive letter for a specific folder in your file system, or for a cd drive.
advanced topics 109 Audio Tab In the Audio tab, you can change the audio settings. This fea- ture allows you to change the audio source that Wine will use for Windows applications (speakers, microphones, etc.). About Tab In the About tab, you can see the current Wine version you have installed, including Wine’s note to all users. This feature also allows you to add a Name and Company Name to the Windows information. Ap- plications use this information to identify you by name. Microsoft .NET Framework and Wine Microsoft has created many programs that are needed to run commonly used applications, Microsoft .NET Framework being the most common. .NET Framework is needed to run most of the newer applications created by Microsoft, and by other companies as well. Wine is not fully supported by all versions of .NET, but is compatible with most versions. Here is a list of .NET versions, and their compatibility with Wine: ‣ .NET Framework 1.0 ‣ .NET Framework 1.1 ‣ .NET Framework 2.0 ‣ .NET Framework 3.0 ‣ .NET Framework 3.5 ‣ .NET Framework 4.0 ‣ .NET Framework 4.5* * This framework has known issues running under Wine and is, in most cases, installable and stable enough to use for most applications. ‣ .NET Framework 4.5.1 This framework has not been tested using a current version of Wine running on Ubuntu, so it is unknown if it will be compatible or not. Use at your own risk. ‣ .NET Framework 4.5.2** For more compatibility information about installing and running Mi- crosoft .NET Framework using Wine, go to: http://appdb.winehq.org/ objectManager.php?sClass=application&iId=2586.
7 Troubleshooting Resolving problems Sometimes things may not work as they should. Luckily, problems encoun- tered while working with Ubuntu are often easily fixed. This chapter is meant as a guide for resolving basic problems users may encounter while using Ubuntu. If you need any additional help beyond what is provided in this chapter, take a look at other support options that are discussed in Finding additional help and support later in this book. Troubleshooting guide The key to effective troubleshooting is to work slowly, complete all of the troubleshooting steps, and to document the changes you made to the utility or application you are using. This way, you will be able to undo your work, or give fellow users the information about your previous attempts—the latter is particularly helpful in cases when you look to the community of Ubuntu users for support. Ubuntu fails to start after I’ve installed Windows Occasionally you may install Ubuntu and then decide to install Microsoft Windows as a second operating system running side-by-side with Ubuntu. This is supported in Ubuntu, but you might also find after installing Win- dows that you will no longer be able to start Ubuntu. When you first turn on your computer, a “bootloader” is responsible for initiating the start of an operating system, such as Ubuntu or Windows. A bootloader is the initial software that loads the operating system when the computer is powered up. When you installed Ubuntu, you automatically installed an advanced bootloader called grub. grub allows you to choose between the various operating systems installed on your computer, such as Ubuntu, Windows, Solaris, or OS X. If Windows is installed after Ubuntu, the Windows instal- lation removed grub and replaced the bootloader with it’s own. As a result, you can no longer choose an operating system to use. You can restore grub and regain the ability to choose your operating system by following the steps below, using the same dvd you used to install Ubuntu. First, insert your Ubuntu dvd into your computer and then restart the computer, making sure to instruct your computer to boot from the dvd drive and not the hard drive (see Chapter 1: Installation). Next, choose your language (e.g., English) and select Try Ubuntu. Once Ubuntu starts, click on the top-most icon in the Launcher (the Dash icon). Then, search for Terminal using the search box. Then, select Terminal in the search results (or press Ctrl+Alt+T). A window should open with a blinking prompt line. Enter the following, and press the Enter key: $ sudo fdisk -l Disk /dev/hda: 120.0 GB, 120034123776 bytes 255 heads, 63 sectors/track, 14593 cylinders Units = cylinders of 16065 * 512 = 8225280 bytes Device Boot Start End Blocks Id System
112 getting started with ubuntu 16.04 /dev/sda1 1 1224 64228+ 83 Linux /dev/sda2 * 1225 2440 9767520 a5 Windows /dev/sda3 2441 14593 97618972+ 5 Extended /dev/sda4 14532 14593 498015 82 Linux swap Partition table entries are not in disk order This output shows that your system (Linux, on which Ubuntu is based) The device (/dev/sda1, /dev/sda2, etc.) we are looking for is identified by the word “Linux” in the System column. Modify the instructions below if necessary, replacing /dev/sda1 with the name of your Linux device. is installed on device /dev/sda1, but as indicated by the asterisk in the Boot column, your computer is booting to /dev/sda2 (where Windows is located). We need to fix this by telling the computer to boot to the Linux device instead. To do this, create a place to connect your existing Ubuntu installation with your temporary troubleshooting session: $ sudo mkdir /mnt/root Next, link your Ubuntu installation and this new folder: $ sudo mount /dev/sda1 /mnt/root If you’ve done this correctly, then you should see the following: $ ls /mnt/root bin dev home lib mnt root srv usr boot etc initrd lib64 opt sbin sys var cdrom initrd.img media proc selinux tmp vmlinuz Now, you can reinstall grub: $ sudo grub-install --root-directory=/mnt/root /dev/sda Installation finished. No error reported. This is the contents of the device map /boot/grub/device.map. Check if this is correct or not. If any of the lines is incorrect, fix it and re-run the script grub-install. (hd0) /dev/sda Next you’ll want to unmount the hard drive. This ensures that the drive won’t become corrupted when you reboot: $ sudo umount /mnt/root Finally, remove the Ubuntu disc from your dvd-rom drive, reboot your computer, and then start enjoying your Ubuntu operating system once again. This guide may not work for all Ubuntu users due to differences in the various system configuration. Still, this is the recommended and most successful method for restoring the grub bootloader. If you are following this guide and if it does not restore grub on your computer, then try the other troubleshooting methods at https://help.ubuntu.com/community/ RecoveringUbuntuAfterInstallingWindows. I forgot my password If you forgot your password in Ubuntu, you will need to reset it using the “Recovery mode.” To start the Recovery mode, shut down your computer and then start again. As the computer starts up, press Shift. Select the Recovery mode option using the arrow keys on your keyboard. Recovery mode should be under the heading Advanced Options in the list. Wait until Ubuntu starts up—this may take a few minutes. Once booted, you will not be able to see a normal login screen. Instead, you will be pre- sented with the Recovery Menu. Select root using the arrow keys and press Enter. You will now be at a terminal prompt:
troubleshooting 113 Figure 7.1: This is the grub screen in which you can choose recovery mode. root@ubuntu:~# To reset your password, enter: # passwd username Replace “username” above with your username, after which Ubuntu will prompt you for a new password. Enter your desired password, press the Enter key, and then re-type your password again, pressing Enter again when done. (Ubuntu asks for your password twice to make sure you did not make a mistake while typing). Once you have restored your password, return to the normal system environment by entering: # init 2 Login as usual and continue enjoying Ubuntu. I accidentally deleted some files that I need If you’ve deleted a file by accident, you may be able to recover it from Ubuntu’s Trash folder. This is a special folder where Ubuntu stores deleted files before they are permanently removed from your computer. To access the Trash folder click on the trash icon at the bottom of the Unity Launcher. If you want to restore deleted items from the Trash: 1. Open Trash 2. Click on each item you want to restore to select it. Press and hold Ctrl to select multiple items. 3. Click Restore to move the deleted items back to their original locations. How do I clean Ubuntu? Ubuntu’s software packaging system accumulates unused packages and temporary files through regular updates and use. These temporary files, also called caches, contain files from all of the installed packages. Over time, this cache can grow quite large. Cleaning out the cache allows you to reclaim space on your computer’s hard drive for storing your documents, music, photographs, or other files. To clear the cache, you can either use the clean, or the autoclean option for the command-line program apt-get. To run clean, open Terminal and enter: The clean command will remove every single cached item, while the autoclean command only removes cached items that can no longer be downloaded (these items are often unnecessary). $ sudo apt-get clean
114 getting started with ubuntu 16.04 Packages can also become unused over time. If a package was installed to assist with running another program—and that program was subse- quently removed—you no longer need the supporting package. You can remove it with apt-get autoremove. Load Terminal and enter: $ sudo apt-get autoremove I can’t play certain audio or video files Many of the formats used to deliver rich media content are proprietary, meaning they are not free to use, modify, or distribute with an open-source operating system like Ubuntu. Therefore, Ubuntu does not include the ca- pability to use these formats by default; however, users can easily configure Ubuntu to use these proprietary formats. For more information about the differences between open source and proprietary software, see Chapter 8: Learning More. If you find yourself in need of a proprietary format, you can install the required files from the Terminal. This is covered in the Codecs portion of Chapter 3. Ensure that you have the Universe and Multiverse repositories enabled before continuing. See the Software Sources section to learn how to enable these repositories. One program that can play many of these formats is vlc. It can be in- stalled from the Terminal or Ubuntu Software. Once Ubuntu has success- fully installed this software, your rich media content should work properly. How can I change my screen resolution? The image on every monitor is composed of millions of little colored dots called pixels. Changing the number of pixels displayed on your monitor is called “changing the resolution.” Increasing the resolution will make the displayed images sharper, but will also tend to make them smaller. The opposite is true when screen resolution is decreased. Most monitors have a “native resolution,” which is a resolution that most closely matches the number of pixels in the monitor. Your display will usually be sharpest when your operating system uses a resolution that matches your display’s native resolution. The Ubuntu configuration utility Displays allows users to change the resolution. Open it by clicking on the session indicator and then on Dis- plays…. The resolution can be changed using the drop-down list within the program. Picking options higher up on the list (for example, those with larger numbers) will increase the resolution. You can experiment with various resolutions by clicking Apply at the bottom of the window until you find one that is comfortable. Typically, the highest resolution will be the native resolution. Selecting a resolution and clicking Apply will temporarily change the screen resolution to the selected value, and a dialog box will also be displayed for 30 seconds. This dialog box allows you to revert to the previous resolution setting or keep the new resolution setting. If you’ve not accepted the new resolution and/or 30 seconds have passed, the dialog box will disappear and the display’s resolution will return to its previous setting. This feature was implemented to prevent someone from being locked out of the computer by a resolution that distorts the monitor output and makes it unusable. When you have finished setting the screen resolution, click Close.
troubleshooting 115 Figure 7.2: You can change your display settings. Figure 7.3: You can revert back to your old settings if you need to. Ubuntu is not working properly on my Apple MacBook or MacBook Pro When installed on notebook computers from Apple—such as the MacBook or MacBook Pro—Ubuntu does not always enable all of the computer’s built-in components, including the iSight camera and the Airport wireless Internet adapter. Luckily, the Ubuntu community offers documentation on fixing these and other problems. If you are having trouble installing or using Ubuntu on your Apple notebook computer, please follow the instruc- tions at https://help.ubuntu.com/community/MacBook. You can select the appropriate guide after identifying your computer’s model number. Ubuntu is not working properly on my Asus EeePC When installed on netbook computers from Asus—such as the EeePC— Ubuntu does not always enable all of the computer’s built-in components, including the keyboard shortcut keys and the wireless Internet adapter. The Ubuntu community offers documentation on enabling these com- ponents and fixing other problems. If you are having trouble installing or using Ubuntu on your Asus EeePC, please follow the instructions at https://help.ubuntu.com/community/EeePC. This documentation page con- tains information pertaining specifically to EeePC netbooks. To enable many of the features and Function Keys, a quick fix is to add “acpi_osi=Linux” to your grub configuration. From the Terminal $ gksudo gedit /etc/default/grub and very carefully change the line GRUB_CMDLINE_LINUX_DEFAULT="quiet splash" to GRUB_CMDLINE_LINUX_DEFAULT="quiet splash acpi_osi=Linux" Save and close the file. Then, from the terminal: $ sudo update-grub After the command finishes, and you restart the computer, you will be able to use the Fn keys normally.
116 getting started with ubuntu 16.04 My hardware is not working properly Ubuntu occasionally has difficulty running on certain computers, usually when hardware manufacturers use non-standard or proprietary compo- nents. The Ubuntu community offers documentation to help you trou- bleshoot many common issues in this situation, including problems with wireless cards, scanners, mice, and printers. You can find the complete hardware troubleshooting guide on Ubuntu’s support wiki, accessible at https://wiki.ubuntu.com/HardwareSupport. If your hardware problems persist, please see Getting more help for more troubleshooting options or information on obtaining support or assistance from an Ubuntu user. Getting more help This guide does not cover every possible workflow, task, issue, or problem in Ubuntu. If you require assistance beyond the information in the manual, you can find a variety of support opportunities online. More details about many support options available to you can be found at Finding additional help and support later in this book.
8 Learning More What else can I do with Ubuntu? At this point, you should now be able to use Ubuntu for most daily activ- ities—such as browsing the web, sending email, and creating documents. Now, you may be interested in learning about other versions of Ubuntu that may integrate into your digital lifestyle. In this chapter, we’ll introduce additional versions of Ubuntu designed and specialized for certain tasks. We’ll also provide resources for answering any remaining questions as well as direct you to how you can get involved in the worldwide community of Ubuntu users. First, we’ll discuss the technologies that make Ubuntu a powerful collection of software and a progressive operating system. Open source software Ubuntu is open source software (OSS). OSS differs from proprietary soft- ware. Proprietary software is defined as software whose source code is not freely available for modification or distribution by anyone but the rightsholder. Microsoft Windows and Adobe Photoshop are examples of proprietary software. Unlike proprietary software applications, the software included with Ubuntu is specifically licensed to promote sharing and collaboration. The legal rules governing Ubuntu’s production and distribution ensure that anyone can obtain, run, or share it for any purpose. Users can modify open source software to suit their individual needs, to share it, to improve it, or to translate it into other languages—provided they release the source code for these modifications so others can do the same. In fact, the terms of many open source licensing agreements actually make it illegal not to do so. This understanding helps explain why Ubuntu is called open source software. For more information regarding Ubuntu’s software licensing standards, see http://www.ubuntu.com/project/about-ubuntu/licensi ng. Because OSS is developed by large communities of programmers located throughout the world, it benefits from both rapid development cycles and speedy security releases when bugs are identified in the software. In other words, OSS is updated, enhanced, and made more secure every day as programmers all over the world continue to improve it. In addition to these technical advantages, OSS also has economic bene- fits. While users must adhere to the terms of an OSS licensing agreement when installing and using Ubuntu, they needn’t pay to obtain this license. While not all OSS is free of monetary costs, a vast majority of OSS is avail- able for free. To learn more about open source software, see the Open Source Initia- tive’s open source definition, available at http://www.opensource.org/docs/ definition.php. Distribution families Ubuntu is one of several popular operating systems based on Linux. These Linux-based operating systems—called Linux “distributions”—may look
118 getting started with ubuntu 16.04 different from Ubuntu at first glance, but they share similar characteristics because of their common roots. Linux distributions can be divided into two broad families: the Debian family and the Red Hat family. Each family is named for a distribution on which subsequent distributions are based. For example, “Debian” refers to both the name of a Linux distribution as well as the family of distributions derived from Debian. Ubuntu is part of this family. When describing rela- tionships between various open source projects, software developers often use the metaphor of tributaries connecting to a common body of water. For this reason, you may hear someone say that Ubuntu is located “down- stream” from Debian, because alterations to the Debian family ”flow” into new versions of Ubuntu. Additionally, improvements to Ubuntu usually trickle “upstream”—back to Debian and its family members as the Debian family benefits from the work of the Ubuntu community. Other distribu- tions in the Debian family include Linux Mint, Xandros, and CrunchBang Linux. Distributions in the Red Hat family include Fedora and Mandriva. The most significant difference between Debian-based and Red Hat- based distributions is the system each uses for installing and updating software. These systems are called Package management systems. Package management systems are the means by which users can install, remove, and organize software installed on computers with open source operating systems like Ubuntu. Debian software packages are deb files, while Red Hat software packages are rpm files. The two systems are generally incompati- ble. For more information about package management, review the chapter on Chapter 5: Software Management. You will also find specialized Linux distributions for certain tasks. Next, we’ll describe these versions of Ubuntu and explain the uses for which each has been developed. Choosing amongst Ubuntu and its derivatives Just as Ubuntu is based on Debian, several distributions are subsequently based on Ubuntu. Each differs with respect to the software included as part of the distribution. Some are developed for general use, while others are designed for accomplishing a more narrow set of tasks. Alternative interfaces Ubuntu features a graphical user interface (gui) based on the open source unity7 desktop. Previous versions of Ubuntu used the gnome desktop. As we explained in Chapter 2: The Ubuntu Desktop, a “user interface” is a collection of software elements—icons, colors, windows, themes, and menus—that determine how someone may interact with a computer. Some people prefer using alternatives to gnome, so they have created Ubuntu distributions featuring different user interfaces. These include: ‣ Kubuntu, which uses the kde graphical environment ‣ Lubuntu, which uses the lxde graphical environment ‣ Xubuntu, which uses the xfce graphical environment Additionally, each of these distributions may contain default applications different from those featured in Ubuntu. For instance, the default music player in Ubuntu is Rhythmbox. In Lubuntu, the default music player is Audacious, and in Kubuntu, the default is Amarok. Be sure to investigate
learning more 119 these differences if you are considering installing an Ubuntu distribution with an alternative desktop environment. For more information about these and other derivative distributions, see http://www.ubuntu.com/project/derivatives. Task-specific distributions Other Ubuntu distributions have been created to accomplish specific tasks or run in specialized environments and settings. Ubuntu Server Edition The Ubuntu Server Edition is an operating system optimized to perform multi-user tasks. Such tasks may include file sharing, website, or email hosting. If you are planning to use a computer to perform these types of tasks, you may wish to use this specialized server distribution in conjunc- tion with server hardware. While it is possible to run a server-type envi- ronment using only the desktop version of Ubuntu, it is not advised as the Server Edition is better optimized for the multi-user environment. This manual does not explain the process of running a secure web server or performing other tasks with Ubuntu Server Edition. For details on using Ubuntu Server Edition, refer to the manual at http://www.ubuntu.com/ business/server/overview. Edubuntu Edubuntu is an Ubuntu derivative customized for use in schools and other educational institutions. Edubuntu contains software similar to that offered in Ubuntu but also features additional applications like a collaborative text editor and educational games. For additional information regarding Edubuntu, visit http://www. edubuntu.org/ Ubuntu Studio The derivative of Ubuntu called Ubuntu Studio is designed specifically for people who use computers to create and edit multimedia projects. Ubuntu Studio features applications to help users manipulate images, compose music, and edit video. While users can install these applications on comput- ers running the desktop version of Ubuntu, Ubuntu Studio makes them all available immediately upon installation. If you would like to learn more about Ubuntu Studio (or obtain a copy for yourself), visit http://ubuntustudio.org/. Mythbuntu Mythbuntu allows users to turn their computers into entertainment sys- tems. Mythbuntu helps users organize and view various types of multime- dia content such as movies, television shows, and video podcasts. Users with tv tuners in their computers can also use Mythbuntu to record live video and television shows. To learn more about Mythbuntu, visit http://www.mythbuntu.org/.
120 getting started with ubuntu 16.04 Finding additional help and support This guide cannot possibly contain everything you’ll ever need to know about Ubuntu. We encourage you to take advantage of Ubuntu’s vast com- munity when seeking further information, troubleshooting technical issues, or asking questions about your computer. It’s important to note that the Internet is full of third-party resources as well as individuals who post information on blogs and forums. While these resources can often seem like great resources, some could be mis- leading or outdated. It’s always best to verify information from third-party sources before taking their advice. When possible, rely on official Ubuntu documentation for assistance with Ubuntu. Now, let’s discuss a few of the available resources to learn more about Ubuntu and other Linux distributions. Live chat If you are familiar with Internet Relay Chat (irc), you can use chat clients such as XChat or Pidgin to join the channel #ubuntu on irc.freenode.net. In this channel, hundreds of volunteer users can answer your questions or of- fer technical support in real time. To learn more about using Internet Relay Chat to seek help with Ubuntu, visit https://help.ubuntu.com/community/ InternetRelayChat. LoCo teams The Ubuntu community contains dozens of local user groups called “LoCo teams.” Distributed throughout the world, these teams offer support and advice, answer questions, and promote Ubuntu in their communities by hosting regular events. To locate or contact the LoCo team nearest you, visit http://loco.ubuntu.com/. Books and Magazines Many books have been written about Ubuntu, and professional magazines often feature news and information related to Ubuntu. You will frequently find these resources at your local bookstore or newsstand. If you know the name of a book or magazine, e.g. this manual or Full Circle Magazine, you can search for it on the Internet. Official Ubuntu Documentation The Ubuntu Documentation Team maintains a series of official wiki pages designed to assist both new and experienced users wishing to learn more about Ubuntu. The Ubuntu community endorses these documents, which serve as a reliable first point of reference for users seeking online help. You can access these resources at http://help.ubuntu.com. To get to the built-in Ubuntu Desktop Guide, type help in the Dash. The Ubuntu Forums The Ubuntu Forums are the official forums of the Ubuntu community. Mil- lions of Ubuntu users use them daily to seek help and support from one another. You can create an Ubuntu Forums account in minutes. To create
learning more 121 an account and learn more about Ubuntu from community members, visit http://ubuntuforums.org. Launchpad Answers Launchpad, an open source code repository and user community, provides a question and answer service that allows anyone to ask questions about any Ubuntu-related topic. Signing up for a Launchpad account takes just a few seconds. You can ask a question by visiting Launchpad at https://answers. launchpad.net/ubuntu. Ask Ubuntu Ask Ubuntu is a free, community-driven website for Ubuntu users and developers. Like the Ubuntu Forums, it allows users to post questions for other members of the Ubuntu community to answer. But Ask Ubuntu also allows visitors to “vote” on the answers users provide, so the most useful or helpful responses get featured more prominently on the site. Ask Ubuntu is part of the Stack Exchange network of websites and is one of the best free Ubuntu support resources available. Visit http://www.askubuntu.com to get started. Search Engines Because Ubuntu is a popular open source operating system, many users have written about it online. Therefore, using search engines to locate answers to your questions about Ubuntu is often an effective means of acquiring help. When using search engines to answer questions about Ubuntu, ensure that your search queries are as specific as possible. In other words, a search for “Unity interface” will return results that are less useful than those associated with the query “how to use Ubuntu Unity interface” or “how to customize Ubuntu Unity interface.” Community support If you’ve exhausted all these resources and still can’t find answers to your questions, visit Community Support at http://www.ubuntu.com/support/ community. The Ubuntu community Ubuntu is the flagship product created by a global community of passionate users who want to help others adopt, use, understand, and even modify or enhance Ubuntu. By choosing to install and run Ubuntu, you’ve become part of this community. As you learn more about Ubuntu, you may wish to collaborate with others as you promote Ubuntu to new users, to share Ubuntu advice, or to answer other users’ questions. In this section, we’ll discuss a few community projects that can connect you to other Ubuntu users. Full Circle Magazine Full Circle Magazine is “the independent magazine for the Ubuntu Linux community.” Released every month, Full Circle Magazine contains reviews of new software (including games) for Ubuntu, step-by-step tutorials for
122 getting started with ubuntu 16.04 projects you can accomplish with Ubuntu, editorials discussing important issues in the Ubuntu community, and Ubuntu tips from other users. Full Circle Magazine is released in many different formats and is always free. You can download current and back issues of Full Circle Magazine at http:// fullcirclemagazine.org/. The Ubuntu UK Podcast Produced by members of the UK’s Ubuntu LoCo team, this bi-weekly online audio broadcast (or “podcast”) features lively discussion about Ubuntu and often includes interviews with Ubuntu community members who work to improve Ubuntu. Episodes are available at http://ubuntupodcast.org/. OMG! Ubuntu! OMG! Ubuntu! is a weblog that aims to inform the Ubuntu community about Ubuntu news, events, announcements, and updates in a timely fash- ion. It also allows Ubuntu users to discuss ways they can promote or share Ubuntu. You can read this blog or subscribe to it at http://www.omgubuntu. co.uk/. Contributing Contributing to Ubuntu As we mentioned earlier in this chapter, Ubuntu is a community-maintained operating system. You can help make Ubuntu better in a number of ways. The community consists of thousands of individuals and teams. If you would like to contribute to Ubuntu, please visit https://wiki.ubuntu.com/ ContributeToUbuntu. You can also participate in the Ubuntu community by contributing to this manual. You might choose to write new content for it, edit its chapters so they are easier for new Ubuntu users to understand and use, or translate it in your own language. Or maybe taking screenshots is your passion! Regardless of your talent or ability, if you have a passion to contribute to the Ubuntu community in a meaningful way, then the Ubuntu Manual Project invites you to join! To get involved in the Ubuntu Manual Project, visit http://ubuntu-manual.org/getinvolved.
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Glossary Access Point A device that allows for a wireless connection to a local net- work using Wi-Fi, Bluetooth, etc. applet A small program that runs in a panel. Applets provide useful func- tions such as starting a program, viewing the time, or accessing the main menu of an application. Canonical Canonical, the financial backer of Ubuntu, provides support for the core Ubuntu system. It has over 500 staff members worldwide who ensure that the foundation of the operating system is stable, as well as checking all the work submitted by volunteer contributors. To learn more about Canonical, go to http://www.canonical.com. cli cli or command-line interface is another name for the terminal. desktop environment A generic term to describe a gui interface for humans to interact with computers. There are many desktop environments such as Unity, gnome, kde, xfce and lxde, to name a few. dhcp dhcp stands for Dynamic Host Configuration Protocol, it is used by a dhcp server to assign computers on a network an ip address automati- cally. dialup connection A dialup connection is when your computer uses a mo- dem to connect to an isp through your telephone line. distribution A distribution is a collection of software that is already com- piled and configured ready to be installed. Ubuntu is an example of a distribution. dual-booting Dual-booting is the process of being able to choose one of two different operating systems currently installed on a computer from the boot menu. Once selected, your computer will boot into whichever operating system you chose at the boot menu. The term dual-booting is often used generically, and may refer to booting among more than two operating systems. encryption Encryption is a security measure, it prevents others from access- ing and viewing the contents of your files and/or hard drives, the files must first be decrypted with your password. Ethernet port An Ethernet port is what an Ethernet cable is plugged into when you are using a wired connection. gui The gui (which stands for Graphical User Interface) is a type of user in- terface that allows humans to interact with the computer using graphics and images rather than just text. isp isp stands for Internet Service Provider, an isp is a company that provides you with your Internet connection. Live dvd A Live dvd allows you to try out an operating system before you actually install it, this is useful for testing your hardware, diagnosing problems and recovering your system. lts lts stands for long-term support and is a type of Ubuntu release that is officially supported for far longer than the standard releases.
132 getting started with ubuntu 16.04 maximize When you maximize an application in Ubuntu it will fill the whole desktop, excluding the panels. minimize When you minimize an open application, the window will no longer be shown. If you click on a minimized application’s icon in the Launcher, it will be restored to its normal state and allow you to interact with it. notification area The notification area is an applet on the panel that pro- vides you with all sorts of information such as volume control, the cur- rent song playing in Rhythmbox, your Internet connection status and email status. output The output of a command is any text it displays on the next line after typing a command and pressing enter, e.g., if you type pwd into a terminal and press Enter, the directory name it displays on the next line is the output. package Packages contain software in a ready-to-install format. Most of the time you can use Ubuntu Software instead of manually installing packages. Packages have a .deb extension in Ubuntu. panel A panel is a bar that sits on the edge of your screen. It contains ap- plets which provide useful functions such as running programs, viewing the time, or accessing the main menu. parameter Parameters are special options that you can use with other commands in the terminal to make that command behave differently, this can make a lot of commands far more useful. ppa A personal package archive (ppa) is a custom software repository that typically contains either packages that aren’t available in the primary Ubuntu repositories or newer versions of packages that are available in the primary repositories. prompt The prompt displays some useful information about your computer. It can be customized to display in different colors, display the time, date, and current directory or almost anything else you like. proprietary Software made by companies that don’t release their source code under an open source license. router A router is a specially designed computer that, using its software and hardware, routes information from the Internet to a network. It is also sometimes called a gateway. server A server is a computer that runs a specialized operating system and provides services to computers that connect to it and make a request. shell The terminal gives access to the shell, when you type a command into the terminal and press enter the shell takes that command and performs the relevant action. Synaptic Package Manager Synaptic Package Manager is a tool that, instead of listing applications (like Ubuntu Software) lists individual packages that can then be installed, removed and fixed. terminal The terminal is Ubuntu’s text-based interface. It is a method of controlling the operating system using only commands entered via the keyboard as opposed to using a gui like Unity. Ubuntu Software Ubuntu Software is where you can easily manage soft-
glossary 133 ware installation and removal as well as the ability to manage software installed via Personal Package Archives. usb Universal Serial Bus is a standard interface specification for connecting peripheral hardware devices to computers. usb devices range from external hard drives to scanners and printers. wired connection A wired connection is when your computer is physically connected to a router or Ethernet port with a cable. This is the most common method of connecting to the Internet and local network for desktop computers. wireless connection A network connection that uses a wireless signal to communicate with either a router, access point, or computer.
Credits This manual wouldn’t have been possible without the efforts and contribu- tions from the following people: Team leads Kevin Godby—Lead TEXnician Hannie Dumoleyn—Editors Coordinator & Translation Maintainer Sylvie Gallet—Screenshots Thorsten Wilms—Designer Authors, Editors & Reviewers Pravin Dhayfule Hannie Dumoleyn Sylvie Gallet Kevin Godby Eric Marsh Miles Robinson Tiffany Tisler Translation editors Fran Diéguez (Galician) Hannie Dumoleyn (Dutch) Sylvie Gallet (French) Aleksey Kabanov (Russian) Xuacu Saturio (Asturian) Daniel Schury (German) Susah Sebut (Malay) Jose Luis Tirado (Spanish) Chris Woollard (British English) John Xygonakis (Greek) Andrej Znidarsic (Slovenian) Past contributors Bryan Behrenshausen (Author) Senthil Velan Bhooplan (Author) Mario Burgos (Author/Editor) John Cave (Author) Edmond Condillac (Editor) Jim Connett (Author/Editor/Coordinator) Thomas Corwin (Author/Editor) Sayantan Das (Author/Editor) Che Dean (Author) Patrick Dickey (Author) Mehmet Atif Ergun (Author/Editor) Rick Fosburgh (Editor-in-Chief) Herat Gandhi Amrish (Author) Benjamin Humphrey (Project Founder) Mehmet Kani (Author/Editor) Sam Klein (Author) Will Kromer (Author) Paddy Landau (Author/Editor) Simon Lewis (Author) Andrew Montag (Editor) Ryan Macnish (Author) Mez Pahlan (Author) Vibhav Pant (Editor) Brian Peredo (Author) Joel Pickett (Author) David Pires (Editor) Eric Ponvelle (Author) Tony Pursell (Author/Editor) Kev Quirk (Author) Scott Stainton (Editor) Kartik Sulakhe (Author) Tom Swartz (Author) David Wales (Author) Chris Woollard (Editor)
Index 32-bit versus 64-bit, 9 accessibility, 32 screen reader, 32 alternative interfaces, 118–119 Apple, see MacBook applications adding and removing, 21 presentation, see LibreOffice running, 21 searching, 23 spreadsheet, see LibreOffice word processor, see LibreOffice audio, see sound and music audio, playing, see Rhythmbox Bluetooth, 86 booting troubleshooting, 111 camera, importing photos, 65 Canonical, 6 cds and dvds blanking, 75 burning, 73–77 codecs, 68 copying, 76 playing, 69, 70 ripping, 71 Choqok, 64–65 codecs audio, 73 video, 68 command line, see terminal Corebird, 64 Dash, 21 Debian, 6, see also Linux derivatives, 118 desktop background, 20 customization, 30 appearance, 30 background, 31 theme, 30 menu bar, 20 sharing, 62 disk, see cds and dvds display adding secondary, 80–81 changing resolution, 80 troubleshooting, 114 drivers, 79–80 DRM, 68 dual-booting, 13 dvds and cds, see cds and dvds Edubuntu, 119 EeePC troubleshooting, 115 email, see Thunderbird Empathy, 59–63 add accounts, 59 chatting, 61–62 desktop sharing, 62 setup, 59 encryption, see security file system structure, 99–100 Files, 27 multiple tabs, 29 multiple windows, 29 window, 27 files browsing, 26 opening files, 28 recovering, 113 files and folders copying, 28 creating, 28 displaying hidden, 28 moving, 28 searching, 29–30 Firefox, 46–55 firewall installing, 104 using, 104 FireWire, see ieee 1394 gestures, 85 groups, see also users adding, 103 deleting, 103 files and folders, 104 managing, 103 modifying, 103 hardware troubleshooting, 116 help Ask Ubuntu, 121 documentation, 120 forums, 120 Full Circle Magazine, 121 general help, 34 heads-up display (hud), 35 Launchpad Answers, 121 live chat, 120 online, 34 home folder, 26 ieee 1394, 86 instant messaging, see Empathy Internet browsing, 46–55 connecting, 39–46 wireless, 42 Internet radio, 71 kernel, 6 keyboard, 85 Launcher, 21 running applications, 21 LibreOffice, 77 Linux, 6–7 Linux distributions, 117–118 Live dvd, see Ubuntu Live dvd locking the screen, 33 logging out, 33 login options, 15–16 Mac OS X, see MacBook MacBook troubleshooting, 115 microblogging, see Choqok, see Corebird monitor, see display mounting devices, 100 mouse, 85 Movie Player, 68 multitouch, 85 music, see Rhythmbox Mythbuntu, 119 NetworkManager, 39 open-source software, 117 OS X, see MacBook password, see security photos, see also Shotwell editing, 66 importing, 65 viewing, 65 podcasts, 72 presentation application, 77 printer, 81, 82 add via usb, 81 adding via network, 81
138 getting started with ubuntu 16.04 rebooting, 33 ReplayGain, 72 Rhythmbox, 69–73 Internet radio, 71 playing music, 69 podcasts, 72 scanner, 84 troubleshooting, 84 screen, see display security encryption, 105 introduction, 100–101 passwords, 101 permissions, 101 resetting passwords, 112 screen locking, 101 system updates, 104 Shotwell, 65–68 shutting down, 33 Shuttleworth, Mark, 6 slide show, see LibreOffice software adding repository, 93–94 email, 37 finding applications, 88–89 installing, 89 managing, 91 manual installation, 94 movie players, 38 multimedia players, 38 music players, 38 office suites, 37 pdf reader, 37 podcast readers, 38 presentation, 37 recommendations, 91 removing, 89–91 repositories, 91 servers, 92–93 spreadsheet, 37 video players, 38 web browser, 37 word processor, 37 Software Center, 88 sound input, 83 output, 83 recording, 83 troubleshooting, 114 volume, 82 sound effects, 83 spreadsheet, 77 start up, see boot suspending the computer, 33 system requirements, 9 terminal about, 97 using, 98 Thunderbird, 55–59 setup, 55 torrent Ubuntu image, 10 touchpad, 85 Twitter, see Choqok, see Corebird Ubuntu bootable usb drive, 10 definition of, 5 downloading, 9 history of, 6 installing, 11–16 philosophy of, 5–6 Ubuntu Live dvd, 10–11 Ubuntu Promise, 6 Ubuntu Server Edition, 119 Ubuntu Studio, 119 Unity, 19 Unix, 6, 7 unmounting devices, 100 updates about, 95–96 automatic, 96 release updates, 96 usb, 85 users, see also groups adding, 102 creating during installation, 15–16 deleting, 103 managing, 102 modifying, 103 video troubleshooting, 114 videos codecs, 68 playing, 68 volume, see sound webcam, 83 Wi-Fi, 42 windows, 24 closing, 24 force on top, 25 minimizing, 24 moving, 25 moving between, 25 resizing, 25 restoring, 24 switching, 25 word processor, 77 workspaces, 24
colophon This book was typeset with XƎL A TEX. The book design is based on the Tufte-L A TEX document classes available at http:// code.google.com/p/tufte-latex/. The text face is Linux Libertine, designed by Philipp H. Poll. It is an open font available at http://linuxlibertine.sf.net/. The captions and margin notes are set in Ubuntu, a font commissioned by Canonical and designed by Dalton Maag. It is freely available for download at http://font. ubuntu.com/. The terminal text and keystrokes are set in DejaVu Sans Mono (available at http:// dejavu-fonts.org/), originally developed by Bitstream, Inc. as Bitstream Vera. The cover and title page pictograms contain shapes taken from the Humanity icon set, available at https://launchpad.net/humanity. The title page and cover were designed using Inkscape, available at http://inkscape. org/. | <urn:uuid:9290973a-2b38-4d2b-9014-8485bfe67500> | {
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About Dr. Mohammad H Madantschi
Dr. Mohammad H Madantschi, MD is a Doctor primarily located in Peoria, AZ, with other offices in Phoenix, AZ and Glendale, AZ (and 1 other location). His specialties include Pulmonary Disease and Critical Care Medicine. Dr. Madantschi has received 3 awards. He speaks English.
Dr. Mohammad H Madantschi has the following 2 specialties
- Pulmonary Disease
A pulmonologist is a physician who specializes in the diagnosis and treatment of conditions related to the lungs and respiratory tract.
These specialists are similar to critical care specialists in that their patients often require mechanical ventilation to assist their breathing.
Pulmonologists diagnose and treat patients with conditions such as asthma, cystic fibrosis, asbestosis, pulmonary fibrosis, lung cancer, COPD, and emphysema. Exposure and inhalation of certain toxic substances may also warrant the services of a pulmonologist.
Some of the tools and tests pulmonologists use to diagnose a patient are a stethoscope in order to listen for abnormal breathing sounds, chest X-rays, CT scans, blood tests, bronchoscopy, and polysomnography.
- Critical Care Medicine
Also sometimes referred to as intensivists, critical care specialists are physicians with specialized training in the diagnosis and management of life-threatening conditions. Some of these conditions affect vital organs like the heart and lungs, those that make breathing difficult or impossible, and those that affect entire organ systems, like the renal system.
Critical care specialists are typically found in a hospital's intensive care unit where they monitor patients with life-threatening conditions and make determinations as to the best course of treatment.
Dr. Mohammad H Madantschi has the following 13 expertise
- Obstructive Sleep Apnea
- Chest Infection
- Chronic Obstructive Pulmonary Disease (COPD)
- Tuberculosis (TB)
- Central Sleep Apnea
- Intrinsic Sleep Disorders
- REM Sleep Behavior Disorder
- Angiographic Visualization
- Disorders of Excessive Sleepiness (Hypersomnia)
Dr. Mohammad H Madantschi has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 16
Dr. Madantchi is an excellent Dr. He is extremely kind, listens to every word you say and explains everything in detail. I just wish I would have found him years ago. I? have a friend that was dying and Dr Madantchi saved his life. He is here today due to the care he provided for my friend. The best in the business in my opinion??????
Compassionate Doctor Recognition (2017, 2018)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Patients' Choice Award (2017, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
On-Time Doctor Award (2017, 2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Allegheny University Hospitals
Dr. Mohammad H Madantschi accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Savings Plus of AZ
- Aetna Signature Administrators PPO
- Aetna Whole Health Banner Health Network HMO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Health Net AZ PPO HSA
- Humana Choice POS
- Humana National POS
- Humana Phoenix HMOx
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Options PPO
Locations & Directions
Dr. Mohammad H Madantschi is similar to the following 3 Doctors near Peoria, AZ. | <urn:uuid:a6a12c05-c1d2-4b59-b0c2-f67bd8d752e7> | {
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In recent years, a number of independent researchers and various government agencies have conducted research on the efficiency, appropriateness, and cost-effectiveness of chiropractic treatment. Several of the important studies are listed below.
U.S. Government Agency Report
A 1994 study published by the U.S Agency for Health Care Policy and Research (AHCPR) and the U.S. Department of Health and Human Services endorses spinal manipulation for acute low back pain in its Clinical Practice Guideline #14. An independent multidisciplinary panel of private-sector clinicians and other experts convened and developed specific statements on appropriate health care of acute low back problems in adults. One statement cited relief of discomfort (low back pain) can be accomplished most safely with spinal manipulation and/or nonprescription medication.
The Manga Report
A major study to assess the most appropriate use of the available health care resources was reported in 1993. This was an outcome study funded by the Ontario Ministry of Health and conducted in hopes of sharing information about ways to reduce the incidence of work related injuries and to address cost-effective ways to rehabilitate disabled and injured workers. The study was conducted by three economists led by University of Ottawa Professor Pran Manga, Ph D. The report of the study is commonly called the Manga Report. The Manga Report overwhelmingly supported the efficacy, safety, scientific validity, and cost-effectiveness of chiropractic for low back pain. Additionally, it found that higher patient satisfaction levels were associated with chiropractic care than with medical treatment alternatives. "Evidence from Canada and other countries suggests potential saving of hundreds of millions annually," the Manga Reports states. "The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, fewer hospitalizations, and highly significant reduction in chronic problems, as well as in levels and duration of disability."
Rand Study on Low Back Pain
A four-phase study conducted in the early 1990's by Rand, one of America's most prestigious centers for research in public policy, science and technology, explored many indications of low-back pain. In the Rand studies, an expert panel of researchers, including medical doctors and doctors of chiropractic, found that:
- Chiropractors deliver a substantial amount of health care to the U.S. population.
- Spinal manipulation is of benefit to some patients with acute low back pain.
- The Rand report marked the first time that representatives of the medical community went on record stating that spinal manipulation is an appropriate treatment for certain low-back pain conditions.
The New Zealand Commission Report
A particularly significant study of chiropractic care was conducted between 1978-1980 by the New Zealand Commission of Inquiry. In its 377 page report to the House of Representatives, the Commission called its study, "probably the most comprehensive detailed independent examination of chiropractic ever undertaken by any country." The general impression...shared by many in the community that chiropractic was an unscientific cult, not to be compared with orthodox medical or paramedical services. By the end of the inquiry the commission reported itself "irresistibly and with complete unanimity drawn to the conclusion that modern chiropractic is soundly-based and a valuable branch of health care in a specialized area..." Conclusions of the Commission's report, based on investigations in New Zealand, United States, Canada, United Kingdom, and Australia stated:
- Spinal manual therapy in the hands of a registered chiropractor is safe.
- Spinal manual therapy can be effective in relieving musculoskeletal symptoms such as back pain and other symptoms known to respond to such therapy, such as migraine.
- Chiropractors are the only health practitioners who are necessarily equipped by their education and training to carry out spinal manual therapy.
- In the public interest and the interest of patients, there must be no impediment to full professional cooperation between chiropractors and medical practitioners.
Florida Workers Compensation Study
A 1998 study of 10,652 Florida workers' compensation cases was conducted by Steve Wolk, Ph.D., and reported by the Foundation for Chiropractic Education and Research. It was concluded that "a claimant with a back related injury, when initially treated by a chiropractor versus a medical doctor, is less likely to become temporarily disabled or if disabled, remains disabled for a shorter period of time; and claimants treated by medical doctors were hospitalized at a much higher rate than claimants treated by chiropractors."
Washington HMO Study
In 1989, a survey administered by Daniel C. Cherkin, Ph.D., and Frederick A. Mac Cornack, Ph D., concluded that patients receiving care from health maintenance organizations (HMO's) within the state of Washington were three times as likely to report satisfaction with care from chiropractors as they were with care from other physicians. The patients were also more likely to believe that their chiropractors were concerned about them.
Utah Workers' Compensation Study
A workers' compensation study conducted in Utah by Kelly B. Jarvis, D.C., Reed B. Philips, D.C., Ph. D., and Elliot K Morris, JD, MBA, compared the cost of chiropractic care to the costs of medical care for conditions with identical diagnostic codes. Results were reported in the August 1991 Journal of Occupational Medicine. The study indicated that costs were significantly higher for medical claims than for chiropractic claims; in addition, the number of work days lost was nearly ten times higher for those who receive medical care instead of chiropractic care.
Patient Disability Comparison
A 1992 article in the Journal of Family Practice reported a study by D.C. Cherkin, Ph.D., which compared patients of family physicians and of chiropractors. The article stated "the number of days of disability for patients seen by family physicians was significantly higher (mean 39.7) than for patients managed by chiropractors (mean 10.8)." A related editorial in the same issue referred to risks of complications from lumbar manipulation as being "very low."
Oregon Workers' Compensation Study
A 1991 report on workers' compensation study conducted in Oregon by Joanne Nyiendo, Ph. D. concluded that the median time loss days (per case) for comparable injuries was 9.0 for patients receiving treatment by a doctor of chiropractic and 11.5 for treatment by a medical doctor.
Stano Cost Comparison Study
A study by Miron Stano, Ph D., reported in the June 1993 Journal of Manipulative and Physiological Therapeutics involved 395,641 patients with neuromusculoskeletal conditions. Results over a two-year period showed that patients who received chiropractic care incurred significantly lower health care costs than did patients treated solely by medical or osteopathic physicians.
Saskatchewan Clinical Research
Following a 1993 study, researchers J. David Cassidy, D.C. and Haymo Thiel, Royal University Hospital in Saskatchewan, concluded that "the treatment of lumbar intervertebral disk herniation by side posture manipulation is both safe and effective."
Wight Study on Recurring Headaches
A 1978 study, conducted by J.S. Wight, D.C. and reported in the ACA Journal of Chiropractic, indicated that 74.6% of patients with recurring headaches, including migraines, were either cured or experienced reduced headache symptomatology after receiving chiropractic manipulation.
1991 Gallop Poll
A 1991 demographic poll conducted by the Gallop Organization revealed that 90% of chiropractic patients felt their treatment was effective; more than 80% were satisfied with that treatment; and nearly 75% felt most of their expectations had been met during their chiropractic visits.
1990 British Medical Journal
A study conducted by T.W. Meade, a medical doctor, and reported in the June 2, 1990, British Medical Journal concluded after two years of patient monitoring, "for patients with low-back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long-term benefit in comparison with hospital outpatient management."
Virginia Comparative Study
A 1992 study conducted by L.G. Schifrin, Ph. D., provided economic assessment of mandated health insurance coverage for chiropractic treatment within the Commonwealth of Virginia. As reported by the College of William and Mary and the Medical College of Virginia, the study indicated that chiropractic provides therapeutic benefits at economical costs. The report also recommended that chiropractic be a widely available form of health care.
1992 American Health Policy Report
A 1992 review of data from over 2,000,000 users of chiropractic care in the U.S. reported in the Journal of American Health Policy, stated that "chiropractic users tend to have substantially lower total health care costs" and "chiropractic care reduces the use of both physician and hospital care."
1985 University of Saskatchewan Study
In 1985 the University of Saskatchewan conducted a study of 283 patients "who had not responded to previous conservative or operative treatment" and who were initially classified as totally disabled. The study revealed that "81%...became symptom free or achieved a state of mild intermittent pain with no work restrictions" after daily spinal manipulations were administered.
Landmark Legal Decision Supports Chiropractic
Further validation of chiropractic care evolved from an antitrust suit which was filed by four members of the chiropractic profession against the American Medical Association (AMA) and a number of other health care organizations in the U.S. (Wilk et al v. AMA et al, 1990). Following eleven years of litigation, a federal appellate court judge upheld a ruling by U.S. District Court Judge Susan Getzendanner that the AMA had engaged in a "lengthy, systematic, successful and unlawful boycott" designed to restrict cooperation between MD's and chiropractors in order to eliminate the profession of chiropractic as a competitor in the U.S. health care system. Judge Getzendanner rejected the AMA's patient care defense and cited scientific studies which implied that "chiropractic care was twice as effective as medical care in relieving many painful conditions of the neck and back as well as related musculoskeletal problems." Since the court's findings and conclusions were released, an increasing number of medical doctors, hospitals, and health care organizations in the U.S. have begun to include the services of chiropractors. | <urn:uuid:af7ae92a-0422-43a1-a90b-0c83c20c6404> | {
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Ten Things You Should Know about How Health Insurance Works
You probably understand many of the key concepts of health insurance, but you not know as much as you think. Health insurance is a financial product, and like most other financial products, it is a complex instrument that has been developed over centuries. The modern incarnation of health insurance is governed by both industry standards as well as state and federal regulations, making it both difficult to understand and beneficial in some surprising ways.
1. You can’t be denied a policy because you’re sick—Under the Affordable Care Act of 2010, the federal government made it illegal for insurance companies to refuse you a health policy because you are ill. Likewise, it is also illegal for them to offer you a policy at a higher price because you have a health condition. However, they may adjust prices depending on your age and geographic location.
2. Insurers have to explain why they rejected a claim—If your insurer refuses to pay a claim, you are legally entitled to a reason why. If you still think that you should be reimbursed, you have the option of pursuing an internal appeal (through the insurance company) or an external review (an independent third party makes a judgment).
3. If you don’t get health insurance, you may have to pay a financial penalty—When Congress passed the Affordable Care Act of 2010, they included a component called the Individual Mandate. This part of the law requires that all Americans with a certain amount of income must get covered or pay a penalty which in 2017 was $695 or 2.5 percent of your income, whichever is higher.
4. Health plans must include free preventive care—Many people don’t realize that their health insurance grants them many free preventive care services. This includes
- Blood pressure screening
- Cholesterol screening
- Diet counseling
- Depression screening
- Diabetes screening
- Hepatitis B screening
- Immunization vaccines
- Lung cancer screening
- STD counseling
- Obesity screening and counseling
5. Avoid lapses in coverage—If you have insurance through your employer and leave your job, make sure to re-enroll in a health plan within 63 days. That is the deadline to sign up for COBRA, the federally sponsored health plan extension that may provide coverage for an additional 18 to 36 months. This is also the maximum amount of time you have to enroll in a new health plan without having to divulge any health conditions; after this time period a new employer insurer has the right to inquire.
6. Don’t settle for your employer health plan—You may not realize it, but you don’t have to get coverage through your employer. Closely examine the coverage terms to see if you are getting the most for your money. If you are enrolled in a high deductible policy, you may have to pay thousands of dollars out of pocket before your insurer starts to kick. If you are young and healthy you may find better options elsewhere, because group plans base premiums on the entire group’s health and age.
7. Deductibles in health plans don’t preempt benefits—Unlike your home or auto insurance policy where you must pay the deductible before enjoying any of the policy’s benefits, a health insurance policy may provide you some benefits even if you haven’t met your annual deductible limit. These benefits may include discounts for prescription drugs, free annual checkups or preventive care services.
8. Low premiums may not mean low overall cost—Like most things, with health insurance, you are likely to get what you pay for. If you want a low premium policy, you will probably have to pay in other ways including higher deductibles or other out-of-pocket expenses. In the long run, if you encounter a major health crisis, or even a few minor ones, you may wish that you had gone with a plan with a higher premium that offered benefits. Take into consideration how often you and your family are likely to use medical services before you finally decide on a health plan.
9. You may use government subsidies to pay for health insurance—One of the most important features of the Affordable Care Act of 2010 was that it helped many Americans get enrolled in a health plan by helping to pay for monthly premiums. If your household makes between 100 percent and 400 percent of the federal poverty level, then you probably qualify for these ACA-sponsored subsidies. If you qualify, you may apply hundreds of dollars a month to your monthly premium, saving thousands of dollars annually. To use these subsidies, you must apply through one of the state or federal health insurance marketplaces and enroll in one of the plans available there. You must also verify your income by filing a tax return for any year are enrolled in a ACA plan.
10. Choose a network that suits your lifestyle—When you are shopping for a health plan, look closely at the three letters denoting the type of network. These should be HMO, PPO, EPO, or POS. An HMO is the most restrictive, in that you can only see providers in your network, but these plans are usually the most cost effective. A PPO plan allows you to see doctors out of network and has less limitations on what kind of doctors you may see, but these are often more expensive. EPO and POS plans are hybrids of HMO and PPO plans.
Health insurance, at its most basic, is simple to understand; you pay an insurer to help protect you from the financial consequences of a medical emergency. However, there is often much more involved when you examine the finer points of your health plan. If you would like to learn more about your current health insurance policy or would like to know what other health plans are available to you, you may find answers with one of the experienced insurance agents at Boost Health Insurance.
Find the best plans in Los Angeles, CA
Speak to one of our licensed health insurance agents. | <urn:uuid:d05f89b7-f53e-4957-838f-6b12cec6dd9e> | {
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Mediciad: A Primer
Prepared for Members and Committees of Congress
In existence for 43 years, Medicaid is a means-tested entitlement program that finances the
delivery of primary and acute medical services as well as long-term care to more than 61 million
people at an estimated cost to the federal and state governments of roughly $317 billion. Of all
federally supported programs, only Medicare comes close to this level of spending, and only
Social Security costs more.
Each state designs and administers its own version of Medicaid under broad federal rules. State
variability in eligibility, covered services, and how those services are reimbursed and delivered is
the rule rather than the exception.
This report describes the basic elements of Medicaid, focusing on federal rules governing who is
eligible, what services are covered, how the program is financed and how beneficiaries share in
the cost, how providers are paid, and the role of special waivers in expanding eligibility and
modifying benefits. The Deficit Reduction Act of 2005 or DRA (P.L. 109-171), as amended by
the Tax Relief and Health Care Act of 2006 (P.L. 109-432), included many provisions affecting
Medicaid. DRA allows states to make fundamental changes in Medicaid program design,
including covered benefits and beneficiary cost-sharing. In 2007, the Bush Administration issued
several regulations and program guidances affecting Medicaid. Most recently, the Medicare,
Medicaid and SCHIP Extension Act of 2007 (P.L. 110-173) delayed implementation of two such
regulations affecting school-based and rehabilitation services. Additional laws placed restrictions
on other Administration actions as well. These and other major regulatory and legislative activity
are summarized here. Lastly, basic program statistics and citations to in-depth CRS reports on
specific topics are provided. This report will be updated.
Who is Eligible for Medicaid?........................................................................................................1
What Benefits Does Medicaid Cover?............................................................................................3
How Is Medicaid Financed?............................................................................................................6
Do Beneficiaries Pay for Medicaid Services?.................................................................................7
Service-Based Cost-Sharing Under Traditional Medicaid........................................................7
Participation-Related Cost-Sharing Under Traditional Medicaid.............................................8
Beneficiary Cost-Sharing Under DRA......................................................................................8
How are Providers Paid Under Medicaid?......................................................................................9
How Do Medicaid Research and Demonstration Waivers Work?.................................................10
Some Medicaid Statistics...............................................................................................................11
Where is Medicaid Headed?..........................................................................................................12
CRS Medicaid Resources..............................................................................................................13
Eligibility ................................................................................................................................ 13
Benefits ................................................................................................................................... 13
Financing ................................................................................................................................. 14
Waivers .................................................................................................................................... 14
St atisti cs .................................................................................................................................. 14
Author Contact Information..........................................................................................................15
edicaid was enacted in 1965 in the same legislation that created the Medicare program
(i.e., the Social Security Amendments of 1965; P.L. 89-97). It grew out of and replaced
two earlier programs of federal grants to states that provided medical care to welfare M
recipients and the elderly. It has expanded in additional directions since that time.
In the federal budget, Medicaid is an entitlement program that constitutes a large share of
mandatory spending. Two other federally supported health programs—Medicare and the State 1
Children’s Health Insurance Program (SCHIP)—are also entitlements, and are also components
of mandatory spending in the federal budget. All three programs finance the delivery of certain
health care services to specific populations. While Medicare is financed exclusively by the federal
government, both Medicaid and SCHIP are jointly financed by the federal and state governments.
Federal Medicaid spending is open-ended, with total outlays dependent on the generosity of state
Medicaid programs. In contrast, SCHIP is a capped federal grant to states.
Even though Medicaid is an entitlement program in federal budget terms, states may choose to
participate, and all 50 states do so. If they choose to participate, states must follow federal rules in
order to receive federal reimbursement to offset a portion of their Medicaid costs.
The federal Medicaid statute (Title XIX of the Social Security Act) defines more than 50 distinct
population groups as being potentially eligible. To qualify for Medicaid coverage, applicants’
income (e.g., wages, Social Security benefits) and often their resources or assets (e.g., value of a
car, savings accounts) must meet program financial requirements. These requirements vary
considerably among states, and different rules apply to different population groups within a state.
Medicaid eligibility is also subject to categorical restrictions—generally, it is available only to
the elderly, persons with disabilities (as generally defined under the federal Supplemental 2
Security Income Program, or SSI), members of families with dependent children, and certain
other pregnant women and children. In recent years, Medicaid has been extended to additional
groups with specific characteristics, including certain women with breast or cervical cancer and
uninsured individuals with tuberculosis.
In general, while Medicaid is targeted at individuals with low income, not all of the poor are
eligible, and not all those covered are poor. For example, adults without a qualifying disability
and no dependent children are not eligible for Medicaid, no matter how poor they are (unless a
state has a special waiver; see the subsection on waivers below). And, the income standards
applicable to some Medicaid eligibility groups exceed the poverty level, as described below.
Moreover, from state to state, applicants with substantial differences in gross income may qualify
for Medicaid under the same eligibility group, depending on the income methodology used (i.e.,
what types of income are counted, and how much, if any, income of a given type is disregarded or
1 The term “entitlement” has two meanings in this context. Individuals who meet state eligibility requirements are
entitled to Medicaid. Similarly, individuals who meet federal eligibility requirements are entitled to Medicare. In
contrast, states that meet certain federal requirements are entitled, or have access to, federal SCHIP grants. All states
have qualified for SCHIP. There is no individual entitlement under SCHIP.
2 SSI provides cash assistance to the elderly and adults with certain disabilities that significantly restrict their ability to
be gainfully employed. In the case of children, disabilities must result in marked and severe functional limitations.
Some eligibility groups are mandatory, meaning that all states must cover them; others are
optional. Examples of groups that states must provide Medicaid to include:
• poor families that meet the financial requirements (based on family size) of the
former Aid to Families with Dependent Children (AFDC) cash assistance 3
• families transitioning from welfare to work who receive up to 12 months of
Medicaid coverage (reinstated and extended under DRA and P.L. 109-432),
• pregnant women and children under age six with family income below 133% of 4
the federal poverty level (FPL),
• children ages six through 18 with family income below 100% FPL,
• poor individuals with disabilities or poor individuals over age 64 who qualify for 5
cash assistance under the SSI program, and
• certain groups of legal permanent resident immigrants (e.g., refugees for the first
seven years after entry into the U.S.; asylees for the first seven years after asylum
is granted; lawful permanent aliens with 40 quarters of creditable coverage under
Social Security; immigrants who are honorably discharged U.S. military
Examples of groups that states may choose to cover under Medicaid:
• pregnant women and infants with family income exceeding 133% FPL up to
• individuals with disabilities and people over age 64 whose income exceeds the
SSI level (about 75% FPL nationwide) up to 100% FPL,
• children with disabilities whose family income is above the financial standards
for SSI but below 300% FPL (added under DRA),
• individuals who require institutional care (in a nursing facility or other medical
institution) whose income exceeds the SSI level up to 300% of the applicable SSI
payment standard (based on family size) or roughly 221% FPL,
• “medically needy” individuals who meet categorical requirements (e.g., are over
64 or under 19, have a disability, are pregnant, or are members of families with
dependent children) with income up to 133⅓% of the maximum payment amount 6
applicable under states’ former AFDC programs based on family size. Unlike
most other eligibility groups, medical expenses (if any) may be subtracted from
3 AFDC income standards are well below the federal poverty level, but states can modify (liberalize or further restrict)
these criteria. Under the 1996 welfare reform law, AFDC was replaced with the Temporary Assistance for Needy
Families (TANF) program. Although TANF recipients are not automatically eligible for Medicaid, some states have
aligned income rules for TANF and Medicaid, thus facilitating Medicaid coverage for some TANF recipients.
4 For example, in 2007, the FPL for a family of four was $20,650—133% of FPL for such a family would equal
5 Some states use income, resource and disability standards that differ from current SSI standards.
6 This limit can be raised or lowered based on specific provisions in the 1996 welfare reform legislation.
income in determining financial eligibility for medically needy coverage, which
is often referred to as “spend down,” and
• legal immigrants after their first five years in this country.
DRA made significant changes to asset transfer rules that potentially affect eligibility for
Medicaid’s long-term care services (both institutional care and services provided in homes or the
community, described below). In general, states must delay the start date for Medicaid enrollment
for individuals who transfer assets for less than the fair market value on or after a “look-back
date” of five years prior to application (rather than the three years typically applicable under prior
law). Under DRA, the penalty period begins on the later of: (1) the first month following the date
of the improper transfer (as under prior law), or (2) the date the person is Medicaid-eligible and
would qualify for an institutional level of care. In sum, these DRA changes could lengthen the
period of ineligibility for some individuals.
Like eligibility, federal rules require states to cover certain benefits under the traditional Medicaid
program. Certain other services may also be offered at state option. States define the specific
features of each covered benefit within four broad federal guidelines:
• Each service must be sufficient in amount, duration, and scope to reasonably
achieve its purpose. States may place appropriate limits on a service based on
such criteria as medical necessity.
• Within a state, services available to categorically needy groups7 must be equal in
amount, duration, and scope. Likewise, services available to medically needy 8
groups must be equal in amount, duration, and scope. These requirements are
called the “comparability rule.”
• With certain exceptions, the amount, duration, and scope of benefits must be the
same statewide, also referred to as the “statewideness rule.”
• With certain exceptions, beneficiaries must have freedom of choice among health
care providers or managed care entities participating in Medicaid.
Standard benefits identified in the federal statute and regulations include a wide range of medical
care and services. Some benefits are specific items, such as eyeglasses and prosthetic devices.
Other benefits are defined in terms of specific types of providers (e.g., physicians, hospitals)
whose array of services are designated as coverable under Medicaid. Still other benefits define
specific types of service (e.g., family planning services and supplies, pregnancy-related services)
that may be delivered by any qualified medical provider that participates in Medicaid.
Examples of benefits that are mandatory for most Medicaid groups:
7 Categorically needy groups include families with children, the elderly, persons with disabilities, and certain other
pregnant women and children who meet former AFDC- and SSI-related financial standards, or have income below
specified percentages of the FPL.
8 Medically needy groups include individuals meeting the same categorical restrictions, but different (typically
somewhat higher) financial standards apply.
• inpatient hospital services (excluding services for mental disease),
• services provided by federally qualified health centers,
• laboratory and x-ray services,
• physician services,
• pregnancy-related services,
• nursing facility services for individuals age 21 and over, and
• home health care for those entitled to nursing home care.
Examples of optional benefits for most Medicaid groups that are offered by many states:
• prescribed drugs (covered by all states),
• routine dental care,
• physician-directed clinic services,
• other licensed practitioners (e.g., optometrists, podiatrists, psychologists),
• inpatient psychiatric care for the elderly and for individuals under age 21,
• nursing facility services for individuals under age 21,
• physical therapy,
• prosthetic devices, and
The optional, traditional benefits offered vary across states. In addition, the breadth of coverage
for a given benefit can and does vary from state to state, even for mandatory services. For
example, states may place different limits on the amount of inpatient hospital services a
beneficiary can receive in a year (e.g., up to 15 inpatient days per year in one state versus
unlimited inpatient days in another state). Exceptions to stated limits may be permitted under
circumstances defined by the state.
The federal Medicaid statute also specifies special benefits or special rules regarding certain
benefits for targeted populations. For example:
• Most children under age 21 are entitled to Early and Periodic Screening,
Diagnostic and Treatment (EPSDT) services. Under EPSDT, children receive
well-child visits, immunizations, laboratory tests, and other screening services at
regular intervals. In addition, medical care that is necessary to correct or
ameliorate identified defects, physical and mental illness, and other conditions
must be provided, including optional services that states do not otherwise cover
in their Medicaid programs.
• While all women who qualify for Medicaid are eligible for pregnancy-related
services, women who qualify under one of the pregnancy-related eligibility
groups are eligible for only pregnancy-related services (including treatment of
conditions that may complicate pregnancy) through a period of 60 days
• Special benefit rules apply to optional medically needy populations. States may
offer a more restrictive benefit package than is provided to categorically needy
populations, but at a minimum, must offer (1) prenatal and delivery services for
pregnant women, (2) ambulatory services for individuals under 18 and those
entitled to institutional services, and (3) home health services for individuals 9
entitled to nursing facility care.
• State Medicaid programs must pay Medicare cost-sharing expenses (e.g.,
Medicare premiums and, in some cases, deductibles and co-insurance) for certain
low-income individuals eligible for both programs, often called “dual eligibles.”
Another example of special long-term care benefits for targeted populations is home and
community based services. Under Section 1915(c) of the federal Medicaid statute, the Secretary
of Health and Human Services (HHS) may waive certain Medicaid requirements allowing states
to cover a broad range of home and community-based services (HCBS) for persons who would
otherwise be eligible for Medicaid-funded institutional care. Waiver participants must be
members of targeted groups (as designated by the state), including the aged, persons with
physical disabilities, persons with mental retardation or developmental disabilities (MR/DD), and
persons with mental illness. Benefits may include, for example, personal care (e.g., assistance
with eating/drinking, toileting, medication management); habilitation services (e.g., assistance
with socialization and adaptive skills) for individuals with MR/DD; transportation; case
management; psychosocial rehabilitation and clinic services for persons with chronic mental
illness. A cost-effectiveness test requires that expenditures for HCBS not exceed the cost of
institutional care that would have otherwise been provided to waiver participants. Thus, states
may cap enrollment and/or set expenditure limits on a per capita or aggregate basis to meet this
DRA allows states to establish HCBS under a new optional benefit category; thus, under specific
circumstances, certain services no longer require a Section 1915(c) waiver. States have long
complained that waiver requirements and processes are burdensome. To add this new HCBS
benefit, states will instead submit a Medicaid state plan amendment to the federal government for
approval. This new benefit is available to certain individuals with income below 150% FPL who
are not required to need an institutional level of care to qualify. Unlike other state plan benefits,
states offering this new HCBS benefit will be allowed to cap the number of enrollees and
establish waiting lists as they did under Section 1915(c) waivers.
Finally, as an alternative to providing all of the mandatory and selected optional benefits under
traditional Medicaid, DRA gives states the option to enroll state-specified groups in new
benchmark and benchmark-equivalent benefit plans. These plans are nearly identical to the
benefit packages offered through the State Children’s Health Insurance Program (SCHIP). The
benchmark options include
• the Blue Cross/Blue Shield preferred provider plan under the Federal Employees
Health Benefits Program (FEHBP),
• a plan offered to state employees,
• the largest commercial HMO in the state, and
9 Broader requirements apply if a state has chosen to provide coverage for medically needy persons in institutions for
mental disease and intermediate care facilities for the mentally retarded.
• other Secretary-approved coverage appropriate for the targeted population.
Benchmark-equivalent coverage must have the same actuarial value as one of the benchmark
plans identified above. Such coverage includes (1) inpatient and outpatient hospital services, (2)
physician services, (3) lab and X-ray services, (4) well-child care, including immunizations, and
(5) other appropriate preventive care (designated by the Secretary). Such coverage must also
include at least 75% of the actuarial value of coverage under the benchmark plan for (1)
prescribed drugs, (2) mental health services, (3) vision care, and (4) hearing services.
For any child under age 19 in one of the major mandatory and optional Medicaid eligibility
groups, wrap-around benefits must include EPSDT. States may choose to provide other wrap-
around and additional benefits. Wrap-around typically refers to situations in which the state
provides a specific service (e.g., rehabilitation services, nursing home care) to beneficiaries
enrolled in a plan that does not cover that service. For a given group of beneficiaries, ensuring
coordination of care between two (or more) entities responsible for managing different benefits
(e.g., the state Medicaid agency and a managed care plan) is always an issue, and one that is not
unique to these DRA provisions.
The federal and state governments share the cost of Medicaid. States are reimbursed by the
federal government for a portion (the “federal share”) of a state’s Medicaid program costs.
Because Medicaid is an open-ended entitlement, there is no upper limit or cap on the amount of
federal funds a state may receive. Medicaid costs in a given state and year are primarily
determined by the expansiveness of eligibility rules and beneficiary participation rates, the
breadth of benefits offered, the generosity of provider reimbursement rates, and other 10
The state-specific federal share for benefit costs is determined by a formula set in law that
establishes higher federal shares for states with per capita personal income levels lower than the
national average (and vice versa for states with per capita personal income levels that are higher 11
than the national average). The federal share, called the federal medical assistance percentage
(FMAP), is at least 50% of state Medicaid benefit costs, and can be as high as 83% (statutory
maximum). For FY2008, the federal share for benefit costs ranges from 50% (in 13 states) up to
just over 76% (in one state).
The federal match for administrative expenditures does not vary by state and is generally 50%,
but certain administrative functions have a higher federal matching rate. Functions with a 75%
federal match include, for example, survey and certification of nursing facilities, operation of a
state Medicaid fraud control unit (MFCU), and operation of an approved Medicaid management
10 Key supplemental payments are described in CRS Report 97-483, Medicaid Disproportionate Share Payments, and
in CRS Report RL31021, Medicaid Upper Payment Limits and Intergovernmental Transfers: Current Issues and
Recent Regulatory and Legislative Action. P.L. 109-432 made some technical changes to certain supplemental
payments (e.g., disproportionate share hospital or DSH payments). More recently, P.L. 110-173 extended DSH
payments for Tennessee and Hawaii.
11 For one benefit, family planning services and supplies, the federal share is 90% for all states. In addition, the federal
share is 100% for Medicaid services provided by an Indian Health Service facility (whether operated by the IHS or
certain Indian tribes or tribal organizations) to Medicaid beneficiaries.
information system (MMIS) for claims and information processing. The implementation and
operation of immigration status verification systems by each state is fully financed by the federal
government. Overall, administrative costs represent about 5% of total Medicaid spending in a
For Hurricane Katrina fiscal relief, DRA appropriated $2 billion to cover the state share of
Medicaid expenditures for certain states that provided care to affected individuals or evacuees
under approved multi-state Section 1115 waiver projects and under existing Medicaid (and
SCHIP) state plans, for certain administrative expenses, and to restore access to health care in
impacted communities (as approved by the Secretary of HHS).
Under traditional Medicaid, states are allowed to require certain beneficiaries to share in the cost
of Medicaid services, although there are limits on (1) the amounts that states can impose, (2) the
beneficiary groups that can be required to pay, and (3) the services for which cost-sharing can be
charged. The rules for service-based cost-sharing (e.g., copayments paid to a provider at the time
of service delivery) are different from those for participation-related cost-sharing (e.g., premiums
paid by beneficiaries typically on a monthly basis independent of any services rendered).
For some groups of beneficiaries, all service related cost-sharing is prohibited unless the
prohibitions are lifted under a special waiver (see the subsection on waivers below). All service
related cost-sharing is prohibited for children under 18 years of age. Service related cost-sharing
is prohibited for pregnant women for any services that relate to the pregnancy or to any other
medical condition which may complicate pregnancy. In addition, such cost-sharing cannot be
• services furnished to individuals who are inpatients in a hospital, or are residing
in a long term care facility or in another medical institution if the individual is
required to spend most of their income for medical care;
• services furnished to individuals receiving hospice care;
• emergency services; and
• family planning services and supplies.
For most other beneficiaries and services, Medicaid programs are allowed to establish “nominal”
service related cost-sharing requirements. Nominal amounts are defined in regulations and are
generally between $0.50 and $3, depending on the cost of the service provided. For working
individuals with disabilities who qualify for Medicaid under eligibility pathways established by
the Balanced Budget Act of 1997 (BBA97) and the Ticket to Work and Work Incentives
Improvement Act of 1999 (TWWIIA), service related cost-sharing charges may be required that
exceed nominal amounts as long as they are set on a sliding scale based on income. The DRA (as
amended by P.L. 109-432) made some changes to these traditional service-related cost-sharing
rules; see below for more details.
Premiums and enrollment fees are prohibited under traditional Medicaid, except for the following
• For certain families transitioning from welfare to work, states may charge
premiums but only for the final six months of receiving transitional Medicaid
• For pregnant women and infants with family income that exceeds 150% of the
FPL, states are allowed to implement nominal premiums or enrollment fees
between $1 and $19 per month depending on family income.
• For individuals who qualify for Medicaid through the medically needy pathway,
states may implement a monthly fee as an alternative to meeting the financial
eligibility thresholds by deducting medical expenses from income (i.e., the
“spend down” method).
• For individuals who qualify under pathways for working individuals with
disabilities, states may charge premiums or enrollment fees. Those fees are not
capped when charged to individuals with a disability qualifying under the
provisions of BBA97 whose family income does not exceed 250% FPL.
Premiums charged to those who qualify under TWWIIA, whose income is
between 250% and 450% FPL, cannot exceed 7.5% of income. (When a state
covers both groups, the same cost-sharing rules must apply.)
As an alternative to traditional Medicaid, DRA (as modified by P.L. 109-432) provides states with
a new option for premiums and service-related cost-sharing. Under this option, states may impose
premiums and cost-sharing for any group of individuals for any type of service, through Medicaid
state plan amendments rather than through waiver authority, subject to specific restrictions.
In general, for individuals with income under 100% FPL:
• no premiums may be imposed,
• service-related cost-sharing cannot exceed nominal amounts, and
• the total aggregate amount of all cost-sharing cannot exceed 5% of monthly or
quarterly family income.
For individuals in families with income between 100 and 150% FPL:
• no premiums may be imposed,
• service-related cost-sharing cannot exceed 10% of the cost of the item or service
• the total aggregate amount of all cost-sharing cannot exceed 5% of monthly or
quarterly family income.
For individuals in families with income above 150% FPL:
• service-related cost-sharing cannot exceed 20% of the cost of the item or service
• the total aggregate amount of all cost-sharing cannot exceed 5% of monthly or
quarterly family income.
Certain groups (e.g., some children, pregnant women, individuals with special needs) are exempt
from paying premiums under this new DRA option. Also, certain groups and services (e.g.,
preventive care for children, emergency care, family planning services) are exempt from the
service-related cost-sharing provisions. Nominal cost-sharing amounts in regulations will be
indexed (increased) by medical inflation over time. Special rules apply to cost-sharing for non-
preferred prescription drugs, and for emergency room copayments for non-emergency care. DRA
also allows states to condition continuing Medicaid eligibility on the payment of premiums.
Providers may also deny care for failure to pay service-related cost-sharing.
Finally, DRA provides an opportunity to test an alternative to traditional Medicaid that covers
certain benefits combined with a new beneficiary cost-sharing structure, similar to health savings
accounts in the private sector. In general, the Secretary is required to establish a demonstration for
health opportunity accounts (HOAs) for which participants would have an HOA to pay for state-
specified services, and, after an annual deductible is met (set at 100%, but no more than 110%, of
the annual state contribution to the HOA), would also provide coverage for Medicaid items and
services otherwise available in the state. HOA contributions could be made by the state or by
other persons or entities, including charitable organizations as permitted under current law.
Including federal shares, the state contributions generally may not exceed $2,500 for each adult
and $1,000 for each child.
For the most part, states establish their own payment rates for Medicaid providers. Federal
regulations require that these rates be sufficient to enlist enough providers so that covered
benefits will be available to Medicaid beneficiaries at least to the same extent they are available
to the general population in the same geographic area.
Prior to DRA, providers could not deny care or services based on an individual’s ability to pay
Medicaid cost-sharing amounts. However, this requirement did not eliminate the liability of a
Medicaid beneficiary for payment of such amounts. In practice, some states have allowed
providers to refuse to provide services to Medicaid beneficiaries who have failed to make 12
copayments in the past, but most states do not have specific policies on this issue. As noted
above, DRA permits providers to deny care for failure to pay service-related cost-sharing.
Medicaid regulations place restrictions on how Medicaid cost-sharing may be used in determining
provider reimbursement. States are prohibited from increasing the payments they make to
providers to offset uncollected amounts for deductibles, co-insurance, co-payments or similar
charges that the provider has waived or are uncollectable (with the exception of providers 13
reimbursed by the state under Medicare reasonable cost reimbursement principles). In addition,
12 U.S. Department of Health and Human Services, Office of Inspector General, Medicaid Cost Sharing, OEI-03-91-
01800 (July 1993), available at http://oig.hhs.gov/oei/reports/oei-03-91-01800.pdf.
13 For providers reimbursed under such principles, the state may increase its payment to offset uncollected Medicaid
if a state contracts with certain managed care organizations that do not impose the state’s
Medicaid cost-sharing requirements on their Medicaid members, the state must calculate
payments to such organizations as if those cost-sharing amounts were collected.
Section 1115 of the Social Security Act provides the Secretary of HHS with broad authority to
conduct research and demonstration projects that further the goals of the Medicaid program (as
well as other programs, such as SCHIP). Some policy makers at both the federal and state level
view Section 1115 authority as a means to restructure Medicaid coverage, control costs, and
increase state flexibility in a variety of ways. To obtain such a waiver, a state must submit
proposals outlining the terms and conditions of its waiver for approval by the federal agency that
oversees and administers the Medicaid program—the Centers for Medicare and Medicaid
Under this authority, the Secretary may waive any Medicaid requirements contained in Section
and comparability and statewideness of benefits (as described above in the benefits section). For
example, states may obtain waivers that allow them to provide services to individuals who would
not otherwise meet Medicaid eligibility rules (e.g., childless adults without a disability), cover
non-Medicaid services, limit benefit packages for certain groups, adapt programs to the special
needs of particular geographic areas or groups of recipients, or accomplish a policy goal such as
to temporarily extend Medicaid in the aftermath of a disaster (as was done in New York City after
the September 11 terrorist attacks and in Gulf Coast states after Hurricane Katrina).
Approved waivers are deemed to be part of a state’s Medicaid plan, and thus, the federal share of
the costs for such waivers is determined by the FMAP formula (described earlier). Unlike 14
traditional Medicaid, waiver guidance specifies that the costs of 1115 waivers must be budget
neutral over the life of the program. To meet this requirement, estimated spending under the
waiver cannot exceed the estimated cost of the state’s existing Medicaid program under current
law requirements. For example, states may move certain existing Medicaid populations into
managed care arrangements and use the savings accrued from that action to finance coverage of
otherwise ineligible individuals under an approved waiver.
There are specific limits and restrictions on how a state may operate a waiver program. For
example, such waivers must not limit mandatory services for the mandatory pregnant women and
children eligibility groups. Another provision specifies restrictions on cost-sharing that may be
imposed under waivers.
cost-sharing amounts that are bad debts for such providers. See Medicare Payment Advisory Commission, Report to
the Congress: Selected Medicare Issues (June 2000), pp. 112-113, available at http://www.medpac.gov/publications/
14 Medicaid Program; Demonstration Proposals Pursuant to Section 1115(a) of the Social Security Act; Policies and
Procedures, 59 Federal Register 49249, September 27, 1994.
In FY2007, a total of 60.9 million people were enrolled in Medicaid at some time during the year.
Nearly one-half of these beneficiaries (29.2 million) were children, and 16.2 million were adults
in families with dependent children. There were also 9.5 million individuals with disabilities and 15
6.0 million people over the age of 65 enrolled in Medicaid that year. The latest published
estimate of total Medicaid spending available from CMS, including the costs of benefits and
program administration for the federal and state governments combined, was $316.7 billion for 16
Across the nation, traditional Medicaid covers a very diverse population, and compared to both
Medicare and employer-sponsored health care plans, offers the broadest array of medical care and
related services available in the United States today. Different groups under Medicaid have very
different service utilization patterns. These patterns result in large differences in the proportion of
total benefit expenditures by group. For example, for FY2005:
• While the majority of enrollees were children without disabilities (roughly 50%),
such children accounted for only about 17% of Medicaid’s total expenditures on
benefits. Most of the expenditures for such children are typically for primary and
acute care in the fee-for-service setting, and for managed care premiums.
• The next-largest beneficiary group—adults without disabilities in families with
dependent children—accounted for about 26% of all enrollees, but only about
12% of benefit expenditures. Like children, primary and acute fee-for-service
care and managed care premiums account for the majority of these costs.
• In contrast, individuals with disabilities represented about 15% of Medicaid
enrollees, but this group accounted for the largest share of Medicaid expenditures
for benefits (about 43%) of all groups. Most of the costs for persons with
disabilities are typically for institutional and non-institutional long-term care
services, primary and acute fee-for-service care, and outpatient prescription
• Finally, the elderly represented about 9% of Medicaid enrollees, but about 23%
of all expenditures for benefits. For the aged, the vast majority of costs are
usually for long-term care and outpatient prescription drugs.
While these statistics vary somewhat from year to year and state to state, the patterns described
above generally hold true.
Beginning in 2006, Medicaid beneficiaries who are also eligible for Medicare (i.e., the elderly
and certain individuals with disabilities) receive their outpatient prescription drugs through the
new Medicare prescription drug benefit (known as Medicare Part D) instead of through Medicaid.
While the long-term impact of the Part D program on Medicaid is unclear, Medicaid’s drug costs
for these populations have been considerably reduced. In fact, CY2006 was the first time in
15 Beneficiary statistics for FY2007 were taken from Table 11, 2007 CMS Statistics, U.S. Department of Health and
Human Services http://cms.hhs.gov/CapMarketUpdates/Downloads/2007CMSstat.pdf.
16 Total Medicaid spending for FY2006 was taken from Table 26, 2007 CMS Statistics, U.S. Department of Health and
Medicaid’s 43-year history that overall spending decreased, due in part to the new Medicare Part 17
D benefit and also to slower overall enrollment growth compared to prior years.
Medicaid’s role in providing access to health care for millions of Americans has been regularly
scrutinized by Congress, resulting in important legislative changes. For example, in the 1980s,
eligibility expansions for pregnant women and children were adopted. In the mid-1990s, welfare
reform restricted access to Medicaid for new immigrants, and removed the automatic link
between receipt of cash assistance and Medicaid for low-income families. In the 1990s, managed
care was expanded significantly as was coverage for workers with disabilities. Largely because of
concerns about questionable financing practices at the state level, on several occasions, Congress
has restricted supplemental Medicaid payments made to hospitals serving a disproportionate
share of Medicaid and uninsured patients (also called DSH payments). Similarly, in 2000,
Congress also required new, more restrictive upper payment limit rules for institutional providers
under Medicaid. Other significant changes, such as the recently enacted DRA, have also been
In February every year, the President submits a federal budget proposal to the Congress. In the
President’s FY2008 budget proposal, a number of changes to Medicaid were outlined. Some of
proposed changes would require legislative action by Congress, while others would be 18
implemented administratively (e.g., via regulatory changes, issuance of program guidance, etc.).
The Administration has issued a number of rules and program guidances, some of which have
been modified by Congress through subsequent legislation. For example, P.L. 109-432 prevents
the President’s provider tax proposal to limit the extent to which states may tax certain providers
to obtain additional federal Medicaid funds from being implemented via administrative action.
This law also sets the provider tax ceiling to 6% of revenues, except for the period of January 1,
2008-September 30, 2011, during which the rate is fixed at 5.5% (compared to 3% in the
A final rule would also restrict the use of certain intergovernmental transfers and certified public
expenditures to finance the non-federal share of Medicaid costs and would implement payment 19
caps for government providers. In addition, a proposed rule would end federal payments 20
associated with graduate medical education costs under the Medicaid. P.L. 110-28 delayed
implementation of these two rules for one year (until May 25, 2008). This law also requires the
use of tamper-resistant pads for Medicaid prescriptions, and provides a Medicaid Pharmacy Plus
waiver extension. Subsequently, P.L. 110-90 delayed implementation of the tamper-resistant pads
provision for six months (until March 31, 2008). This law also temporarily extended transitional
medical assistance for families who lose Medicaid eligibility due to increased earnings and the
Medicaid Qualifying Individuals (QI-1) program that pays the Medicare Part B premiums for
low-income Medicare beneficiaries through December 31, 2007, both of which were then further
17 A. Catlin, C. Cowan, M. Hartman, and S. Heffler, “National Health Spending in 2006: A Year of Changes for
Prescription Drugs, ” Health Affairs, Vol. 27, No. 1, pages 1 - 16, January/February 2008.
18 See CRS Report RL33866, Medicaid, SCHIP, and Health Insurance: FY2008 Budget Issues.
19 Medicaid Program; Cost Limit for Providers Operated by Units of Government and Provisions to Ensure the
Integrity of Federal-State Financial Partnership; 72 Federal Register 29748, May 29, 2007.
20 Medicaid Program; Graduate Medical Education, 72 Federal Register 28930, May 23, 2007.
extended through June, 2008 under P.L. 110-173. The Administration also issued rules to clarify 21
what constitutes federally-reimbursable rehabilitation services and to restrict federal payments 22
for school-based administration and transportation services under Medicaid. P.L. 110-173
delayed implementation of these two rules until June 30, 2008.
At the start of the 2nd session of the 110th Congress, it is difficult to predict what, if any, changes
to Medicaid may be in the offing. The upcoming budget resolution process may provide a
blueprint for such action.
CRS Report RL31413, Medicaid - Eligibility for the Aged and Disabled, by Julie Stone.
CRS Report RL33593, Medicaid Coverage for Long-Term Care: Eligibility, Asset Transfers, and
Estate Recovery, by Julie Stone, as modified by the Deficit Reduction Act of 2005.
CRS Report RL33019, Medicaid Eligibility for Adults and Children, by Jean Hearne.
CRS Report RL31698, Transitional Medical Assistance (TMA) Under Medicaid, by April Grady.
CRS Report RS22629, Medicaid Citizenship Documentation, by April Grady.
CRS Report RL33495, Integrating Medicare and Medicaid Services Through Managed Care, by
Julie Stone and Karen Tritz.
CRS Report RL32977, Dual Eligibles: A Review of Medicaid’s Role in Providing Services and
Assistance, by Karen Tritz.
CRS Report RL33268, Medicare Prescription Drug Benefit: An Overview of Implementation for
Dual Eligibles, by Jennifer O’Sullivan and Karen Tritz.
CRS Report RS21837, Implications of the Medicare Prescription Drug Benefit for Dual Eligibles
and State Medicaid Programs, by Karen Tritz.
CRS Report RL33919, Long-Term Care: Consumers, Providers, Payers, and Programs, by Carol
O’Shaughnessy et al.
CRS Report RL33357, Long-Term Care: Trends in Public and Private Spending, by Karen Tritz.
21 Medicaid Program; Coverage for Rehabilitative Services, 72 Federal Register 45201, August 13, 2007.
22 Medicaid Program; Elimination of Reimbursement under Medicaid for School Administration Expenditures and
Costs Related to Transportation of School-Age Children Between Home and School, 72 Federal Register 73635,
December 28, 2007.
CRS Report RL32219, Long-Term Care: Consumer-Directed Services Under Medicaid, by Karen
CRS Report RS22448, Medicaid's Home and Community-Based Services State Plan Option:
Section 6086 of the Deficit Reduction Act, by Cliff Binder.
CRS Report RL30726, Prescription Drug Coverage Under Medicaid, by Jean Hearne.
CRS Report RL32950, Medicaid: The Federal Medical Assistance Percentage (FMAP), by April
CRS Report 97-483, Medicaid Disproportionate Share Payments, by Jean Hearne.
CRS Report RL31021, Medicaid Upper Payment Limits and Intergovernmental Transfers:
Current Issues and Recent Regulatory and Legislative Action, by Elicia J. Herz.
CRS Report RS22101, State Medicaid Program Administration: A Brief Overview, by April
CRS Report RL32644, Medicaid Reimbursement Policy, by Mark Merlis.
CRS Report RS21054, Medicaid and SCHIP Section 1115 Research and Demonstration Waivers,
by Evelyne P. Baumrucker.
CRS Report 96-891, Health Insurance Coverage: Characteristics of the Insured and Uninsured
Populations in 2007, by Chris L. Peterson and April Grady.
CRS Report 97-975, Health Insurance Coverage of Children, 2007, by Chris L. Peterson and
CRS Report RL33866, Medicaid, SCHIP, and Health Insurance: FY2008 Budget Issues, by April
Grady et al.
CRS Report RL33251, Side-by-Side Comparison of Medicare, Medicaid, and SCHIP Provisions
in the Deficit Reduction Act of 2005, by Karen Tritz et al.
Elicia J. Herz
Specialist in Health Care Financing | <urn:uuid:7edb1b7f-cd9d-4e40-9d65-337a49f0704f> | {
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Welcome to 2020! We’re excited to start the new year with a short newsletter to keep you up to date on all things biodefense.
Alcatraz of Viruses
The Island of Riems in the Baltic Sea, once inhabited by the Nazis for biological weapon research, is now a heavily restricted site for German scientists to develop vaccines against viruses. The island hosts the Friedrich Loeffler Institute, Germany’s National Institute for Animal Health, which is a hub for the study of pathogens like rabies, African swine fever, and Ebola, and maintains the primary objective of preparing for future infectious disease outbreaks. The deputy head of the Friedrich Loeffler Institute, Franz Conraths, dubbed the island to be the “Alcatraz of Viruses.” Given its nickname-sake, the island is subject to stringent security protocols in order to safely contain all pathogenic samples and protect researchers and visitors. Since 2008, the German government has invested over $300 million in the Institute for infrastructural upgrades; there are now 89 laboratories and 163 stables for the research animals within the facility. Animal welfare is an important pillar for the Institute, hence their efforts to minimize animal research and minimizing the suffering of any tested animal. That said, the potential for their vaccine research to save millions of human and animal lives, protect the livelihoods of farmers, and alleviate global hunger, according to the head of the diagnostics department, outweighs the desire to eliminate animal testing.
NAS Workshop Proceedings: Improving International Resilience and Response to Chemical, Biological, Radiological, and Nuclear Events
In October 2017, the National Academies of Sciences, Engineering, and Medicine (NAS) coordinated an international, science-based workshop in Tokyo regarding resilience to Chemical, Biological, Radiological, and Nuclear (CBRN) events. The CBRN resilience workshop, in collaboration with Niigata University and the Japan National Research Institute for Earth Sciences and Disaster Resilience (NIED), aimed to “increase understanding of the communication, interoperability, and coordination issues that arise among various international stakeholders who are responsible for responding to CBRN event.” Partakers included experts and representatives from the government/public sector, private sector and industry, international organizations, academia, and NGOs. The event included a simulation as well as various plenaries covering topics such as lessons from past CBRN events and strengthening collaborative capacity. The workshop included a Resilience Exercise that used an explosion created by the collision of a large Liquid Natural Gas Tanker into a chemical depot on the shore near the Tokyo Motor Show as its base scenario. The explosion was compounded when the adjacent industrial complex ignited and debris oil was launched into Tokyo Bay. The flames and smoke of the chemical fire travelled inland toward Tokyo, home to about 14 million people, and smoke is further spreading toward the Tokyo Big Sight complex. Additional simulation components include the challenges of responding to a cascading CBRN event and the difficulty stimulating multi-party discussion for rapid response and international cooperation. Examples of some of the issues recognized during the workshop include delayed information sharing, incongruent definitions and terminologies across organizations, and the lack of defined roles and responsibilities for response.
Antimicrobial Resistance – A New Plan For A New Year?
Since the CDC announced their latest report and findings that each year 2.8 million Americans are infected with a drug-resistant organism, 35,000 of whom later die, we can safely say we’ve got a big problem. Antimicrobial resistance (AMR) isn’t new though and the problem has been boiling up for decades however it seems that we’re starting to truly take it seriously. From rivers to traveling patients, it’s hard to escape resistant microbes. New efforts to invigorate surveillance/reporting, as well as stewardship initiatives and even addressing the drying pipeline of antibiotics, are all tactics that have been employed. In fact, this latest piece is the one that is perhaps the most damning – big pharma has all but fled the antibiotic R&D field and those start-ups courageous enough to try, are increasingly falling upon financial ruin. “Antibiotic start-ups like Achaogen and Aradigm have gone belly up in recent months, pharmaceutical behemoths like Novartis and Allergan have abandoned the sector and many of the remaining American antibiotic companies are teetering toward insolvency.” Sadly, this is only adding to the issue as it paints a grim image for those considering any investment in antibiotic R&D. Many are calling for government intervention to help address the push-pull dynamics of antibiotic development – noting that “If this doesn’t get fixed in the next six to 12 months, the last of the Mohicans will go broke and investors won’t return to the market for another decade or two,” said Chen Yu, a health care venture capitalist who has invested in the field. Another component though is the heavy push on stewardship and prescribing practices, which often makes hospitals and providers weary against using new antimicrobials. Adding to this sentiment, Dr. Rick Bright, BARDA Director and Deputy Assistant Secretary for Preparedness and Response, wrote on the need for better diagnostics for resistant infections. Dr. Bright shares his own experiences with a simple-turned-complex infection that required several antibiotics. From delays in diagnostics/treatment, to being on six antibiotics, this is a great personal account of what it’s like to have a resistant infection and the inherent limits of existing diagnostics. “The gardening incident gave me personal insight into the many challenges that confront medical professionals and every patient fighting a resistant infection. I am more committed than ever to overcoming this challenge, to identifying solutions, and to partnering with private sector to get ahead of antimicrobial resistant infections and protect our nation’s health security. I hope more potential industry partners will look closely at the problem and join me by partnering through programs like CARB-X, BARDA DRIVe and other BARDA-supported initiatives.”
Happy Friday fellow health security friends! We will be on holiday next week, but rest assured, your favorite source for all things biodefense will be back right after the New Year. We hope you have a lovely holiday – remember, wash your hands!
Speeding Ahead- the Pace of Biotech Democratization
Gryphon Scientific researchers recent discussed in Nature the fast pace of biotech development and the challenges of establishing regulatory oversight and policies. They underscored that to set about such a course would require considerable dedication and resources – both in terms of financial and personnel. But what really does the investment into democratizing biotech look like? In this novel approach, researchers analyzed the exact pace of biotech and what those timeframes for democratization of novel techs look like. “Our assessment provides evidence that novel technologies currently can complete this transition in less than 4.5 years from their discovery and may do so in less than 3.5 years by the end of the next decade.” Investigating 22 biotechnologies, they highlighted milestones that point to the spread of such tech from lab to easily accessible. This is a highly enlightening article and includes data on reproduction of biotechnology trends and regression analysis that helps predict current and future trends in both the development and spread of these biotechnologies. “These results underpin the necessity for constant review of the security implications of the democratization of powerful biotechnologies, and the proactive development of policies, oversight and guidance systems, to ensure that they are leveraged responsibly by those outside the established scientific community.” You can find the article here.
GMU Class on Medical Countermeasures
Spring semester is fast approaching and if you’re a GMU biodefense student, don’t miss out on the chance to take BIOD766: Development of Vaccines and Therapeutics with Dr. Robert House. The course analyzes the process of developing new medical countermeasures against biological weapons and emerging infectious diseases such as SARS and pandemic influenza. Special attention is paid to the scientific, technical, political, regulatory, and economic obstacles to developing new vaccines and therapeutics. Examines the causes and potential solutions of public and private sector failures. Dr. House is an expert in the field of MCMs and worked for more than 11 years at DynPort Vaccine Company in Frederick, Md., where he held the positions of VP of Science and Technology, Chief Scientific Officer and President. During this time he developed extensive experience in winning and managing large USG-funded programs for developing medical countermeasures. He previously worked at Covance Laboratories in Madison, Wis. and IIT Research Institute in Chicago, Ill., where he managed highly successful programs in immunotoxicology assessment. Don’t miss out on your chance to take this engaging class with one of the top minds in the field.
Smallpox Virus Stocks
9 December 1979 was the historic day on which smallpox was confirmed as eradicated. A few months later, the World Health Assembly (WHA) officially declared that “the world and all its peoples have won freedom from smallpox.” Yet, four decades later, two nations maintain a stockpile of the variola virus that causes smallpox: The United States and the Russian Federation. Smallpox is an infectious and disfiguring viral disease that plagued humans for thousands of years, so its eradication is, arguably, one of the greatest achievements of our species and the greatest achievement of modern medicine. These specimens are stored under high-security conditions at the US Centers for Disease Control and Prevention (CDC) laboratory in Atlanta and at Russia’s State Research Centre of Virology and Biotechnology (Vector) in Novosibirsk, a town in Siberian. The decision to maintain a store of the virus is based on the completion of five fundamental goals goals: (1) further research in case of disease reemerge, (2) vaccine improvement, (3)creation of new treatments, (4) development of antivirals, and (5) improvements in diagnostics methods. According to guidance by the WHO, the stocks will be maintained until those goals are realized; however, disagreement exists on the status of their completion. Last year, the US Food and Drug Administration (FDA) approved a new drug for smallpox treatment; however, the WHO’s Advisory Committee on Variola Virus Research concluded that another antiviral treatment is needed. Arguments against keeping these stockpiles include the risk of variola being used as a weapon of bioterrorism and the risk that an accident could spur an accidental release of the pathogen. Additionally, there exist fears of undeclared stocks and the intentions with those potential samples. David Relman, professor of microbiology and immunology at Stanford University, asserts that the arguments in favor of maintaining the stockpiles outweighs those of destroying them. Another expert, Grant McFadden, director of the Biodesign Center for Immunotherapy, Vaccines, and Virotherapy at Arizona State University, who remains on the fence about retaining or destroying stockpiles, states “A great deal has been achieved on the original research goals, but the argument that more remains to be done is hard to refute…It is important to have these debates about whether mankind should deliberately eliminate feared pathogens, or study them.” As the debate continues, the future of the US and Russian variola virus stockpiles remains to be seen.
Tis the season of giving and here are some great books to buy as a gift for others or keep for yourself. Mark Kortepeter’s Inside the Hot Zone: A Soldier on the Front Lines of Biological Warfare is being released soon – “During Kortepeter’s seven and a half years in leadership at USAMRIID, the United States experienced some of the most serious threats in modern germ warfare, including the specter of biological weapons during the Iraq War, the anthrax letters sent after 9/11, and a little-known crisis involving a presumed botulism attack on the president of the United States. Inside the Hot Zone is a shocking, frightening eye-opener as Kortepeter describes in gripping detail how he and his USAMRIID colleagues navigated threats related to anthrax, botulism, smallpox, Lassa, and Ebola.” Nathan Myers’ Pandemics and Polarization – Implications of Partisan Budgeting for Responding to Public Health Emergencies is also out, “Partisan divisions over policy in the U.S. Congress and rising disease threats put millions of Americans at risk. The Zika public health emergency is used to illustrate the key functions of coordination, providing countermeasures, and engaging in disease surveillance which the government must engage in during such an emergency. The author looks at how the standoff over Zika funding negatively affected the government’s response within federal agencies, as well as at the state and local level. Also examined in the book are serious threats still on the horizon that are expected to require strong government action in the future. Possible policies to avoid future gridlock are considered.”
GMU Biodefense December Graduates
We’re so excited to celebrate the graduation of several students from the Schar School biodefense graduate and certificate programs. PhD graduates include Margaret D.M. Barber (Dissertation Title: Call of Duty? How Insurgent Organizations Choose to Provide Social Services) and Katherine V. Paris (Dissertation Title: An Assessment of the Risk of Misuse of Genome Editing Technologies). Congrats to Rubi Izquierdo on graduating with a MS in biodefense. We’re also happy to announce several students who completed their graduate certificates in Biodefense: Global Health Security and Terrorism and Homeland Security – Kelly Choic, Dianna Del Valle, Hiwot Yohannes, Joe Bob Merriman, and Gula Tang. Congrats! Read more about our biodefense graduate programs here.
Chinese Gangs Spreading African Swine Fever
African Swine Fever (ASF) is a viral infectious disease that is fatal for pigs, domestic and wild, and it is obliterating the Chinese pork industry, which is the largest in the world. To put the severity into perspective, certain estimates indicate that the number of pigs in China that have died from ASF exceeds the number of pigs in the entire US pork industry. Recent reports by PRC state media claim that Chinese criminals are intentionally propagating the ASF outbreak in an effort to drive down domestic pork prices so that these criminals can smuggle the meat and sell it as safe product. These criminal efforts range from spreading rumors about ASF to using drones that drop fomites into healthy farms. ASF-related losses plummeted China’s herd stock by over 40% to date, both as a result of infections and mass culling to contain the disease. Shortages in pork products, a cultural and nutritional protein staple in China, surged prices to over double the pre-outbreak prices. The price drops provided opportunities for the criminals to exploit the situation. Gang members traffic pigs or meat, regardless of its health and safety, to regions with especially high prices and sell it. The profit margin can reach 1,000 yuan (US$143) per pig for smugglers, and estimates fear a further rise of ¥65-75 per kilogram in the near future. Further price surges are expected as the Lunar New Year approaches, further incentivizing criminal meddling in China’s already suffering pork industry.
Investigations into Chinese Lab Outbreaks
A painful truth: biosafety failures do occur…it’s the name of the game when working with dangerous pathogens. While we have the proper practices and safety processes to avoid exposures, human mistakes do happen. Currently, two Chinese agriculture research facilities are assessing how over 100 staff and students were not only exposed, but ultimately infected with Brucella. One institute, the Lanzhou Veterinary Research Institute reported 96 asymptomatic infections. Despite their forthcomings about the numbers, the institute has not released where the source of the exposure occurred. In the Harbin Veterinary Research Institute, it was reported last week that 13 students were infected with the zoonotic disease. “The outbreak at the Lanzhou Veterinary Research Institute was first uncovered in November when some students in the institute‘s foot and mouth disease research unit noticed that large numbers of their lab mice were infertile, according to The Beijing News. The mice tested positive for Brucella, as did four students. The institute then tested 317 people, and found that 96 had been infected.” Lab-associated infections with Brucella do occur frequently, as it is the most commonly reported bacterial infection in labs and the ease of aerosol transmission facilitates such cases. Sadly, this is not the first exposure and it will likely not be last, but it does give insight into the risks of such work and a clear need for heightened biosafety measures. You can read more here.
Mobile Lab Created Out of Ebola Frustrations
Often the greatest developments are created out of sheer frustration during situations – vaccines, biocontainment units, etc. In this case, a lab-on-wheels was developed to help combat outbreaks in countries that have limited laboratory resources. “A prototype was recently displayed at the annual American Society of Tropical Medicine and Hygiene (ASTMH) conference. The company that developed it, Greensboro, North Carolina–based Integrum Scientific, says the first vehicle may soon be tested in Uganda. Integrum Scientific’s lab units can be configured to provide on-site diagnostic capabilities for known pathogens or experimental diagnostics. This configuration also supports standard care during an outbreak or attack, providing routine chemistry, hematology, and blood products.” Check out the mobile lab here.
A Deep-Dive Into Samoa’s Measles Outbreak
Recent estimates put the outbreak on the small island at over 5267 cases with 73 associated deaths. Vaccination rates had dropped dramatically over the years, and were recently estimated at 31% prior to response efforts. The herd immunity threshold for measles is 93-95%, which means that the low rates of vaccination in Samoa were essentially a ticking time bomb. Thankfully, response efforts have gotten the islands vaccination rate up to 93%, which will hopefully slow the deadly outbreak. Currently, the island continues to be in a state of emergency, which was first declared in mid-November. The government has barred children 0-14 years of age from attending public gatherings and requires children of that age to also show proof of immunization prior to boarding inter-island ferries. “The government has also closed its offices (with the exception of public utilities) so that civil servants can aid in the response efforts. Response efforts have continued to pour in to help halt this devastating outbreak. The population of Samoa is just over 196,000 individuals and when there are more than 5000 cases, more than 2.6% of the population have been infected.” Read more here.
When A Lab Explosion Ruins Your Day – Stories of Vector
A few months back, an explosion at the Russian laboratory complex known as the State Research Centre of Virology and Biotechnology (Vector), raised a red flag regarding the stockpiling of smallpox and realistically, biosafety/biosecurity. Not surprisingly, stories about where the explosion occurred, what was kept in that area, and all manner of horror movie-esque plots began to swirl. Gwyn Winfield though, has broken down the rumors, the realities, and the challenges of understanding what exactly happened when well, there’s not a lot of trust in Russian explanations. Gwyn takes care to highlight how fast speculation occurred though, and that while it may not have been easy to get answers right away, the theatrics of lab-to-bioweapon speculation does little good. Noting that the blast occurred on the 5th floor of building one – “The floor had been under repair since July, and since there was no research in progress there, and the area was not secure, there were no pathogens on that floor to be released.” As Winfield notes, the lack of information makes things challenging and while experts might make guesses, “the individuals that need to take the most lessons from this are exercise planners, globally but especially in Russia”. You can read the full article here.
The Microbiome and AMR
Microbiota bear effects on a variety of chronic diseases such as gastrointestinal, autoimmune, respiratory, neurological, and cardiovascular conditions; however, the microbiome also plays a role with infectious diseases. The growing body of research on the importance of the microbiome to human health links natural flora and the immune system, which are in a largely symbiotic relationship. More specifically, a healthy microbiome aids in the induction, training, and function of the immune system and, in return, the immune system maintains a happy balance between natural flora and the host human. Unfortunately, that relationship is under great threat as the persistent overuse of antibiotics destroys not only the invasive bacteria but also the healthy bacteria that help maintain immune function. Antimicrobial resistance (AMR) is ability of microbes – bacteria, viruses, fungi – to circumvent the mediating effects of antibiotic, antiviral, and antifungal therapeutics. The overuse of antibiotics enables strong, resistant bacteria to survive in the host, so your gut ultimately populates with mostly resistant bacteria, even bacteria resistant to multiple drugs. Disruptions to the microbiome by antibiotic use adds to the spread and strength of antimicrobial resistance in harmful microbes. Our overreliance on the prescription of antibiotics to alleviate bacterial infections, even minor ones that the immune system may be able to overcome, and a lack of medication compliance resulting in misuse are chipping away at the clinical efficacy of these drugs. This is of considerable concern as microbes become cleverer and less susceptible to multiple medications, resulting in infections that are less and less treatable. According to the CDC, there are over 2.8 million antibiotic-resistant infections in the US each year and more than 35,000 people die from those infections. The critical task at hand is to develop alternative therapeutics that can treat infections while, at least, not contributing to further microbial resistance. As a mediator for colonization resistance and a symbiote of the immune system, the microbiome possesses potential as a therapeutic gateway to subvert resistance.
Biodosimetry Biomarkers and Serum Proteomic Signatures – GMU Biodefense Alum Tackles It All
GMU Biodefense doctoral student Mary Sproull is our resident guru on radiation – she’s a biologist in the Radiation Oncology Branch of the National Cancer Institute at NIH. Here are just two more reasons why Sproull is the go-to person for things like biodosimetry: she has two new publications that you’ll want to check out. The first, Comparisons of Proteomic Biodosimetry Biomarkets Across Five Different Murine Strains (try saying that five times fast) “seeks to compare the expression levels of five previously established proteomic biodosimetry biomarkers of radiation exposure, i.e., Flt3 ligand (FL), matrix metalloproteinase 9 (MMP9), serum amyloid A (SAA), pentraxin 3 (PTX3) and fibrinogen (FGB), across multiple murine strains and to test a multivariate dose prediction model based on a single C57BL6 strain against other murine strains.” Make sure to read this study as it discusses why these strain specific differences exist between expression levels. In the second article A Serum Proteomic Signature Predicting Survival in Patients with Glioblastoma, Sproull and the research team discuss this common brain tumor and how developing adequate biomarkers can help drive stronger patient outcomes. “Analysis of potentially relevant gene targets using The Cancer Genome Atlas database was done using the Glioblastoma Bio Discovery Portal (GBM-BioDP). A ten-biomarker subgroup of clinically relevant molecules was selected using a functional grouping analysis of the 40 plex genes with two genes selected from each group on the basis of degree of variance, lack of co-linearity with other biomarkers and clinical interest. A Multivariate Cox proportional hazard approach was used to analyze the relationship between overall survival (OS), gene expression, and resection status as covariates.”
Advancements in biotechnology pose potentials and perils as such technology becomes easier to access and use by a wide array of bio-users, not just formally trained scientists at professional laboratories. Gene editing, the alteration of an organism’s DNA, is one such biotechnology. A number of research and government entities are working diligently to maximize the potential benefits of gene editing while simultaneously minimizing its perils. Two such entities are the National Academies of Sciences, Engineering, and Medicine and the Defense Advanced Research Projects Agency (DARPA). The former is concerned with perils of synthetic biology while the latter is trying to unlock its potential. The National Academies of Sciences, Engineering, and Medicine just released Strategies for Identifying and Addressing Vulnerabilities Posed by Synthetic Biology: Proceedings of a Workshop in Brief, which summarizes the key discussions in an October 2018 meeting of experts and policymakers following a report for the DOD, Biodefense in the Age of Synthetic Biology. The meeting’s purpose was to assemble federal personnel and the committee for the DOD report to consider the implications for actions DOD might take to quell potential misuse of synthetic biology capabilities. The committee evaluated 12 capabilities associated with (1) the synthesis and modification of pathogens; (2) production of chemicals, biochemicals, and toxins; and (3) modulation of human physiology. Each of the three capability areas were assigned relative levels of concern in terms of the usability of a technology, its usability as a weapon, its requirements of actors, and the potential for its mitigation. Additional workshop discussions included the potential of delivery mechanisms to serve as a barrier to the misuse of synthetic biology to produce weapons, the possibility to use synthetic biology to modify human physiology in new ways, and opportunities in computational biology to alleviate fears about synthetic biology capabilities through the prevention, detection, and attribution of its misuse. DARPA’s latest biotechnology project is the “Detect It with Gene Editing Technologies” program, more lovingly called DIGET. The primary objective of DIGET is “to provide comprehensive, specific, and trusted information about health threats to medical decision-makers within minutes, even in far-flung regions of the globe, to prevent the spread of disease, enable timely deployment of countermeasures, and improve the standard of care after diagnosis.” The DIGET dream deliverables are two devices: (1) a handheld and disposable point-of-need tool that simultaneously screens 10 or more pathogens or host biomarkers and (2) a multiplexed detection platform that simultaneously screens at least 1,000 clinical and environmental samples. DIGET seeks to incorporate gene editors and detectors biosurveillance as well as swift point-of-need diagnostics for endemic, emerging, and engineered pathogens. DARPA is hosting a Proposer’s Day meeting about the DIGET program on 11 December 2019.
Biological Threats to U.S. National Security – Subcommittee on Emerging Threats and Capabilities
On Wednesday, Dr. Thomas V. Inglesby, Dr. Tara J. O’Toole, and Dr. Julie Gerberding gave testimony to this subcommittee within the U.S. Senate Committee on Armed Services. During the testimony, Dr. Inglesby “noted the growing threat of biological events that can emerge from nature, deliberate attack, or accidental release and reviewed current US government efforts in this arena. He presented recommendations to improve the government’s response to and preparedness for a major biological event.” You can read his full testimony here.
Revisiting the Biological Weapons Convention Protocol Lynn Klotz recently wrote on the gaps within the BWC in relation to compliance monitoring. Despite efforts to change this in the past, those pushing for a protocol to randomly select site visits as means to do quality checks, have been disappointed over the years as administrations cite that such additions would not truly verify or provide greater security. As Klotz underscores – this sentiment fundamentally misses the goal of the protocol…which is transparency. “But recent events serve to underscore that a protocol to the convention to address the treaty’s shortcomings is an idea that should be revisited. Unfounded Russian allegations about biological weapons development in former Soviet countries are threatening the effectiveness of the convention. This concern along with strong arguments for the high importance of transparency in international treaties calls for revisiting the protocol, which had provisions for both transparency and for dealing with allegations like Russia’s.” Citing the 2019 meeting in which Russia alleged that several former Soviet states had active bioweapons programs, distrust soon grew and disruption rippled throughout the BWC. Klotz emphasizes that this exact situation is a prime reason why a protocol should be revisited – to help build confidence through increasing transparency. Not a free-for-all, but rather through managed-access rules, such as random visits by inspection teams would help verify the absence of bioweapons. Klotz takes care to discuss why protocol efforts were abandoned in 2001 and the role of transparency in multilateral arms control regimes, which you can read more about here.
GMU Hosts Health Security Career Panel
Last week, adjunct professor Ashley Grant, a lead biotechnologist at the MITRE Corporation, held a career panel at the Schar School of Policy and Government at George Mason University as part of her course on Global Health Security Policy. To highlight the different paths that graduate students in the Biodefense program can take in the health security field, Professor Grant convened a diverse panel of health security practitioners to discuss their jobs and the skills they have needed to succeed. The panel included professionals from a variety of different backgrounds ranging from local health providers to Federal employees. Students in the Schar School’s Biodefense Graduate Program were able to ask the panelists about the challenges of moving from a technical career path into science policy and opportunities for internships. The panel included Stuart Evenhaugen of the Assistant Secretary for Preparedness and Response (ASPR)’s Strategy Division in the Department of Health and Human Services (HHS); Syra Madad, the Senior Director of System-Wide Special Pathogens Program at NYC Health + Hospitals; Halley Smith, a program lead with the U.S. Department of State Cooperative Threat Reduction Program, on detail from Sandia National Laboratories Global Chemical and Biological Security Program; Sapana Vora, the Deputy Team Chief for the U.S. Department of State’s Biosecurity Engagement Program (BEP) and Iraq Program in the Office of Cooperative Threat Reduction (CTR); and Malaya Fletcher, a Lead Scientist at Booz Allen Hamilton in Washington, DC. The panel also included LTC Justin Hurt a CBRN/WMD Organizational Integration Officer in the Army G-3/5/7 Office who is currently enrolled in the Biodefense PhD program. As biodefense graduate student Michael Krug noted, “The panel was immensely valuable in providing detailed insights and experiences into each of the panelist’s unique career paths. Emphasizing the demand for multi-disciplined approaches, as well as active communication to answer the many health security questions facing the world.”
A Little Bit of Plague and A Whole Lot of Panic
Plague – a word that still sparks fear after hundreds of years. Two cases were recently reported in China’s Inner Mongolia and of course, it involved a hunter and butchering/eating a wild animal. Diagnosed on November 5th, there were two additional cases reported in Beijing but from the Inner Mongolia area. “In both cases, the two patients from Inner Mongolia were quarantined at a facility in the capital after being diagnosed with pneumonic plague, health authorities said at the time. The Inner Mongolia health commission said it found no evidence so far to link the most recent case to the earlier two cases in Beijing.” As many have pointed out, the fear around this news has been more damaging to response efforts. Pneumonic plague is not as highly contagious as many news outlets have let on – only requiring Droplet + Standard isolation precautions and plague is easily treatable with antibiotics or prophylaxis.
Should We Be Celebrating CRISPR’s Anniversary?
It’s not many times an expert and innovator writes an article entitled “CRISPR’s unwanted anniversary” about a tech they were instrumental in developing. Dr. Jennifer Doudna recently wrote on those moments that can make or break a disruptive technology and in the case of CRISPR, it was last year, when Hong Kong-based scientist He Jiankui started the CRISPR baby drama. This was a pivotal moment in not only biotech, but also genome editing and its future. As Doudna notes, it’s comforting that scientists around the world reacted with conversations about the need for safeguards and transparency as CRISPR technology grows. In the face of this anniversary though, what has been done? Are there consequences for going against widely accepted norms? Doudna leaves us with the notion that “The ‘CRISPR babies’ saga should motivate active discussion and debate about human germline editing. With a new such study under consideration in Russia, appropriate regulation is urgently needed. Consequences for defying established restrictions should include, at a minimum, loss of funding and publication privileges. Ensuring responsible use of genome editing will enable CRISPR technology to improve the well-being of millions of people and fulfill its revolutionary potential.”
Hot Spots and Inadequate Monitoring for Bioterrorism – An American Story
Law professor Ana Santos Rutschman of Saint Louis University recently wrote on the usual and unusual biological suspects and how organisms like Salmonella can easily be overlooked as cases of bioterrorism (case in point the 1984 Oregon attack). Rutschman delves into preparedness efforts, like BioWatch, and how “there is a profound lack of coordination between federal agencies and local communities. When asked about what happens after notifications of a possible bioterrorism attack, Dr. Asha George, executive director of the Bipartisan Commission on Biodefense, answered: “They go off but nobody knows what to do.”
Stories You May Have Missed:
Ongoing Outbreaks Trigger Laws to Limit Vaccine Exemptions – in the middle of measles outbreaks and pertussis cases occurring frequently, there is a desperate need for reducing vaccine exemptions that protect the anti-vaccine instead of the public’s health. “In 2018, the same research group published a study showing that, despite rising numbers of proposed antivaccine laws, pro-vaccine bills were more likely to become law. For the current study, the team looked at how health data might affect laws. The new findings come following a surge of measles activity in the United States this year, mostly fueled by a few large outbreaks that nearly cost the nation the measles elimination status that it achieved in 2000.”
Acinetobacter Baumannii Risk Factors– “After assessing 290 isolates, they found that 169 were endemic (96 of REP-1) and the most common site for isolation was the respiratory tract. In total, 109 patients (37%) had only Acinetobacter baumannii isolated, while some had up to 5 other organisms also identified. In those colonized, 69 were REP-1, and 64 with REP-2-5, the research team found that for those patients with REP-1, there was a 70% increase in carriage per increase in Schmid score (statistically significant), and a 50% increase in REP-2-5. Interestingly, prior colonization, longer lengths of stay, and immunosuppression did now have a statistically significant relationship with Acinetobacter baumannii colonization. “
We’re back and we’ve got quite a packed newsletter for you, so grab a beverage and get ready for the warm fuzzies of biodefense news.
Failing to PREDICT the Next Pandemic
A few weeks back, it was announced that funding for the PREDICT program would cease after $207 million was sunk into the initiative. GMU biodefense MS student Michael Krug has provided a deep-dive into what PREDICT worked towards, the debated success, and what its cancellation means. “However, even with the billions of dollars spent on ensuring a robust global biosurveillance network, it remains unknown if this network can predict what the next disease will be or where the next outbreak will occur.” Read more here.
An Antibiotic Eclipse – Scenario or Future?
GMU Biodefense doctoral alum and infection preventionist Saskia Popescu discusses the looming threat of antibiotic resistance and what a future with little to no treatment options would look like. From dwindling options for secondary infections related to influenza to declining surgeries, a future without antibiotics is dim. Popescu highlights what this looks like and how we’re quickly approaching it through both the drying antibiotic pipeline, but also limited surveillance, and challenges in changing both stewardship and infection control measures. The existential threat of antimicrobial resistance is very real and Popescu provides a scenario portraying the economic and human costs that antimicrobial resistance could impose on society 30 years from now, if it is not addressed soon. You can read the full article here. This is an especially relevant topic as the CDC just released new data, finding that annually, 2.8 million resistant infections and 35,000 related deaths occur in the United States. The CDC report notes that “However, deaths decreased by 18 percent since the 2013 report. This suggests that prevention efforts in hospitals are working. Yet the number of people facing antibiotic resistance in the United States is still too high.”
Event Recap – People, Pigs, Plants, and Planetary Pandemic Possibilities
If you happened to miss this November 5th event, no worries – GMU biodefense doctoral student Stevie Kiesel has provided an in-depth summary of the panel and discussions. Kiesel notes that the panel had insightful discussions on the need to understand local context and empower people and local public health communities. Local context is important for combating misinformation and getting a more accurate understanding of conditions on the ground. For example, the public health community must understand why a country may be disincentivized to report a disease outbreak in its early stages, when it is more easily controlled. Authoritarian governments who maintain tight messaging control may not want to admit to an active outbreak, or the economic drawbacks of announcing an outbreak may be so severe that leaders try to hide what’s going on. You can read more here.
Pandemic Policy: Time To Take A Page Out Of The Arms Control Book
Rebecca Katz is holding back no punches in her latest article on the broken policy approaches we have to international outbreak accountability, and frankly, it’s long overdue. Full disclosure, the first line is one of my favorites – “Last month, the World Health Organization (WHO) was reduced to the equivalent of playground pleading: ‘But you promised!’” Katz highlights that in the face of countries failing to meet their obligations within the International Health Regulations (IHR), the WHO has little recourse to act and frankly, the path to accountability isn’t particularly clear. Ultimately, this problem could be solved though, if instead of rewriting the IHR, we modeled such treaties in the image of the Biological Weapons Convention (BWC) to help convene regular review conferences, discuss developments, and establish a regulatory response that could help drive accountability. “As the former US representative to the BWC, Charles Flowerree, wrote, treaties ‘cannot be left simply to fend for themselves’.”
The 5th Annual Pandemic Policy Summit at Texas A&M University
GMU Biodefense doctoral student Rachel-Paige Casey has provided an in-depth review of this important summit earlier this week. The objective of each Summit is to convene researchers, medical professionals, practitioners, private sector experts, NGO representatives, and political leaders to examine issues in pandemic preparedness and response, health security, and biodefense. The foci of this year’s Summit were the promises and perils of technology; BARDA leadership through its history and today; the effect of the anti-vaccine movement on pandemic preparedness and response; and ongoing outbreaks. Key discussions included the inadequacy of biopreparedness, worries regarding emerging biotechnologies, the modern vaccine hesitancy movement in the US, and the leadership and future of BARDA. You can read more about the summit here.
Catalyst- A Collaborate Biosecurity Summit
Don’t miss this February 22, 2020 event in San Francisco. “Catalyst will be a day of collaborative problem-solving for a broad range of people invested in the future of biotechnology, including synthetic biologists, policymakers, academics, and biohackers. We aim to catalyze a community of forward-looking individuals who will work together to engineer a future enhanced by biology and not endangered by it.The summit is free to attend for everyone accepted, and the application only takes a few minutes. We expect participants to come from diverse backgrounds, and welcome applicants who do not work professionally in biosecurity or biotechnology, who are early in their careers, and who are skeptical of how biosecurity discussions are typically framed. You can apply to attend here.
Firehosing – the Antivaxxer Strategy for the Transmission of Misinformation
Researchers Christopher Paul and Miriam Matthews of Rand introduced this idea in 2016 and it’s proving to be pretty accurate for how anti-vaccine advocates are pushing out their opinions. Lucky Tran of The Guardian recently made the link between antivaxxers and the strategy of firehosing, which entails a massive flow of disinformation to overwhelm the audience. Just like it sounds, firehosing involves pushing out as many lies as frequently as possible to overwhelm people with information and making it nearly impossible for a logical response to combat that much disinformation. Tran stumbled across this application by seeing it on a television show with anti-vaccine influencers like Jay Gordon and he employed this strategy. “Anti-vax influencers such as Jay Gordon and Andrew Wakefield can keep repeating disproved claims – and in the case of Wakefield, doing so despite having had his medical license revoked – because their lying effectively debases reality and gains them followers and fame in the process.” The Rand study can be found here, which originally discussed firehosing in the context of Russian propaganda – as it has two “distinctive features: high numbers of channels and messages and a shameless willingness to disseminate partial truths or outright fictions. In the words of one observer, ‘[N]ew Russian propaganda entertains, confuses and overwhelms the audience’.” In the face of this relatively new tactic, there is a desperate need to remove false anti-vaccine content from social media and websites, and to put more pressure on media and news platforms to not provide support for such guests/conversations.
Crowd-Control Weapons – Are They Really Non-Lethal?
The term “non-lethal” or “less-than-lethal” gets thrown around a lot when it comes to crowd/riot-control weapons but just how non-lethal are these methods if they’re overused? Physicians for Human Rights (PHR) dug into this very issue because frankly, the use of these weapons is quite common and if they’re not used properly, or with the proper training, they can be devastating. Routine use or misuse of agents like tear gas can be deadly. The PHR conducted several investigations into their use by governments in Bahrain, Georgia, Kashmir, Turkey, and other countries and ultimately, what they found was some pretty startling misuse that can result in long-term health outcomes or even death. They put together a report and factsheets on specific “non-lethals” like acoustic weapons, rubber bullets, stun grenades, tear gas, and even water cannons. Within each factsheet, you can read about the history, how they work, device types, health effects, legality of use, and considerations and policy recommendations. Within the report, they reviewed usage of the weapons including things like people who suffered injuries or even death. As protests occur in China, the use of sonic weapons for crowd control are a very real reminder of the fine line we walk when using “non-lethals”.
Ebola Outbreak Updates and Vaccine Approval
This week, the European Medicines Agency (EMA) approved the V920 vaccine for Ebola Virus Disease (EVD) and it is already being administered in the Democratic Republic of the Congo. The ongoing EVD outbreak in the Democratic Republic of the Congo (DRC) started in August 2018 and has now exceeded 3,000 cases and 2,000 deaths. Since the 2014-15 outbreak in West Africa, advances in medical research produced new vaccination and therapeutic options. The V920 vaccine, developed and produced by Merck, was tested during the outbreak and showed a 97% efficacy rate and protects against the Zaire species, which is the strain responsible for the current outbreak. Johnson-and-Johnson is also beginning trials for its investigational EVD vaccine. Johnson-and-Johnson’s vaccine requires two doses, a barrier for patient compliance, and does not contain any antigens from the Ebola Bundibugyo species of the virus. Dr. Dan Lucey, professor of medicine at Georgetown University, wrote an editorial in the British Medical Journal about the new treatments for EVD. Dr. Lucey’s article reviews the findings and shortcomings of the four-arm randomized controlled trial (RCT) evaluating the efficacy of four potential EVD treatments: ZMapp, remdesivir, mAb114, and REGN-EB3. The RCT was discontinued when a strict statistical threshold for decreased mortality was reached REGN-EB3, a monoclonal antibody drug. The punchline for the efficacy of REGN-EB3 is that it is efficacious if administered during the early stage of the disease but not as the diseases progresses. Lucey recommends continuing research on EVD treatments that are successful at later stages of the diseases. Last but not least, the article applauds the rigor and difficulty of this randomized-controlled trial given it was conducted during the outbreak, making it a precedent-setting achievement.
GMU Biodefense Alum Changing the Face of Aerospace Physiology
We’re excited to share some of the achievements of one of GMU’s biodefense alum – Nereyda Sevilla, a May 2017 doctoral graduate in Biodefense, who is a civilian aerospace physiologist for the Defense Health Agency working as Acting Director of the Military Health System Clinical Investigations Program. She was also recently awarded the Air Force Medical Service Biomedical Specialist Civilian of the Year Award and the Air Force Meritorious Service Medal. If you’d like to see more of Nereyda’s hard work in action, check out the article she and the Spatiotemporal Epidemiologic Modeler (STEM) Team published in the Sept 2019 edition of Health Security, “STEM: An Open Source Tool for Disease Modeling.” (Volume 17, Number 4, 2019).
Phase 3 Trial of Modified Vaccinia Ankara Against Smallpox
In the last Pandora Report, we discussed the FDA approval of the new smallpox vaccine JYNNEOS, that was tested by USAMRIID. The vaccine, developed by biotechnology company Bavarian Nordic, will enter the market under the name JYNNEOS. You can read about the Phase 3 efficacy trial of JYNNEOS (a modified vaccinia Ankara, MVA) as a possible vaccine against smallpox in the latest New England Journal of Medicine. GMU Biodefense professor and director of the graduate program, Dr. Gregory Koblentz noted that one of the key findings of this Phase 3 efficacy trial is that even though the FDA has approved a two-dose regimen for MVA (since it is a non-replicating vaccine that uses an ), a single dose of MVA provided the same level of protection as a single dose of the replicating vaccinia vaccine ACAM 2000. “At day 14, the geometric mean titer of neutralizing antibodies induced by a single MVA vaccination (16.2) was equal to that induced by ACAM2000 (16.2), and the percentages of participants with seroconversion were similar (90.8% and 91.8%, respectively).” An additional advantage of MVA over ACAM 2000 is that the former can be administered by a subcutaneous injection while the latter requires scarification through the use of a bifurcated needle. The article concludes that “No safety concerns associated with the MVA vaccine were identified. Immune responses and attenuation of the major cutaneous reaction suggest that this MVA vaccine protected against variola infection.”
Key Global Health Positions – A Who’s Who in the U.S. Government
Have you ever wondered who helps support global health within the U.S. government? The Kaiser Family Foundation (KFF) has created a substantial list on not only the positions, but also who (if anyone) is occupying them. From the Department of Health and Human Services to the Department of the Treasury, you’ll want to utilize this list to not only realize the scope of global health efforts within the USG, but also who you might need to get in touch with.
Stories You May Have Missed:
African Swine Fever Continues to Spread in Asia – Unfortunately, this outbreak isn’t showing signs of letting up… “The update shows new outbreaks in Vietnam, Cambodia, Laos, the Philippines, South Korea and on the Russian side of the Chinese border reported during the first week of November. Meanwhile, formal confirmation is awaited of ASF outbreaks in Indonesia. The FAO reports that more than 4,500 pigs are said to have died in 11 regencies/cities in North Sumatra. Dead pigs were also found in a river. FAO is liaising with the Indonesian authorities to ‘confirm the cause and explore needs’.”
What’s New with Novichoks?
Gregory Koblentz, Director of the Biodefense Program, and Stefano Costanzi, a chemistry professor at American University, have published an article in The Nonproliferation Review about recent efforts to add Novichok nerve agents to the Chemical Weapons Convention’s list of Schedule 1 chemicals which are subject to the highest level of verification. Novichok become a household word after Russian agents used this new type of chemical weapon in the attempted assassination of Sergei and Julia Skripal in Salisbury, United Kingdom in March 2018, but there is still a good deal of public confusion about this family of nerve agents. In “Controlling Novichoks After Salisbury: Revising the Chemical Weapons Convention Schedules,” Koblentz and Costanzi clarify the identity of the nerve agent used in the Salisbury incident and evaluate two proposals regarding Novichoks that will be considered by the Organization for the Prohibition of Chemical Weapons (OPCW) in November. This will be the first time the CWC’s Schedules have been revised since the treaty was opened for signature in 1993.
Bipartisan Commission on Biodefense Cyberbio Convergence Recap & The Germy Paradox
GMU Biodefense graduate student Georgia Ray has provided us with a detailed summary of this Commission event. We’d also like to show off her blog, Eukaryote Writes, which just so happens to delve into bioweapons and how close we’ve gotten to actual use. Georgia notes “I’ve heard a lot about ‘nuclear close calls.’ Stanislav Petrov was, at one point, one human and one uncomfortable decision away from initiating an all-out nuclear exchange between the US and the USSR. Then that happened several dozen more times. As described in Part 1, there were quite a few large state biological weapons programs after WWII. Was a similar situation unfolding there, behind the scenes like the nuclear near-misses?” In Georgia’s in-depth review of the Cyberbio Convergence event, she notes that “Tom Dashchle described biosecurity as a cause area with ‘broad support but few champions’ and agreed with the importance of creating career paths and pipelines into the field. (Great news for optimistic current Biodefense program students like myself.) The panel also agreed on the importance of education starting earlier, through STEM education and basic numeracy skills.”
1918/1919 Pandemic Museum Exhibit
Check out the Mutter Museum for a permanent exhibit on the influenza pandemic that hit Philadelphia, PA. “On Sept. 28, 1918, in the waning days of World War I, over 200,000 people gathered along Broad Street in Philadelphia for a parade meant to raise funds for the war effort. Among the patriotic throngs cheering for troops and floats was an invisible threat, which would be more dangerous to soldiers and civilians than any foreign enemy: the influenza virus. Officials went ahead with the parade despite the discouragement of the city health department about the ever-spreading virus. Within 72 hours of the parade, all the hospital beds in Philadelphia were full of flu patients. Within six weeks, more than 12,000 people died — a death every five minutes — and 20,000 had died within six months.” Named “Spit Spreads Death”, the exhibit opens on October 17th and will include interactive maps, artifacts, and images. Personal stories and accounts from historians brings this exhibit to life and drives home the message.
The Story of Technology
GMU biodefense doctoral alum Dr. Daniel Gerstein has the latest book for you to add to the reading list – The Story of Technology. “Technology–always a key driver of historical change–is transforming society as never before and at a far more rapid pace. This book takes the reader on a journey into what the author identifies as the central organizing construct for the future of civilization, the continued proliferation of technology. And he challenges us to consider how to think about technology to ensure that we humans, and not the products of our invention, remain in control of our destinies? In this informative and insightful examination, Dr. Daniel M. Gerstein–who brings vast operational, research, and academic experience to the subject–proposes a method for gaining a better understanding of how technology is likely to evolve in the future. He identifies the attributes that a future successful technology will seek to emulate and the pitfalls that a technology developer should try to avoid. The aim is to bring greater clarity to the impact of technology on individuals and society.” As General David Petraeus (former commander of the troop surge in Iraq, US Central Command, and Coalition Forces in Afghanistan, and former director of the CIA), noted “Gerstein brings a unique perspective to The Story of Technology, as both a national security expert and a technologist. He examines, in a compelling fashion, the inextricable link between humans and technological advancement—and specifically how the latter has granted America security, economic, and societal advantages. But he also cautions, rightly, that many of the foundations on which these advantages have been built are eroding, threatening our interests and perhaps even redefining what it means to be human. This book is a must-read for our national leaders, technology specialists, and general readers alike.”
Starting with the focus on food safety that we saw within the FDA Food Safety Modernization Act (FSMA), the FDA is launching a new tool to help ensure food safety and security occurs in the U.S. “The new Food Safety Dashboard launched today is part of FDA-TRACK, which is one tool the FDA uses to monitor certain FDA programs through key performance measures and projects, and regularly updates to ensure transparency to the public. While we expect that it will take several years to establish trends in the data, the initial data show that since 2016, the majority of companies inspected are in compliance with the new requirements of the preventive control rules. Additional FDA data also show that overall, industry has improved the time it takes to move from identifying a recall event to initiating a voluntary recall, from an average of four days in 2016 to approximately two days in 2019. In fact, comparing the FSMA data with our recall data shows the bigger picture, demonstrating the effectiveness of preventive measures as food recalls once again have reached a five-year low.”
Ebola Outbreak Update
As cases continue to be identified, albeit slowly (total is now 3,198), much focus has been on community resistance as new research is being released. Researchers “explored community resistance using focus group discussions and assessed the prevalence of resistant views using standardized questionnaires. Despite being generally cooperative and appreciative of the EVD response (led by the government of DRC with support from the international community), focus group participants provided eyewitness accounts of aggressive resistance to control efforts, consistent with recent media reports. Mistrust of EVD response teams was fueled by perceived inadequacies of the response effort (“herd medicine”), suspicion of mercenary motives, and violation of cultural burial mores (“makeshift plastic morgue”). Survey questionnaires found that the majority of respondents had compliant attitudes with respect to EVD control. Nonetheless, 78/630 (12%) respondents believed that EVD was fabricated and did not exist in the area, 482/630 (72%) were dissatisfied with or mistrustful of the EVD response, and 60/630 (9%) sympathized with perpetrators of overt hostility. Furthermore, 102/630 (15%) expressed non-compliant intentions in the case of EVD illness or death in a family member, including hiding from the health authorities, touching the body, or refusing to welcome an official burial team.” GMU Biodefense doctoral alum Saskia Popescu notes that “This research shed light on many of the suspected social dynamics that challenge response efforts but also delved into detail of what is needed to refine education and community outreach to truly be effective.” The U.K. has issued Tanzania travel warnings over a probable Ebola death. “The U.K. advised travelers to Tanzania to be aware of a ‘probable’ Ebola-related death in the East African nation, its Foreign and Commonwealth Office said Tuesday in a statement on its website. About 75,000 British nationals visit Tanzania every year, it said.”
“James F. McDonnell, a presidential appointee who over the last two years downsized the Department of Homeland Security’s efforts to prevent terrorism involving weapons of mass destruction, has agreed to resign. McDonnell’s resignation, department sources said, comes at the request of acting Homeland Security Secretary Kevin McAleenan and would become effective at noon on Thursday, according to an email McDonnell sent his staff at 12:57 p.m. EDT on Wednesday. McDonnell’s seven-sentence memo did not provide a reason for his resignation, saying only it was ‘time for a new leadership team to take things to the next level’.”
“Perhaps one of the increasingly more apparent challenges of battling antimicrobial resistance is that of surveillance. This presentation by Michael Y. Lin, MD, MPH, of Rush University Medical Center, discussed the Illinois XDRO Registry. Created in 2013, this data source for XDROs focuses on carbapenem-resistant Enterobacteriaceae (CRE), carbapenemase-producing Pseudomonas aeruginosa, and Candida auris. The registry essentially allows health care facilities to access data to identify if patients being admitted have a history of colonization or infection with the aforementioned organisms. Data is submitted through hospitals and allows for alerts to be created, automatically, which are sent via email, page, or even a text to the hospital’s infection preventionist when the patient is admitted. Perhaps one of the increasingly more apparent challenges of battling antimicrobial resistance is that of surveillance. This presentation by Michael Y. Lin, MD, MPH, of Rush University Medical Center, discussed the Illinois XDRO Registry. Of those patients who were unknown to the facilities, 33% were not in contact precautions when the alert occurred, indicating that it is highly beneficial for reducing disease transmission.”
Stories You May Have Missed:
EEE Cases Continue in Michigan– “The threat from Eastern Equine Encephalitis is continuing to grow, especially in Michigan where state health officials now say 12 counties have confirmed having human or animal cases of EEE. The mosquito-borne virus usually infects only about seven people annually, but there have been 28 human cases reported so far this year across the country. Nine people have died.”
Welcome to your favorite source for biodefense nerdom! We hope your week was wonderful and you’re ready for a dose of health security news…
STEM: An Open Source Tool for Disease Modeling Have you been looking for a good epidemiological modeling software? Lucky for you, there’s STEM (Spatiotemporal Epidemiologic Modeler) and one of GMU’s very own biodefense doctoral alums, Nereyda Sevilla, was part of a team who published on how great this software is. “The Spatiotemporal Epidemiologic Modeler (STEM) is an open source software project supported by the Eclipse Foundation and used by a global community of researchers and public health officials working to track and, when possible, control outbreaks of infectious disease in human and animal populations. STEM is not a model or a tool designed for a specific disease; it is a flexible, modular framework supporting exchange and integration of community models, reusable plug-in components, and denominator data, available to researchers worldwide at www.eclipse.org/stem. A review of multiple projects illustrates its capabilities. STEM has been used to study variations in transmission of seasonal influenza in Israel by strains; evaluate social distancing measures taken to curb the H1N1 epidemic in Mexico City; study measles outbreaks in part of London and inform local policy on immunization; and gain insights into H7N9 avian influenza transmission in China. A multistrain dengue fever model explored the roles of the mosquito vector, cross-strain immunity, and antibody response in the frequency of dengue outbreaks. STEM has also been used to study the impact of variations in climate on malaria incidence. During the Ebola epidemic, a weekly conference call supported the global modeling community; subsequent work modeled the impact of behavioral change and tested disease reintroduction via animal reservoirs. Work in Germany tracked salmonella in pork from farm to fork; and a recent doctoral dissertation used the air travel feature to compare the potential threats posed by weaponizing infectious diseases. Current projects include work in Great Britain to evaluate control strategies for parasitic disease in sheep, and in Germany and Hungary, to validate the model and inform policy decisions for African swine fever. STEM Version 4.0.0, released in early 2019, includes tools used in these projects and updates technical aspects of the framework to ease its use and re-use.”
GMU Biodefense Fall Courses – Are You Registered?
The start of the Fall semester is just around the corner and if you’re a GMU biodefense graduate student, you’ve got a great menu of courses this term. There are still open spots in three courses – Global Health Security Policy taught by Ashley Grant (lead biotechnologist at the MITRE Corporation and previously the Senior Biological Scientist at the Government Accountability Office where she led government-wide technical performance audits focused on biosafety and biosecurity issues), Nonproliferation and Arms Control with Richard Cupitt (Senior Associate and Director of the Partnerships in Proliferation Prevention program at Stimson and prior to joining Stimson, he served as the Special Coordinator for U.N. Security Council resolution 1540 in the Office of Counterproliferation Initiatives at the U.S. State Department from 2012 through 2016.), and Biosurveillance with Andrew Kilianski (GMU professor and CINO for the Joint Program Executive Office for Chemical, Biological, Radiological, and Nuclear Defense JPEO-CBRND). These are just a handful of the classes but since there are a few spots left in each, now is your change to grab a seat!
GMU Biodefense MS and PhD Open Houses
Have you been considering investing in your education and career through a graduate degree in biodefense? Check out one of our Schar School Open Houses to get a feel for what the MS and PhD programs are like – you can chat with faculty, students, and learn more about the coursework and application process. The Master’s Open House will be at 6:30pm on Thursday, September 12th, and the PhD Open House will be at 7pm on Thursday, September 19th – both will be held at our Arlington campus in Van Metre Hall.
Ebola Outbreak – New Cases in Remote Areas
Late last week two remote regions in the DRC reported cases of Ebola virus disease – North and South Kivu, of which there hadn’t been cases for several incubation periods. Moreover, there were 27 cases reported over 3 days, bringing the outbreak closer to 2,900. “According to Reuters, DRC officials today confirmed a new case of Ebola in the remote, militia-controlled territory of Walikale, which is 95 miles northwest of Goma. Goma recorded four cases of Ebola in the last 6 weeks, and it is unclear if the case in Walikale had any contact with other Ebola patients. Reuters also reported the DRC confirmed a third case in South Kivu region, which reported its first case late last week. South Kivu is more than 430 miles from the outbreak’s epicenter. The first cases in South Kivu were a mother and child who were likely exposed in Beni. For almost a year, the DRC’s Ebola outbreak—the second largest in history—was contained to North Kivu and Ituri provinces along the country’s eastern border.” Unfortunately, there has also been transmission within healthcare facilities where patients are being treated, as infection control is increasingly a challenge. “The World Health Organization (WHO) said today the third case of Ebola identified in South Kivu province was in a patient who contracted the virus at a health center where other Ebola patients had been treated. The details on the nosocomial transmission emerged in the WHO’s latest situation report on the ongoing Ebola outbreak in the Democratic Republic of the Congo (DRC). In the past week, two more DRC regions far from outbreak hot spots have reported cases: South Kivu province and Pinga health zone, which is in North Kivu province. The WHO is still investigating how the case-patient in Pinga contracted the virus, but investigations have shown a mother and child in Mwenga, South Kivu, became infected after contact with a patient from Beni, the city most hard hit by the outbreak this summer. The two towns are about 473 miles apart, and South Kivu province shares a border with Rwanda and Burundi.” The Department of Health and Human Services (HHS) is helping via $23 million funding towards Merck’s Ebola vaccine production. The WHO also just released their list of eight lessons being applied to the DRC outbreak in a “Ebola then and now” segment. This list includes things like putting research at the heart of response and supporting survivors.
Syria: Anniversary of the Ghouta Chemical Weapons Attack
The U.S. State Department recently released a statement on the attack that occurred six years ago. “On August 21, 2013, the Assad regime launched a horrific chemical attack with the nerve agent sarin on the Ghouta district in Damascus – killing more than 1,400 Syrians, many of them children. On this solemn anniversary we remember the numerous lives lost to the Assad regime’s use of chemical weapons. We reiterate our resolve to prevent further use of these deadly weapons and to hold the Assad regime accountable for these heinous crimes. The regime’s barbaric history of using chemical weapons against its own people cannot and will not be forgotten or tolerated. Assad and others in his regime who believe they can continue using chemical weapons with impunity are mistaken. The United States remains determined to hold the Assad regime accountable for these heinous acts and will continue to pursue all efforts alongside partner countries to ensure that those involved in chemical attacks face serious consequences. We will continue to leverage all of the tools available to us to prevent any future use. We condemn in the strongest possible terms the use of chemical weapons anywhere, by anyone, under any circumstances.”
Stories You May Have Missed:
Packed Dorms Help MERS Transmission – Crowded living spaces and a high stress environment encouraged the transmission of a respiratory virus? Shocker… “New findings from an investigation into a large MERS-CoV cluster in a women’s dormitory revealed that crowded living conditions can lead to higher attack rates and hints that even healthcare workers who don’t directly care for patients can play a role in disease spread. In other developments, Saudi Arabia reported one new MERS-CoV (Middle East respiratory syndrome coronavirus) case.”
NIH Study to Offer Genetic Counseling – “A US government study that aims to sequence the genomes of one million volunteers will partner with a genetic-counselling company to help participants understand their results. It will be the largest US government study to provide such a service. The National Institutes of Health (NIH) is leading the project, called All of Us. And on 21 August, the agency announced the award of a US$4.6-million, 5-year grant to Color. The firm, in Burlingame, California, will counsel every study participant with a genetic variant that could have serious health implications — such as BRCA mutations associated with breast cancer — when they receive their results. Color will also develop educational materials for all study participants, and will offer telephone consultations to anyone who wishes to discuss their results with a counsellor.”
Pandemic Bonds – Designed to Fail Ebola
Is the World Bank’s funding approach to outbreak response hurting the DRC during their fight against Ebola? Olga Jones discusses how the Pandemic Emergency Financing Facility (PEF) works and how it is ultimately helping investors but not health security. “The World Bank has said that the PEF is working as intended by offering the potential of ‘surge’ financing. Tragically, current triggers guarantee that payouts will be too little because they kick in only after outbreaks grow large. What’s more, fanfare around the PEF might have encouraged complacency that actually increased pandemic risk. Following false assurance that the World Bank had a solution, resources and attention could shift elsewhere. Rather than a lack of funds, vigilance and public-health capacity have been the main deficiencies. When governments and the World Bank are prepared to respond to infectious-disease threats, money flows within days. In the 2009 H1N1 influenza outbreak in Mexico, clinics could diagnose and report cases of disease to a central authority that both recognized the threat and reacted rapidly. The Mexican government requested $25.6 million from an existing World Bank-financed project for influenza response and received the funds the next day.” Jones notes that “the best investment of funds and attention is in ensuring adequate and stable financing for core public-health capacities. The PEF has failed. It should end early — and IDA funds should go to poor countries, not investors.”
Maximizing Opportunities for US Bioeconomy Growth and National Security with Biology
“Recently, the Johns Hopkins Center for Health Security and Gingko Bioworks convened key science, technical, academic, and industry experts for a meeting to solicit stakeholder input on specific ways that national policy can strengthen the US bioeconomy. Their recommendations are synthesized in a summary report, released today. Participants considered the benefits to the US if its bioeconomy were to be expanded; examined the current health of the US bioeconomy; discussed existing US government programs, policies, and initiatives related to the bioeconomy; and identified priorities for strengthening the US bioeconomy.”
DRC Ebola Outbreak Updates Beni and Madnima continue to be hotspots for the disease as they have accounted for 60% of recent cases, not to mention ongoing violence and unrest. “The security situation increased in volatility as a result of a surge in attacks from suspected ADF elements in Beni Health Zone and successive demonstrations,” the WHO said. “A recent attack in Mbau on the Beni/Oicha axis led to the deaths of six civilians, including a prominent civil society leader. EVD operations in the area were temporarily suspended with resumption pending improvement in the security situation.” On a more positive note, two outbreak treatment trials are showing promise. “An independent monitoring board meets periodically to review safety and efficacy data, and at their Aug 9 review recommended that the study be stopped and all future patients be randomized to receive either Regeneron, an antibody cocktail, or mAB 114, an antibody treatment developed from a human survivor of the virus. The other two drugs involved in the original trial were zMapp, which in an earlier trial didn’t show statistically significant efficacy but performed better than standard care alone, and Remdesivir, an antiviral drug. Earlier in the outbreak, an ethics committee in the DRC approved the four experimental treatments for compassionate use, and patients at all of the country’s Ebola treatment centers have had access to them, along with safety monitoring. However, the formal clinical trial has been under way since November at four treatment centers with the help of the Alliance for International Medical Action (ALIMA), the International Medical Corps (IMC), and Doctors Without Borders (MSF). At a media telebriefing today, Anthony Fauci, MD, director of the National institute of Allergy and Infectious Diseases (NIAID), said Regeneron was the drug that crossed the efficacy threshold, triggering a pause in the study. And he said the group recommended proceeding with mAb 114, because there were only small differences in the data between the two drugs.”
Combatting Legionella and Carbon Footprints
Can we reduce the burden of Legionnaire’s disease while reducing our carbon footprint? GMU Biodefense PhD student and infection preventionist Saskia Popescu discusses a new strategy to preventing this water-based bug. “Typical health care control methods range from routine sampling to temperature control measures, like keeping cold water below 20°C and hot water at a minimum of 60°C. This has been the tried and true approach to Legionella control since there will always be some small level of the bacteria in water and the ultimate goal is to avoid growth that can cause human disease. Investigators in the United Kingdom recently published a study assessing a large health care facility’s approach to reducing Legionella risk through use of copper and silver ionization at hot water temperatures that were deliberately reduced to 43°C within a new water system. The research team collected 1589 water samples between September 2011 and June 2017, looking for not only Legionella bacteria, but also copper and silver ion levels, and total viable counts. To also assess the internal costs and function of this system, investigators collected data on energy consumption and water usage.”
2015 HPAI Outbreaks in the US – Insight Into Airborne Transmission
“The unprecedented 2015 outbreaks of highly pathogenic avian influenza (HPAI) H5N2 in the U.S. devastated its poultry industry and resulted in over $3 billion economic impacts. Today HPAI continues eroding poultry operations and disrupting animal protein supply chains around the world. Anecdotal evidence in 2015 suggested that in some cases the AI virus was aerially introduced into poultry houses, as abnormal bird mortality started near air inlets of the infected houses. This study modeled air movement trajectories and virus concentrations that were used to assess the probability or risk of airborne transmission for the 77 HPAI cases in Iowa. The results show that majority of the positive cases in Iowa might have received airborne virus, carried by fine particulate matter, from infected farms within the state (i.e., intrastate) and infected farms from the neighboring states (i.e., interstate). The modeled airborne virus concentrations at the Iowa recipient sites never exceeded the minimal infective doses for poultry; however, the continuous exposure might have increased airborne infection risks. In the worst-case scenario (i.e., maximum virus shedding rate, highest emission rate, and longest half-life), 33 Iowa cases had > 10% (three cases > 50%) infection probability, indicating a medium to high risk of airborne transmission for these cases. Probability of airborne HPAI infection could be affected by farm type, flock size, and distance to previously infected farms; and more importantly, it can be markedly reduced by swift depopulation and inlet air filtration.”
Serbia Suspects African Swine Fever – Implications for Imports
One Health in a nutshell – the economic implications of zoonotic diseases like African swine fever (ASF). “Serbia has reported four suspected outbreaks of African swine fever among backyard pigs, the Paris-based World Organisation for Animal Health (OIE) said on Monday, prompting neighbouring countries to ban imports of the animals. Three of the cases were detected in the Belgrade area and one in the district of Podunavski, the OIE said, citing a report from Serbia’s Agriculture Ministry. The suspected cases of the disease killed seven pigs while another 114 were slaughtered, the report showed. Bosnia, Montenegro and North Macedonia banned imports of pigs, wild boar and related products from Serbia to prevent the spread of the outbreak, the countries’ veterinary authorities said.”
A New Drug to Tackle Extensively Drug-Resistant TB
XDR-TB is a disease that causes significant health issues on a global scale and the effort to try and treat can be costly. A “new drug, pretomanid, has been approved by the US Food and Drug Administration (FDA) for use in a treatment for XDR-TB. Amazingly, it’s the first time that a treatment for XDR-TB infections has been recognized for actually working—no other treatment has demonstrated any consistent effectiveness. Up until now, people with XDR-TB had to suffer through up to two years or more of toxic treatment that worked only one third of the time. Today’s news means that treatment time is drastically reduced—to six months—while the effectiveness of treatment is significantly improved. We welcome this approval as it shows the real-world impact of US government investment in finding new cures and vaccines for the world’s deadliest diseases. The developer of pretomanid, the nonprofit organization TB Alliance, could not have succeeded in advancing this breakthrough without support from the American people, through the US Agency for International Development (USAID) and National Institutes of Health (NIH).”
Stories You May Have Missed:
Mega Malaria Vaccine Test Postponed in Kenya – “Kenya has postponed a large-scale pilot test for a malaria vaccine that could reduce the burden of the disease. The World Health Organisation (WHO) chose Malawi, Ghana and Kenya to vaccinate 360,000 children per year; and while the two nations began the rollout in April, Kenya is yet to start. The introduction in Kenya, planned for this Thursday, was postponed by the Ministry of Health. ‘I regret to inform you that the stakeholders breakfast meeting planned for this Tuesday, August 13, and the launch planned for Thursday, August 15, have been postponed to a later date to be communicated to you shortly. This is due to the upcoming Health Summit scheduled on August 14 and 15,’ head of the National Vaccines and Immunisation Programme, Dr Collins Tabu, said.”
Launch of the 2019 Next Generation Biosecurity Competition
Are you a global health security and biosecurity student or professional? “NTI | bio is partnering with the Next Generation Global Health Security (GHS) Network to advance the biosecurity and biosafety-related targets of the Global Health Security Agenda (GHSA). Together, we are launching the third annual joint competition to foster a biosecurity professional track within the Next Generation GHS Network. The 2019 competition will spur next generation experts in health security to discuss catalytic actions that can be taken to reduce biological risks associated with advances in technology and promote biosecurity norms. For the 2019 Next Generation for Biosecurity Competition, we will publish creative and innovative papers that promote regional, multi-sectoral, and global collaboration. Each team can include up to three people and should: 1) explore concrete collaborative actions that can be taken to build national, regional, and global norms for preventing deliberate and/or accidental biological events; and 2) promote cross-sectoral and cross-regional partnerships to advance biosecurity and biosafety. Papers should directly address the biosecurity targets included within the World Health Organization Joint External Evaluation and the GHSA Action Package on Biosecurity and Biosafety (APP3).” If you’re a GMU biodefense student or alum – you’re in luck as we’ve got a Next Generation Global Health Security Network chapter (membership is a requirement for the competition).
CSIS- Federal Funding for Biosafety Research is Critically Needed
The Center for Strategic & International Studies (CSIS) has just released their report on why we desperately need to provide funding for biosafety research in the face of new biotech and emerging infectious disease threats. “Currently, we lack the evidence basis to take new, needed measures to prevent accidents in biological laboratories, which, as mankind continues to expand its capabilities to manipulate life (including the viruses and bacteria that cause disease), leaves us more vulnerable to the accidental initiation of disease outbreaks with potentially dangerous consequences locally, regionally, and beyond. New biotechnologies are enabling scientists to design or modify life in ways not previously possible. These biotechnologies enable professional and amateur researchers to use simple life forms (e.g., bacteria and yeast) to create simple sensors and produce industrial chemicals, materials, and pharmaceuticals cheaply and from commonplace reagents. The manipulation of pathogens (the microbes that cause disease) fosters a better understanding of how these agents evolve and interact with the body, enabling the development of next generation cures. Despite the significant U.S. and global investment in biotechnology, concern has been voiced by scientists, policy experts, and members of the community that scientists may be ill-equipped to handle novel, manipulated microbes safely, potentially resulting in accidental infection of themselves or their local communities, accidental release into the environment, or even the initiation of a global pandemic.”
Biological Weapons Convention Meeting of Experts – Updates and Deciding on Emergency Assistance in Cases of Bioweapons Use
If you’ve been missing the MXs, Richard Guthrie has you covered with his daily accounts of these meetings and events. Thursday was the closing day of MX4 and focused on the financial situation. “The Chair of the 2019 Meeting of States Parties (MSP), Ambassador Yann Hwang (France), held informal consultations with delegates from states parties to discuss the financial situation for the BWC which remains difficult. Non- payments of agreed assessments by a number of states parties continue to cause problems. While some of these eventually appear as late payments, the ongoing deficit is sufficiently large to put the MSP at risk. As the financial accounting period is the calendar year, the MSP at the end of the year is always going to be the most vulnerable activity if there is a financial shortfall. In 2018, some economies were made on the MSP by having one informal day of activities without interpretation, putting a number of delegates at a disadvantage. The government of France has a clearly stated position on multilingualism within multilateralism and so the MSP Chair would be extremely reluctant to implement a similar route to financial savings. The Working Capital Fund established by the 2018 MSP is specifically designed not to subsidise non-payment, but to smooth out cash flow during the year. Depleting the fund — which is not even close to its target value – in its first year to cover the costs of the MSP would render it useless for purposes of supporting core activities such as the ISU. There are also financial implications of decisions that will need to be taken in relation to the Ninth Review Conference to be held in 2021.” Dr. Jean Pascal Zanders was also in attendance and has reported out on discussions surrounding Article VII – “Being one of the more obscure provisions in the BTWC, Article VII only attracted state party attention over the past ten years or so. In follow-up to the decision of the 7th Review Conference (2011), parties to the convention looked for the first time more closely at the provision during the August 2014 Meeting of Experts (MX). As it happened, the gathering coincided with the expanding Ebola crisis in West Africa. The epidemic gave urgency to the concrete implementation of Article VII. The daily images of victims and fully protected medical staff broadcast around the world left lasting impressions of how a biological attack from another state or terrorist entity might affect societies anywhere. Operationalising Article VII has proven more complex than anticipated. The provision comprises several clauses that fit ill together upon closer inspection and hence obscure its originally intended goals. In addition, it contains no instructions about how a state party should trigger it or the global community respond after its invocation.”
CSIS Commission on Strengthening America’s Health Security Meeting
“On June 26, 2019, the CSIS Commission on Strengthening America’s Health Security convened for the third time since its launch in April 2018. The Commission’s core aim is to chart a dynamic and concrete vision for the future of U.S. leadership in global health security—at home and abroad.” “On June 26, Commission members—a diverse group of high-level opinion leaders who bridge security and health and the public and private sectors, including six members of Congress—met to discuss a proposed U.S. doctrine for global health security. Commission members deliberated and reached a broad consensus endorsing a doctrine of continuous prevention, protection, and resilience, which would protect the American people from the most pressing global health security threats we face today. The measures outlined in the paper are affordable, proven, and draw support from across the political spectrum. The time to act is now.” Participants called for Congress and the administration to take action across seven areas, including ensuring full and sustained, multi-year funding for the GHSA, ensuring ample and quick-disbursing finances, establishing a global health crises response corps, etc.
Combatting AMR Through Payment Shifts
In the battle against the resistant bug, sometimes you have to change tactics and bring in the big guns – like the Centers for Medicare and Medicaid Services (CMS). Developing antimicrobials has been a particular challenge, despite efforts to push and pull research and development. BARDA Director Rick A. Bright recently discussed this problem, but now a new CMS rule could help guide change. “Without payment reform, the antimicrobials marketplace will not survive. CMS Administrator Seema Verma understands this reality and the necessity for a strong marketplace for both public health and national security purposes. On Friday, August 2, CMS issued its fiscal year (FY) 2020 Hospital Inpatient Prospective Payment System (IPPS) Final Rule. Among other changes to the way CMS pays for Medicare services, CMS recognized the need for greater payment of newer, potentially safer and more effective antimicrobial drugs. The new rule will (1) change the severity level designation for multiple ICD-10 codes for antimicrobial drug resistance from ‘non-CC’ to ‘CC’ (which stands for complications or comorbidities) to increase payments to hospitals due to the added clinical complexity of treating patients with drug-resistant infections, (2) create an alternative pathway for the new technology add-on payment (NTAP) for qualified infectious disease products (QIDPs), under which these drugs would not have to meet the substantial clinical improvement criterion, and (3) increase the NTAP for QIDPs from 50 percent to 75 percent. This final rule lessens economic incentives to utilize older antimicrobial drugs such as colistin, and shift medical practice to employ more appropriate, newer generation antimicrobials. Payment more closely aligned with the value of these lifesaving medicines will shift the current market realities of these drugs for companies, investors, and patients. No single action will solve the antimicrobial resistance problem; however CMS’ efforts undoubtedly can improve the marketplace and re-catalyze innovation in basic science discovery, and research and development efforts. We appreciate and congratulate Administrator Verma for taking such bold leadership in this fight. ”
Ebola in the DRC
The latest WHO dashboard is showing that the outbreak has reached 2,787 cases. Seven cases were reported from the DRC ministry of health earlier this week and there is growing concern about the impact the outbreak is having on children in the area. “Last December UNICEF sounded the alarm about the high number of children infected in the outbreak, noting that one of every third people confirmed infected in the DRC’s outbreak was a child, unusual for Ebola epidemics. The agency noted that 1 in 10 children were under age 5 and that kids were more likely to die from the disease than adults. Save the Children said in its statement yesterday that around 737 children have been infected with Ebola in the DRC’s outbreak. And based on the latest numbers, the impact on kids has increased. In the first 6 months of the outbreak, which was declared on Aug 1, 2018, just under 100 deaths in children had been reported. However, in the 6 months that followed, over four times as many have died. Heather Kerr, Save the Children’s country director in the DRC, said, ‘This is another grim milestone in a crisis that is devastating children in its path, especially the youngest. Some 40% of children who have contracted the disease are under the age of five, and many of them have died.’ She also said the outbreak has had a wider impact on children because of the high overall fatality rate from the virus, with thousands losing at least one of their parents or separated from their families.”
SWP Comment- Why the Containment of Infectious Diseases Alone Is Not Enough
You can now access this commentary by Daniel Gulati and Maike Voss here, which discusses the current DRC Ebola outbreak and that in “crisis situations like these, the interdependencies between health and security are highly complex. Which population groups and which diseases are perceived as suspected health risks, and why, is a normative question for donor countries. It has political consequences above all for affected developing countries. Where health and security are common goals, it is not enough to contain infectious diseases in developing countries. Instead, resilient, well-functioning, and accessible health systems must be established. This fosters the implementation of the human right to health, creates trust in state structures, and takes into account the security interests of other states. In the United Nations (UN) Security Council, the German government could advocate for policies based on the narrative ‘stability through health’.”
Stories You May Have Missed:
MERS and Healthcare Transmission– “Since its last update in June 2018, 219 cases were reported in four countries: Saudi Arabia (204), Oman (13), South Korea (1), and the United Kingdom (1). However, of the 97 secondary cases reported to the WHO, 52 were linked to transmission in hospitals, including 23 infections in healthcare workers. Since the virus was first detected in humans in 2012, 2,449 cases have been reported through Jun 30, 84% of them in Saudi Arabia. The virus is known to spread more easily in healthcare settings, and research is under way to better understand the factors that drive transmission. The WHO said awareness of the disease is still low, and the nonspecific early symptoms can make it difficult to identify cases. Gaps in infection prevention and control measures also contribute to disease spread. ‘Much more emphasis on improving standard IPC [infection prevention and control] practices in all health care facilities is required,’ the WHO said.”
Managing Measles: A Guide to Preventing Transmission in Health Care Setting– “Perhaps one of the most challenging aspects of this outbreak from a health care perspective is preparation. Although some may not consider this to be a concern, between 2001-2014, 6% of US measles cases (that were not imported) were transmitted within a health care setting. Sadly, I experienced this firsthand during a 2015 exposure at the health care facility I worked at, in which a health care worker was exposed to the virus while treating a patient and subsequently became infected. As a result of the health care worker’s infection, 380 individuals were exposed and the response efforts were extensive and significantly disruptive to the daily infection prevention duties. Due to the fact that hospitals can easily act as amplifiers for airborne diseases like measles, the CDC has provided interim infection prevention and control recommendations for measles in health care settings. At its core, this guidance focuses on health aspects of both the employee and the patient. For health workers, it is critical to ensure presumptive evidence of immunity to measles and manage exposed/ill health care workers properly. On the patient side, rapid identification and isolation of known or suspected cases and proper isolation maintenance is critical. “
Greetings fellow biodefense friends! We hope your summer is winding down nicely and you’re ready for your weekly dose of all things health security. You might want to avoid pig ear dog treats as there’s currently an outbreak of multi-drug resistant Salmonella infections.
Bioweapons Convention – Meeting of Experts
The BWC Meeting of Experts (MX) is currently under way and you can get detailed, daily reports via Richard Guthrie’s BioWeapons Prevention Project, which has been covering the BWC since 2006. Guthrie notes “The first Meeting of Experts (MX1) in the 2019 series opened on Monday morning with Ambassador Victor Dolidze (Georgia) in the Chair. Owing to refurbishment work in the Palais des Nations, MX1 opened in Room XX [renowned for its elaborately decorated ceiling] instead of the usual location for BWC meetings two floors below. One advantage of using Room XX is that the proceedings can be webcast via <<http://webtv.un.org/>> After brief opening formalities, six sub-topics were covered during Monday, the full titles of which can be found in the agenda for MX1. There was a full day of activities which means that this report can only be a selective snapshot of proceedings. The background information document produced by the Implementation Support Unit (ISU) for the MX1 held in 2018 contains much information relevant to the discussions this year.” You can also find the Joint NGO Statements that were given here. “In her reflections on last year’s MX1, the Chair, Ambassador Almojuela of the Philippines, suggested several concrete proposals for further consideration at today’s meeting. These included: An action plan for Article X implementation; Guidelines on Article X reports; The creation of a BWC Cooperation and Assistance Officer position within the ISU; and An open-ended working group to monitor, coordinate and review activities of cooperation and assistance. These are all proposals that the NGO community strongly endorses, and which were also set out in our Position Paper last year. Ambassador Almojuela also proposed to further collaboration with INTERPOL, OIE and WHO; we would also wish to draw attention to the importance of further collaboration with non-governmental entities. We would also urge States Parties to facilitate regional S&T dialogues that are focused on regional BWC-related interests and problems, and that draw in regional and international expertise to share information and stimulate collaboration and cooperation.”
DRC Ebola Outbreak
The outbreak has now hit the one year mark and it continues to worsen – with 41 new cases reported since the end of last week. “According to the World Health Organization’s (WHO’s) online Ebola dashboard, the outbreak total now stands at 2,671 cases. The dashboard also recorded a total of 1,782 deaths, an increase in 20 fatalities over the weekend. So far the DRC president’s office, which last week shifted outbreak response activities to its technical group, has not issued any detailed daily updates following the resignation of the country’s health minister.” A day later, the second case of Ebola was identified in the city of Goma. “Reports from DRC journalists and international media outlets said the case was announced at a media briefing where the head of a presidential expert committee, Jean Jacques Muyembe Tamfum, PhD, shared details about the development. The country’s president put the committee in charge of outbreak management on Jul 20, prompting the DRC’s health minister to resign. The infected man, a father of 10 children, is from Mongbwalu, about 43 miles from Bunia, the capital of Ituri province, according to a Tweet from DRC journalist Cedric Ebondo Mulumb. Goma and Bunia are about 347 miles apart, with road travel taking about 13 hours.” The WHO has recently noted how “relentless” this outbreak has been since it began one year ago.
GMU Biodefense MS and PhD Open Houses
Have you been considering adding to your education and career through a graduate degree in biodefense? Check out one of our Schar School Open Houses to get a feel for what the MS and PhD programs are like – you can chat with faculty, students, and learn more about the coursework and application process. The Master’s Open House will be at 6:30pm on Thursday, September 12th, and the PhD Open House will be at 7pm on Thursday, September 19th – both will be held at our Arlington campus in Van Metre Hall.
MERS-CoV: Novel Zoonotic Disease Outbreak a Hard Lesson for Healthcare
“Middle East respiratory syndrome coronavirus (MERS-CoV) was first identified in 2012 and since then, sporadic but continued outbreaks have been occurring within the Arabian Peninsula. There have been 2,428 cases of the coronavirus since 2012, and 838 associated deaths. Reported across 27 countries, this has been a disease that seems to have found a stronghold and established itself as endemic. MERS-CoV challenges response in that while we have diagnostic testing now, there truly is not treatment outside of supportive measures. Spread through the respiratory secretions of infected individuals, there has also been transmission via close contact (i.e. caring or living with an infected person), and ongoing investigation into the role of camels in zoonotic transmission. The disease does circulate in dromedary camels in Africa, the Middle East, and southern Asia, but cases have tended to be related to healthcare exposures and household contacts, with some camel-to-human transmission occurring. Hospitals are encouraged to ensure adherence to Standard, Contact, and Airborne isolation precautions, meaning that the patient should be placed in a negative pressure isolation room and healthcare workers should wear a gown, gloves, eye protection, and N95 respirator. Given the need for these isolation precautions, it’s not surprising that exposures often come from delays in isolation and crowded emergency rooms.”
WHO Statement on Governance and Oversight of Human Genome Editing
The World Health Organization has released the statement from this expert advisory committee held in March of this year. “At this meeting the Committee in an interim recommendation to the WHO Director-general stated that ‘it would be irresponsible at this time for anyone to proceed with clinical applications of human germline genome editing.’ WHO supports this interim recommendation and advises regulatory or ethics authorities to refrain from issuing approvals concerning requests for clinical applications for work that involves human germline genome editing. ‘Human germline genome editing poses unique and unprecedented ethical and technical challenges,’ said WHO Director-General Dr Tedros Adhanom Ghebreyesus. ‘I have accepted the interim recommendations of WHO’s Expert Advisory Committee that regulatory authorities in all countries should not allow any further work in this area until its implications have been properly considered.’ WHO’s Expert Advisory Committee continues its consideration of this matter, and will, at its forthcoming meeting in Geneva on 26-28 August 2019. evaluate, inter alia, effective governance instruments to deter and prevent irresponsible and unacceptable uses of genome edited embryos to initiate human pregnancies.”
Breaking Down Resistant Rumors and C diff Disinfectants
GMU biodefense doctoral student and infection preventionist Saskia Popescu discusses how poor communication regarding resistant organisms can cause confusion and misleading headlines. A recent study noted resistance of Clostridioides difficile to disinfectants however, “The investigators sought to treat the gowns with disinfectant to test its efficacy and whether it would help with the bioburden. The research team found that after being treated with the 1000 ppm chlorine-based disinfectant for 10 minutes, the gowns still were able to pick up and hold the C diff spores. This concern over resistance sent shockwaves and many news outlets picked up on this as an indicator of what’s on the horizon. But an issue with the study was the disinfectant that was used. First and foremost, as an infection preventionist and the first to stand on my soapbox to shout about the perils of antimicrobial resistance, I know that the efficacy of our disinfectants will eventually fail. The issue with this study is that much of the media coverage speaks broadly of a chlorine-based disinfectant and goes into little detail about what exactly what used. For my infection prevention peers, you know that not all disinfectants are alike and, well, some just weren’t designed for combatting hardier bugs like C diff. This is the playbook we live by in health care.”
Rinderpest, Smallpox, and the Imperative of Destruction
To destroy or not to destroy…that is indeed the question. “In June, The Pirbright Institute (UK) announced that it had destroyed its final archived stocks of rinderpest, the devastating viral disease of cattle that was declared eradicated in 2011. Rinderpest is only the second infection to be eradicated from the wild. The decision raises the question once again of what to do with the remaining stocks of the first eradicated virus—smallpox. The Pirbright Institute did not hold the final stocks of rinderpest in existence; samples are also known to be stored in a handful of facilities in China, Ethiopia, France, Japan, and the USA. Still, The Pirbright Institute is the World Reference Laboratory for rinderpest, previously storing more than 3000 viral samples. That it has taken the decision to destroy them represents a bold commitment to permanently ridding the world of the disease and should encourage others to do the same. France plans to destroy its remaining stocks, and discussions continue at other facilities.” The debate surrounding the survival and destruction of smallpox stocks has been ongoing for decades – some argue the risk of accidental or intentional release is too great, while others argue that destruction would remove the potential for research…however the Pirbright Institute’s practice countered this with their “sequence and destroy” policy, which is encouraging others to push for this policy regarding smallpox. “Smallpox stocks have been earmarked for destruction since eradication of the disease in 1980. Yet, successive meetings of the World Health Assembly have postponed making a final recommendation while the threat of re-emergence from elsewhere remains. At its last meeting in September, 2018, the Advisory Committee on Variola Virus Research told WHO that live virus is still needed for the development of new antivirals, with split opinion on whether it is needed for diagnostics. Huge strides have been made in these areas in recent years. New more advanced and safer vaccines have been developed; new diagnostic tests are in development; and the first specific antiviral for smallpox—tecovirimat—was approvedby the US Food and Drug Administration in June last year, after some innovative regulatory manoeuvres. The deliberations over smallpox stocks happen regularly, but the decisions are ad-hoc. For rinderpest, destruction seems only a matter of time. Smallpox stocks will also likely be destroyed once diagnostics are finalised and a second antiviral, with a different mode of action in case of resistance, is approved (many are in development).”
Stories You May Have Missed:
Surge in Drug-Resistant HIV Across Africa, Asia, and the Americas – “Surveys by the World Health Organization (WHO) reveal that, in the past 4 years, 12 countries in Africa, Asia and the Americas have surpassed acceptable levels of drug resistance against two drugs that constitute the backbone of HIV treatment: efavirenz and nevirapine. People living with HIV are routinely treated with a cocktail of drugs, known as antiretroviral therapy, but the virus can mutate into a resistant form. The WHO conducted surveys from 2014 to 2018 in randomly selected clinics in 18 countries, and examined the levels of resistance in people who had started HIV treatment during that period. More than 10% of adults with the virus have developed resistance to these drugs in 12 nations (see ‘Resistance rises’). Above this threshold, it’s not considered safe to prescribe the same HIV medicines to the rest of the population, because resistance could increase. Researchers published the findings this month in WHO report.”
Ebola Outbreak Updates- From PHEIC Declaration to Vaccines
On Wednesday, the WHO declared the outbreak a PHEIC (Public Health Emergency of International Concern). “‘It is time for the world to take notice and redouble our efforts. We need to work together in solidarity with the DRC to end this outbreak and build a better health system,’ said Dr. Tedros. ‘Extraordinary work has been done for almost a year under the most difficult circumstances. We all owe it to these responders — coming from not just WHO but also government, partners and communities — to shoulder more of the burden.’ The declaration followed a meeting of the International Health Regulations Emergency Committee for EVD in the DRC. The Committee cited recent developments in the outbreak in making its recommendation, including the first confirmed case in Goma, a city of almost two million people on the border with Rwanda, and the gateway to the rest of DRC and the world.” A new case of Ebola has been identified in the city of Goma, which represents what the WHO is calling “a game-changer” since the city is a major transportation hub. On July 11th, it was announced that “the Democratic Republic of the Congo (DRC) ministry of health and government officials have agreed that Merck’s rVSV-ZEBOV is the only vaccine that will be used during the current, ever-growing Ebola outbreak in North Kivu and Ituri provinces. ‘Due to the lack of sufficient scientific evidence on the efficacy and safety of other vaccines as well as the risk of confusion among the population, it was decided that no clinical vaccine trials will be allowed throughout the country,’ the ministry said in its daily update yesterday. As of yesterday, a total of 158,830 people have been vaccinated with rVSV-ZEBOV, which clinical data suggest has as high as a 97.5% effectiveness rate against the virus.”
Trump Administration Gutting WMD Detection Programs
Despite 2017 pledges to secure, eliminate, and prevent the spread of WMD and related materials, a new investigation has found that such efforts through the Department of Homeland Security, have been drastically impacted. “Among the programs gutted since 2017, however, was an elite Homeland Security ‘red team,’ whose specialists conducted dozens of drills and assessmentsaround the country each year to help federal, state and local officialsdetect such potential threats as an improvised nuclear device concealed in a suitcase, or a cargo ship carrying a radiation-spewing ‘dirty bomb.’ Another Homeland Security unit, the Operations Support Directorate, had helped lead up to 20 WMD-related training exercises each year with state and local authorities. The directorate participated in less than 10 such exercises last year and even fewer so far this year, according to internal Homeland Security documents.” The Homeland Security’s National Technical Nuclear Forensics Center has also seen a hit as their leadership is out and staffing has dropped from 14 to 3. “A separate Homeland Security component, the International Cooperation Division, which worked closely with foreign counterparts and the United Nations nuclear watchdog agency to track and stop thesmuggling of dangerous nuclear materials overseas, has been disbanded.” “Homeland Security also has halted work to update a formal ‘strategic, integrated’ assessment of chemical, biological and nuclear-related risks.” The investigation also notes that more than 100 scientists and policy experts who specialize in radiological and nuclear threats, have either been reassigned or pushed into jobs that are wholly unrelated to their works. ‘The changes have undermined the U.S. government’s multi-agency commitment since 2006 to build and maintain a ‘global nuclear detection architecture,’ according to the present and former officials.”
Weaponized Ticks, Lyme Disease, and the Smith Amendment
Remember that time a conspiracy-theory book triggered an investigation into whether the DoD ever weaponized ticks? Well here we are…. Earlier this week the US House of Representatives voted on the Smith Amendment on Bioweaponization of Ticks – and it passed. A lot of this stems from stories of Plum Island and the whispers that Lyme disease actually originated from the testing site and ticks were either intentionally or accidentally released into the surrounding areas…triggering the disease a few decades ago. Since the release of a book on the “secret history of Lyme disease and biological weapons”, there’s been a renewed interest in the bedtime story of the disease’s sinister origin story. Unfortunately, the proposed investigation really doesn’t hit the nail on the head. For one, it’s been widely known for years that ticks, among other vectors, were a part of the bioweapons and biodefense research. Two, the “smoking gun” within the book that’s been used to reinvigorate interest, claims an interview with Dr. Willy Durgdorfer (the researcher who identified Lyme disease) gave confirmation of the true origin of the disease….alas, this was reported post-mortem, when he was not able to confirm or deny such statements. Third, Lyme disease actually has some pretty old origins. Last, but not least, this new amendment doesn’t even touch on Lyme disease…but rather focuses on if the DoD did experiments with insects and vectors as disease delivery systems…which we already know to be true. Ultimately, this does a disservice to not only the people with Lyme disease, but also encourages conspiracy theories.
Using “Outbreak Science” to Strengthen Usage of Models in Epidemics
If you’ve been on the frontlines of an outbreak, you’ve likely heard of disease modeling…but sometimes it can be hard to actually apply this technology to drive change. A new article has created “outbreak science” as an inter-disciplinary field to apply epidemic modeling in a way that can really help. “Nevertheless, the integration of those analyses into the decision-making cycle for the Ebola 2014–2016 epidemic was not seamless, a pattern repeated across many recent outbreaks, including Zika. Reasons for this vary. Modeling and outbreak data analysis efforts typically occur in silos with limited communication of methods and data between model developers and end users. Modeling “cross talk” across stakeholders within and between countries is also typically limited, often occurring within a landscape of legal and ethical uncertainty. Specifically, the ethics of performing research using surveillance and health data, limited knowledge of what types of questions models can help inform, data sharing restrictions, and the incentive in academia to quickly publish modeling results in peer-reviewed journals contribute to a complex collaborative environment with different and sometimes conflicting stakeholder goals and priorities. To remedy these challenges, we propose the establishment of ‘outbreak science’ as an inter-disciplinary field to improve the implementation of models and critical data analyses in epidemic response. This new track of outbreak science describes the functional use of models, clinical knowledge, laboratory results, data science, statistics, and other advanced analytical methods to specifically support public health decision making between and during outbreak threats. Outbreak scientists work with decision makers to turn outbreak data into actionable information for decisions about how to anticipate the course of an outbreak, allocate scarce resources, and prioritize and implement public health interventions. Here, we make three specific recommendations to get the most out of modeling efforts during outbreaks and epidemics.” From establishing functional model capacity and fostering relationships before things happen to investing in functional model capabilities, this guide could be a game-changer for outbreak response.
Building a Case of (non?)compliance Concern
Looking for a new book? Check out this review of Biosecurity in Putin’s Russia – “In the early 1990s, the world was rocked when defectors from the Soviet Union revealed the existence of a massive civilian and military biological-weapons program that had employed more than 65,000 people from 1928 to 1992, directly contravening the 1972 Biological and Toxin Weapons Convention (BWC). In 2012, Raymond Zilinskas, a leading biological- weapons expert, coauthored with Milton Leitenberg a comprehensive account of the program, The Soviet Biological Weapons Program: A History, a reference source so thorough that it ran to nearly a thousand pages. Last year, Zilinskas, in collaboration with Philippe Mauger, produced Biosecurity in Putin’s Russia, a sequel of sorts in which the cautionary note that Zilinskas and Leitenberg sounded earlier—that Russia’s relationship with biological weapons remained complicated, and that the current status of its old programs could not be verified—proved to have been foreshadowing.”
Modeling the Complexities of the Gut for Biodefense Application
“The Nutritional Immunology and Molecular Medicine Laboratory (NIMML), with research funding assistance from the Defense Threat Reduction Agency (DTRA), has developed a high-resolution model of the gut immune system to help solve emerging and re-emerging infectious diseases and biodefense challenges. The advanced model predicts new emerging behaviors and responses to biological threats. The gut ecosystem includes trillions of interactions between host epithelial and immune cells, molecules (cytokines, chemokines and metabolites) and microbes is a massively and dynamically interacting network, like a multidimensional jigsaw puzzle with pieces that are constantly changing shape. These interactions with cooperativity and feedback lead to nonlinear dynamics and unforeseen emergent behaviors across spatiotemporal scales. The NIMML agent-based modeling (ABM) of the gut uses an array of HPC-driven advanced computational technologies such as the ENteric Immunity SImulator (ENISI) – multiscale modeling (MSM). These models and tools simulate cell phenotype changes, signaling pathways, immune responses, lesion formation, cytokine, chemokine and metabolite diffusions, and cell movements at the gut mucosa.”
Radiation Injury Treatment Network Meeting
Are you attending this event later this month? If so, check out GMU Biodefense doctoral student Mary Sproull discussing Radiation Biodosimetry – A Mass Screening Tool for Radiological/Nuclear Events.
New WHO insight into 14 cases has identified 2 clusters that involved 4 of the infected people. “Of the 14 patients, 3 had been exposed to camels, a known risk factor for contracting the virus. Ten were men and four were women, and patient ages ranged from 22 to 80. Eleven had underlying health conditions, which is a risk factor for MERS. Ten were from Riyadh region, with other cases reported from Jeddah, Medina, Najran, and Al Qassim. One of the clusters involved two people living in the same household in Al Kharj in Riyadh region, a 22-year-old woman who had diabetes and epilepsy and a 44-year-old woman who had no underlying health conditions. The other cluster consisted of a 65-year-old male patient and a 23-year-old female healthcare worker in Riyadh. Five of the people died from their infections.”
CDC Announces E Coli Outbreak Linked to Ground Bison
Put down your bison burger and take a slow step back….”The US Centers for Disease Control and Prevention (CDC) and US Food and Drug Administration (FDA) have announced that they are collaborating with the Canadian Food Inspection Agency to investigate a multistate outbreak of E coli O103 and E coli O121 infections. Early epidemiologic and traceback information point to ground bison products as the likely source of the outbreak. As of July 12, 2019, there have been 21 individuals infected with E coli in this outbreak. In total, 6 individuals have been infected with the O103 strain, 13 cases of the O121 strain have been confirmed, and 2 individuals have been found to be infected with both strains.”
Stories You May Have Missed:
Polio in Pakistan – “The Global Polio Eradication Initiative (GPEI) today reported nine new cases of wild poliovirus type 1 (WPV1), and, for the first time in more than a year, China has confirmed a case of vaccine-derived poliovirus. In addition, Angola has a new circulating vaccine-derived poliovirus type 2 (cVDPV2) case. The Pakistan patients reported symptom onset on dates ranging from May 28 to Jun 20. The total number of WPV1 cases recorded in Pakistan this year is now 41; last year, the country recorded 12 cases over the entire year. Five of the nine cases originated in Bannu province, where health workers have been targeted by anti-vaccine extremists.”
Food Defense and Intentional Adulteration Rule Training – “The Food Protection and Defense Institute is hosting a Food Defense and Intentional Adulteration Rule training on August 20-21 in Minneapolis, MN. This two-day course provides the convenience and interaction of a single, in person class to more comprehensively learn the breadth and interconnections of IA Rule requirements including how to: Prepare a Food Defense Plan Conduct vulnerability assessments including the full FSPCA Intentional Adulteration, Conducting Vulnerability Assessment Course (IAVA) Identify and explain mitigation strategies, Conduct reanalysis” | <urn:uuid:8adc0fc9-df10-4b18-b2fd-d2ba22ef0f94> | {
"dataset": "HuggingFaceFW/fineweb-edu",
"dump": "CC-MAIN-2021-04",
"file_path": "s3://commoncrawl/crawl-data/CC-MAIN-2021-04/segments/1610703511903.11/warc/CC-MAIN-20210117081748-20210117111748-00219.warc.gz",
"int_score": 3,
"language": "en",
"language_score": 0.9467157125473022,
"score": 2.890625,
"token_count": 24993,
"url": "https://pandorareport.org/tag/ebola/"
} |
NAME¶openssl - OpenSSL command line program
SYNOPSIS¶openssl command [ options ... ] [ parameters ... ]
openssl list -standard-commands | -digest-commands | -cipher-commands | -cipher-algorithms | -digest-algorithms | -mac-algorithms | -public-key-algorithms
openssl no-XXX [ options ]
DESCRIPTION¶OpenSSL is a cryptography toolkit implementing the Secure Sockets Layer (SSL v2/v3) and Transport Layer Security (TLS v1) network protocols and related cryptography standards required by them.
The openssl program is a command line program for using the various cryptography functions of OpenSSL's crypto library from the shell. It can be used for
o Creation and management of private keys, public keys and parameters o Public key cryptographic operations o Creation of X.509 certificates, CSRs and CRLs o Calculation of Message Digests and Message Authentication Codes o Encryption and Decryption with Ciphers o SSL/TLS Client and Server Tests o Handling of S/MIME signed or encrypted mail o Timestamp requests, generation and verification
COMMAND SUMMARY¶The openssl program provides a rich variety of commands (command in the "SYNOPSIS" above). Each command can have many options and argument parameters, shown above as options and parameters.
Detailed documentation and use cases for most standard subcommands are available (e.g., openssl-x509(1)).
Many commands use an external configuration file for some or all of their arguments and have a -config option to specify that file. The default name of the file is openssl.cnf in the default certificate storage area, which can be determined from the openssl-version(1) command. The environment variable OPENSSL_CONF can be used to specify a different location of the file. See openssl-env(7).
The list options -standard-commands, -digest-commands, and -cipher-commands output a list (one entry per line) of the names of all standard commands, message digest commands, or cipher commands, respectively, that are available.
The list parameters -cipher-algorithms, -digest-algorithms, and -mac-algorithms list all cipher, message digest, and message authentication code names, one entry per line. Aliases are listed as:
from => to
The list parameter -public-key-algorithms lists all supported public key algorithms.
The command no-XXX tests whether a command of the specified name is available. If no command named XXX exists, it returns 0 (success) and prints no-XXX; otherwise it returns 1 and prints XXX. In both cases, the output goes to stdout and nothing is printed to stderr. Additional command line arguments are always ignored. Since for each cipher there is a command of the same name, this provides an easy way for shell scripts to test for the availability of ciphers in the openssl program. (no-XXX is not able to detect pseudo-commands such as quit, list, or no-XXX itself.)
- Parse an ASN.1 sequence.
- Certificate Authority (CA) Management.
- Cipher Suite Description Determination.
- CMS (Cryptographic Message Syntax) command.
- Certificate Revocation List (CRL) Management.
- CRL to PKCS#7 Conversion.
- Message Digest calculation. MAC calculations are superseded by openssl-mac(1).
- Generation and Management of Diffie-Hellman Parameters. Superseded by openssl-genpkey(1) and openssl-pkeyparam(1).
- DSA Data Management.
- DSA Parameter Generation and Management. Superseded by openssl-genpkey(1) and openssl-pkeyparam(1).
- EC (Elliptic curve) key processing.
- EC parameter manipulation and generation.
- Encryption, decryption, and encoding.
- Engine (loadable module) information and manipulation.
- Error Number to Error String Conversion.
- FIPS configuration installation.
- Generation of DSA Private Key from Parameters. Superseded by openssl-genpkey(1) and openssl-pkey(1).
- Generation of Private Key or Parameters.
- Generation of RSA Private Key. Superseded by openssl-genpkey(1).
- Display information about a command's options.
- Display diverse information built into the OpenSSL libraries.
- Key Derivation Functions.
- List algorithms and features.
- Message Authentication Code Calculation.
- Create or examine a Netscape certificate sequence.
- Online Certificate Status Protocol command.
- Generation of hashed passwords.
- PKCS#12 Data Management.
- PKCS#7 Data Management.
- PKCS#8 format private key conversion command.
- Public and private key management.
- Public key algorithm parameter management.
- Public key algorithm cryptographic operation command.
- Compute prime numbers.
- Load and query providers.
- Generate pseudo-random bytes.
- Create symbolic links to certificate and CRL files named by the hash values.
- PKCS#10 X.509 Certificate Signing Request (CSR) Management.
- RSA key management.
- RSA command for signing, verification, encryption, and decryption. Superseded by openssl-pkeyutl(1).
- This implements a generic SSL/TLS client which can establish a transparent connection to a remote server speaking SSL/TLS. It's intended for testing purposes only and provides only rudimentary interface functionality but internally uses mostly all functionality of the OpenSSL ssl library.
- This implements a generic SSL/TLS server which accepts connections from remote clients speaking SSL/TLS. It's intended for testing purposes only and provides only rudimentary interface functionality but internally uses mostly all functionality of the OpenSSL ssl library. It provides both an own command line oriented protocol for testing SSL functions and a simple HTTP response facility to emulate an SSL/TLS-aware webserver.
- SSL Connection Timer.
- SSL Session Data Management.
- S/MIME mail processing.
- Algorithm Speed Measurement.
- SPKAC printing and generating command.
- Maintain SRP password file.
- Command to list and display certificates, keys, CRLs, etc.
- Time Stamping Authority command.
- X.509 Certificate Verification.
- OpenSSL Version Information.
- X.509 Certificate Data Management.
Message Digest Commands¶
- BLAKE2b-512 Digest
- BLAKE2s-256 Digest
- MD2 Digest
- MD4 Digest
- MD5 Digest
- MDC2 Digest
- RMD-160 Digest
- SHA-1 Digest
- SHA-2 224 Digest
- SHA-2 256 Digest
- SHA-2 384 Digest
- SHA-2 512 Digest
- SHA-3 224 Digest
- SHA-3 256 Digest
- SHA-3 384 Digest
- SHA-3 512 Digest
- SHA-3 SHAKE128 Digest
- SHA-3 SHAKE256 Digest
- SM3 Digest
Encryption, Decryption, and Encoding Commands¶The following aliases provide convenient access to the most used encodings and ciphers.
Depending on how OpenSSL was configured and built, not all ciphers listed here may be present. See openssl-enc(1) for more information.
- aes128, aes-128-cbc, aes-128-cfb, aes-128-ctr, aes-128-ecb, aes-128-ofb
- AES-128 Cipher
- aes192, aes-192-cbc, aes-192-cfb, aes-192-ctr, aes-192-ecb, aes-192-ofb
- AES-192 Cipher
- aes256, aes-256-cbc, aes-256-cfb, aes-256-ctr, aes-256-ecb, aes-256-ofb
- AES-256 Cipher
- aria128, aria-128-cbc, aria-128-cfb, aria-128-ctr, aria-128-ecb, aria-128-ofb
- Aria-128 Cipher
- aria192, aria-192-cbc, aria-192-cfb, aria-192-ctr, aria-192-ecb, aria-192-ofb
- Aria-192 Cipher
- aria256, aria-256-cbc, aria-256-cfb, aria-256-ctr, aria-256-ecb, aria-256-ofb
- Aria-256 Cipher
- Base64 Encoding
- bf, bf-cbc, bf-cfb, bf-ecb, bf-ofb
- Blowfish Cipher
- camellia128, camellia-128-cbc, camellia-128-cfb, camellia-128-ctr, camellia-128-ecb, camellia-128-ofb
- Camellia-128 Cipher
- camellia192, camellia-192-cbc, camellia-192-cfb, camellia-192-ctr, camellia-192-ecb, camellia-192-ofb
- Camellia-192 Cipher
- camellia256, camellia-256-cbc, camellia-256-cfb, camellia-256-ctr, camellia-256-ecb, camellia-256-ofb
- Camellia-256 Cipher
- cast, cast-cbc
- CAST Cipher
- cast5-cbc, cast5-cfb, cast5-ecb, cast5-ofb
- CAST5 Cipher
- Chacha20 Cipher
- des, des-cbc, des-cfb, des-ecb, des-ede, des-ede-cbc, des-ede-cfb, des-ede-ofb, des-ofb
- DES Cipher
- des3, desx, des-ede3, des-ede3-cbc, des-ede3-cfb, des-ede3-ofb
- Triple-DES Cipher
- idea, idea-cbc, idea-cfb, idea-ecb, idea-ofb
- IDEA Cipher
- rc2, rc2-cbc, rc2-cfb, rc2-ecb, rc2-ofb
- RC2 Cipher
- RC4 Cipher
- rc5, rc5-cbc, rc5-cfb, rc5-ecb, rc5-ofb
- RC5 Cipher
- seed, seed-cbc, seed-cfb, seed-ecb, seed-ofb
- SEED Cipher
- sm4, sm4-cbc, sm4-cfb, sm4-ctr, sm4-ecb, sm4-ofb
- SM4 Cipher
OPTIONS¶Details of which options are available depend on the specific command. This section describes some common options with common behavior.
- Provides a terse summary of all options. If an option takes an argument, the "type" of argument is also given.
- This terminates the list of options. It is mostly useful if any filename
parameters start with a minus sign:
openssl verify [flags...] -- -cert1.pem...
Format Options¶Several OpenSSL commands can take input or generate output in a variety of formats. Since OpenSSL 3.0 keys, single certificates, and CRLs can be read from files in any of the DER, PEM, or P12 formats, while specifying their input format is no more needed.
The list of acceptable formats, and the default, is described in each command documentation. The list of formats is described below. Both uppercase and lowercase are accepted.
- A binary format, encoded or parsed according to Distinguished Encoding Rules (DER) of the ASN.1 data language.
- Used to specify that the cryptographic material is in an OpenSSL engine. An engine must be configured or specified using the -engine option. In addition, the -input flag can be used to name a specific object in the engine. A password, such as the -passin flag often must be specified as well.
- A DER-encoded file containing a PKCS#12 object. It might be necessary to provide a decryption password to retrieve the private key.
- A text format defined in IETF RFC 1421 and IETF RFC 7468. Briefly, this is
a block of base-64 encoding (defined in IETF RFC 4648), with specific
lines used to mark the start and end:
Text before the BEGIN line is ignored. ----- BEGIN object-type ----- OT43gQKBgQC/2OHZoko6iRlNOAQ/tMVFNq7fL81GivoQ9F1U0Qr+DH3ZfaH8eIkX xT0ToMPJUzWAn8pZv0snA0um6SIgvkCuxO84OkANCVbttzXImIsL7pFzfcwV/ERK UM6j0ZuSMFOCr/lGPAoOQU0fskidGEHi1/kW+suSr28TqsyYZpwBDQ== ----- END object-type ----- Text after the END line is also ignored
The object-type must match the type of object that is expected. For example a "BEGIN X509 CERTIFICATE" will not match if the command is trying to read a private key. The types supported include:
ANY PRIVATE KEY CERTIFICATE CERTIFICATE REQUEST CMS DH PARAMETERS DSA PARAMETERS DSA PUBLIC KEY EC PARAMETERS EC PRIVATE KEY ECDSA PUBLIC KEY ENCRYPTED PRIVATE KEY PARAMETERS PKCS #7 SIGNED DATA PKCS7 PRIVATE KEY PUBLIC KEY RSA PRIVATE KEY SSL SESSION PARAMETERS TRUSTED CERTIFICATE X509 CRL X9.42 DH PARAMETERS
The following legacy object-type's are also supported for compatibility with earlier releases:
DSA PRIVATE KEY NEW CERTIFICATE REQUEST RSA PUBLIC KEY X509 CERTIFICATE
- An S/MIME object as described in IETF RFC 8551. Earlier versions were known as CMS and are compatible. Note that the parsing is simple and might fail to parse some legal data.
The options to specify the format are as follows. Refer to the individual manpage to see which options are accepted.
- -inform format, -outform format
- The format of the input or output streams.
- -keyform format
- Format of a private key input source. The only value with effect is ENGINE; all others have become obsolete. See "Format Options" in openssl(1) for details.
- -CRLform format
- Format of a CRL input source.
Pass Phrase Options¶Several commands accept password arguments, typically using -passin and -passout for input and output passwords respectively. These allow the password to be obtained from a variety of sources. Both of these options take a single argument whose format is described below. If no password argument is given and a password is required then the user is prompted to enter one: this will typically be read from the current terminal with echoing turned off.
Note that character encoding may be relevant, please see passphrase-encoding(7).
- The actual password is password. Since the password is visible to utilities (like 'ps' under Unix) this form should only be used where security is not important.
- Obtain the password from the environment variable var. Since the environment of other processes is visible on certain platforms (e.g. ps under certain Unix OSes) this option should be used with caution.
- The first line of pathname is the password. If the same pathname argument is supplied to -passin and -passout arguments then the first line will be used for the input password and the next line for the output password. pathname need not refer to a regular file: it could for example refer to a device or named pipe.
- Read the password from the file descriptor number. This can be used to send the data via a pipe for example.
- Read the password from standard input.
Trusted Certificate Options¶Part of validating a certificate includes verifying that the chain of CA's can be traced up to an existing trusted root. The following options specify how to list the trusted roots, also known as trust anchors. A collection of trusted roots is called a trust store.
Note that OpenSSL does not provide a default set of trust anchors. Many Linux distributions include a system default and configure OpenSSL to point to that. Mozilla maintains an influential trust store that can be found at <https://www.mozilla.org/en-US/about/governance/policies/security-group/certs/>.
- -CAfile file
- Load the specified file which contains one or more PEM-format certificates of CA's that are trusted.
- Do not load the default file of trusted certificates.
- -CApath dir
- Use the specified directory as a list of trust certificates. That is, files should be named with the hash of the X.509 SubjectName of each certificate. This is so that the library can extract the IssuerName, hash it, and directly lookup the file to get the issuer certificate. See openssl-rehash(1) for information on creating this type of directory.
- Do not use the default directory of trusted certificates.
- -CAstore uri
- Use uri as a store of trusted CA certificates. The URI may indicate a single certificate, as well as a collection of them. With URIs in the "file:" scheme, this acts as -CAfile or -CApath, depending on if the URI indicates a single file or directory. See ossl_store-file(7) for more information on the "file:" scheme.
- Do not use the default store.
Random State Options¶Prior to OpenSSL 1.1.1, it was common for applications to store information about the state of the random-number generator in a file that was loaded at startup and rewritten upon exit. On modern operating systems, this is generally no longer necessary as OpenSSL will seed itself from a trusted entropy source provided by the operating system. These flags are still supported for special platforms or circumstances that might require them.
It is generally an error to use the same seed file more than once and every use of -rand should be paired with -writerand.
- -rand files
- A file or files containing random data used to seed the random number generator. Multiple files can be specified separated by an OS-dependent character. The separator is ";" for MS-Windows, "," for OpenVMS, and ":" for all others. Another way to specify multiple files is to repeat this flag with different filenames.
- -writerand file
- Writes the seed data to the specified file upon exit. This file can be used in a subsequent command invocation.
Provider Options¶With the move to provider based cryptographic operations in OpenSSL 3.0, options were added to allow specific providers or sets of providers to be used.
- -provider name
- Use the provider identified by name and use all the methods it implements (algorithms, key storage, etc.). This option can be specified multiple time to load more than one provider.
- -provider_path path
- Specify the search path that is used to locate provider modules. The format of path varies depending on the operating system being used.
Extended Verification Options¶Sometimes there may be more than one certificate chain leading to an end-entity certificate. This usually happens when a root or intermediate CA signs a certificate for another a CA in other organization. Another reason is when a CA might have intermediates that use two different signature formats, such as a SHA-1 and a SHA-256 digest.
The following options can be used to provide data that will allow the OpenSSL command to generate an alternative chain.
- -xkey infile, -xcert infile, -xchain
- Specify an extra certificate, private key and certificate chain. These behave in the same manner as the -cert, -key and -cert_chain options. When specified, the callback returning the first valid chain will be in use by the client.
- Specify whether the application should build the certificate chain to be provided to the server for the extra certificates via the -xkey, -xcert, and -xchain options.
- -xcertform DER|PEM|P12
- The input format for the extra certificate. This option has no effect and is retained for backward compatibility only.
- -xkeyform DER|PEM|P12
- The input format for the extra key. This option has no effect and is retained for backward compatibility only.
Verification Options¶Many OpenSSL commands verify certificates. The details of how each command handles errors are documented on the specific command page.
Verification is a complicated process, consisting of a number of separate steps that are detailed in the following paragraphs.
First, a certificate chain is built up starting from the supplied certificate and ending in a root CA. It is an error if the whole chain cannot be built up. The chain is built up by looking up the certificate that signed (or issued) the certificate. It then repeats the process, until it gets to a certificate that is self-issued.
The process of looking up the issuer's certificate itself involves a number of steps. After all certificates whose subject name matches the issuer name of the current certificate are subject to further tests. The relevant authority key identifier components of the current certificate (if present) must match the subject key identifier (if present) and issuer and serial number of the candidate issuer, in addition the keyUsage extension of the candidate issuer (if present) must permit certificate signing.
The lookup first looks in the list of untrusted certificates and if no match is found the remaining lookups are from the trusted certificates. The root CA is always looked up in the trusted certificate list: if the certificate to verify is a root certificate then an exact match must be found in the trusted list.
The second step is to check every untrusted certificate's extensions for consistency with the supplied purpose. If the -purpose option is not included then no checks are done. The supplied or "leaf" certificate must have extensions compatible with the supplied purpose and all other certificates must also be valid CA certificates. The precise extensions required are described in more detail in "CERTIFICATE EXTENSIONS" in openssl-x509(1).
The third step is to check the trust settings on the root CA. The root CA should be trusted for the supplied purpose. For compatibility with previous versions of OpenSSL, a certificate with no trust settings is considered to be valid for all purposes.
The fourth, and final, step is to check the validity of the certificate chain. The validity period is checked against the system time and the "notBefore" and "notAfter" dates in the certificate. The certificate signatures are also checked at this point. The -attime flag may be used to specify a time other than "now."
If all operations complete successfully then certificate is considered valid. If any operation fails then the certificate is not valid.
The details of the processing steps can be fine-tuned with the following flags.
- Print extra information about the operations being performed.
- -attime timestamp
- Perform validation checks using time specified by timestamp and not current system time. timestamp is the number of seconds since January 1, 1970 (i.e., the Unix Epoch).
- This option suppresses checking the validity period of certificates and CRLs against the current time. If option -attime is used to specify a verification time, the check is not suppressed.
- This disables non-compliant workarounds for broken certificates.
- Normally if an unhandled critical extension is present which is not supported by OpenSSL the certificate is rejected (as required by RFC5280). If this option is set critical extensions are ignored.
- Checks end entity certificate validity by attempting to look up a valid CRL. If a valid CRL cannot be found an error occurs.
- Checks the validity of all certificates in the chain by attempting to look up valid CRLs.
- Enable support for delta CRLs.
- Enable extended CRL features such as indirect CRLs and alternate CRL signing keys.
- -suiteB_128_only, -suiteB_128, -suiteB_192
- Enable the Suite B mode operation at 128 bit Level of Security, 128 bit or 192 bit, or only 192 bit Level of Security respectively. See RFC6460 for details. In particular the supported signature algorithms are reduced to support only ECDSA and SHA256 or SHA384 and only the elliptic curves P-256 and P-384.
- -auth_level level
- Set the certificate chain authentication security level to level. The authentication security level determines the acceptable signature and public key strength when verifying certificate chains. For a certificate chain to validate, the public keys of all the certificates must meet the specified security level. The signature algorithm security level is enforced for all the certificates in the chain except for the chain's trust anchor, which is either directly trusted or validated by means other than its signature. See SSL_CTX_set_security_level(3) for the definitions of the available levels. The default security level is -1, or "not set". At security level 0 or lower all algorithms are acceptable. Security level 1 requires at least 80-bit-equivalent security and is broadly interoperable, though it will, for example, reject MD5 signatures or RSA keys shorter than 1024 bits.
- Allow verification to succeed even if a complete chain cannot be built to a self-signed trust-anchor, provided it is possible to construct a chain to a trusted certificate that might not be self-signed.
- Verify the signature on the self-signed root CA. This is disabled by default because it doesn't add any security.
- Allow the verification of proxy certificates.
- As of OpenSSL 1.1.0 this option is on by default and cannot be disabled.
- As of OpenSSL 1.1.0, since -trusted_first always on, this option has no effect.
- -trusted file
- Parse file as a set of one or more certificates in PEM format. All certificates must be self-signed, unless the -partial_chain option is specified. This option implies the -no-CAfile, -no-CApath, and -no-CAstore options and it cannot be used with the -CAfile, -CApath or -CAstore options, so only certificates in the file are trust anchors. This option may be used multiple times.
- -untrusted file
- Parse file as a set of one or more certificates in PEM format. All certificates are untrusted certificates that may be used to construct a certificate chain from the subject certificate to a trust anchor. This option may be used multiple times.
- -policy arg
- Enable policy processing and add arg to the user-initial-policy-set (see RFC5280). The policy arg can be an object name an OID in numeric form. This argument can appear more than once.
- Set policy variable require-explicit-policy (see RFC5280).
- Enables certificate policy processing.
- Print out diagnostics related to policy processing.
- Set policy variable inhibit-any-policy (see RFC5280).
- Set policy variable inhibit-policy-mapping (see RFC5280).
- -purpose purpose
- The intended use for the certificate. If this option is not specified, this command will not consider certificate purpose during chain verification. Currently accepted uses are sslclient, sslserver, nssslserver, smimesign, smimeencrypt.
- -verify_depth num
- Limit the certificate chain to num intermediate CA certificates. A maximal depth chain can have up to num+2 certificates, since neither the end-entity certificate nor the trust-anchor certificate count against the -verify_depth limit.
- -verify_email email
- Verify if email matches the email address in Subject Alternative Name or the email in the subject Distinguished Name.
- -verify_hostname hostname
- Verify if hostname matches DNS name in Subject Alternative Name or Common Name in the subject certificate.
- -verify_ip ip
- Verify if ip matches the IP address in Subject Alternative Name of the subject certificate.
- -verify_name name
- Use default verification policies like trust model and required certificate policies identified by name. The trust model determines which auxiliary trust or reject OIDs are applicable to verifying the given certificate chain. See the -addtrust and -addreject options for openssl-x509(1). Supported policy names include: default, pkcs7, smime_sign, ssl_client, ssl_server. These mimics the combinations of purpose and trust settings used in SSL, CMS and S/MIME. As of OpenSSL 1.1.0, the trust model is inferred from the purpose when not specified, so the -verify_name options are functionally equivalent to the corresponding -purpose settings.
Name Format Options¶OpenSSL provides fine-grain control over how the subject and issuer DN's are displayed. This is specified by using the -nameopt option, which takes a comma-separated list of options from the following set. An option may be preceded by a minus sign, "-", to turn it off. The default value is "oneline". The first four are the most commonly used.
- Display the name using an old format from previous OpenSSL versions.
- Display the name using the format defined in RFC 2253. It is equivalent to esc_2253, esc_ctrl, esc_msb, utf8, dump_nostr, dump_unknown, dump_der, sep_comma_plus, dn_rev and sname.
- Display the name in one line, using a format that is more readable RFC 2253. It is equivalent to esc_2253, esc_ctrl, esc_msb, utf8, dump_nostr, dump_der, use_quote, sep_comma_plus_space, space_eq and sname options.
- Display the name using multiple lines. It is equivalent to esc_ctrl, esc_msb, sep_multiline, space_eq, lname and align.
- Escape the "special" characters in a field, as required by RFC 2253. That is, any of the characters ",+"<>;", "#" at the beginning of a string and leading or trailing spaces.
- Escape the "special" characters in a field as required by RFC 2254 in a field. That is, the NUL character and and of "()*".
- Escape non-printable ASCII characters, codes less than 0x20 (space) or greater than 0x7F (DELETE). They are displayed using RFC 2253 "\XX" notation where XX are the two hex digits representing the character value.
- Escape any characters with the most significant bit set, that is with values larger than 127, as described in esc_ctrl.
- Escapes some characters by surrounding the entire string with quotation marks, """. Without this option, individual special characters are preceded with a backslash character, "\".
- Convert all strings to UTF-8 format first as required by RFC 2253. If the output device is UTF-8 compatible, then using this option (and not setting esc_msb) may give the correct display of multibyte characters. If this option is not set, then multibyte characters larger than 0xFF will be output as "\UXXXX" for 16 bits or "\WXXXXXXXX" for 32 bits. In addition, any UTF8Strings will be converted to their character form first.
- This option does not attempt to interpret multibyte characters in any way. That is, the content octets are merely dumped as though one octet represents each character. This is useful for diagnostic purposes but will result in rather odd looking output.
- Display the type of the ASN1 character string before the value, such as "BMPSTRING: Hello World".
- Any fields that would be output in hex format are displayed using the DER encoding of the field. If not set, just the content octets are displayed. Either way, the #XXXX... format of RFC 2253 is used.
- Dump non-character strings, such as ASN.1 OCTET STRING. If this option is not set, then non character string types will be displayed as though each content octet represents a single character.
- Dump all fields. When this used with dump_der, this allows the DER encoding of the structure to be unambiguously determined.
- Dump any field whose OID is not recognised by OpenSSL.
- sep_comma_plus, sep_comma_plus_space, sep_semi_plus_space, sep_multiline
- Specify the field separators. The first word is used between the Relative Distinguished Names (RDNs) and the second is between multiple Attribute Value Assertions (AVAs). Multiple AVAs are very rare and their use is discouraged. The options ending in "space" additionally place a space after the separator to make it more readable. The sep_multiline starts each field on its own line, and uses "plus space" for the AVA separator. It also indents the fields by four characters. The default value is sep_comma_plus_space.
- Reverse the fields of the DN as required by RFC 2253. This also reverses the order of multiple AVAs in a field, but this is permissible as there is no ordering on values.
- nofname, sname, lname, oid
- Specify how the field name is displayed. nofname does not display the field at all. sname uses the "short name" form (CN for commonName for example). lname uses the long form. oid represents the OID in numerical form and is useful for diagnostic purpose.
- Align field values for a more readable output. Only usable with sep_multiline.
- Places spaces round the equal sign, "=", character which follows the field name.
TLS Version Options¶Several commands use SSL, TLS, or DTLS. By default, the commands use TLS and clients will offer the lowest and highest protocol version they support, and servers will pick the highest version that the client offers that is also supported by the server.
The options below can be used to limit which protocol versions are used, and whether TCP (SSL and TLS) or UDP (DTLS) is used. Note that not all protocols and flags may be available, depending on how OpenSSL was built.
- -ssl3, -tls1, -tls1_1, -tls1_2, -tls1_3, -no_ssl3, -no_tls1, -no_tls1_1, -no_tls1_2, -no_tls1_3
- These options require or disable the use of the specified SSL or TLS protocols. When a specific TLS version is required, only that version will be offered or accepted. Only one specific protocol can be given and it cannot be combined with any of the no_ options.
- -dtls, -dtls1, -dtls1_2
- These options specify to use DTLS instead of DLTS. With -dtls, clients will negotiate any supported DTLS protocol version. Use the -dtls1 or -dtls1_2 options to support only DTLS1.0 or DTLS1.2, respectively.
- -engine id
- Use the engine identified by id and use all the methods it implements (algorithms, key storage, etc.), unless specified otherwise in the command-specific documentation or it is configured to do so, as described in "Engine Configuration Module" in config(5).
ENVIRONMENT¶The OpenSSL library can be take some configuration parameters from the environment. Some of these variables are listed below. For information about specific commands, see openssl-engine(1), openssl-provider(1), openssl-rehash(1), and tsget(1).
For information about the use of environment variables in configuration, see "ENVIRONMENT" in config(5).
For information about all environment variables used by the OpenSSL libraries, see openssl-env(7).
- Enable tracing output of OpenSSL library, by name. This output will only
make sense if you know OpenSSL internals well. Also, it might not give you
any output at all, depending on how OpenSSL was built.
The value is a comma separated list of names, with the following available:
- The tracing functionality.
- General SSL/TLS.
- SSL/TLS cipher.
- Show details about provider and engine configuration.
- The function that is used by RSA, DSA (etc) code to select registered ENGINEs, cache defaults and functional references (etc), will generate debugging summaries.
- Reference counts in the ENGINE structure will be monitored with a line of generated for each change.
- PKCS#5 v2 keygen.
- PKCS#12 key generation.
- PKCS#12 decryption.
- Generates the complete policy tree at various point during X.509 v3 policy evaluation.
- BIGNUM context.
SEE ALSO¶openssl-asn1parse(1), openssl-ca(1), openssl-ciphers(1), openssl-cms(1), openssl-crl(1), openssl-crl2pkcs7(1), openssl-dgst(1), openssl-dhparam(1), openssl-dsa(1), openssl-dsaparam(1), openssl-ec(1), openssl-ecparam(1), openssl-enc(1), openssl-engine(1), openssl-errstr(1), openssl-gendsa(1), openssl-genpkey(1), openssl-genrsa(1), openssl-kdf(1), openssl-mac(1), openssl-nseq(1), openssl-ocsp(1), openssl-passwd(1), openssl-pkcs12(1), openssl-pkcs7(1), openssl-pkcs8(1), openssl-pkey(1), openssl-pkeyparam(1), openssl-pkeyutl(1), openssl-prime(1), openssl-rand(1), openssl-rehash(1), openssl-req(1), openssl-rsa(1), openssl-rsautl(1), openssl-s_client(1), openssl-s_server(1), openssl-s_time(1), openssl-sess_id(1), openssl-smime(1), openssl-speed(1), openssl-spkac(1), openssl-srp(1), openssl-storeutl(1), openssl-ts(1), openssl-verify(1), openssl-version(1), openssl-x509(1), config(5), crypto(7), openssl-env(7). ssl(7), x509v3_config(5)
HISTORY¶The list -XXX-algorithms options were added in OpenSSL 1.0.0; For notes on the availability of other commands, see their individual manual pages.
The -issuer_checks option is deprecated as of OpenSSL 1.1.0 and is silently ignored.
The -xcertform and -xkeyform options are obsolete since OpenSSL 3.0 and have no effect.
The interactive mode, which could be invoked by running "openssl" with no further arguments, was removed in OpenSSL 3.0, and running that program with no arguments is now equivalent to "openssl help".
COPYRIGHT¶Copyright 2000-2020 The OpenSSL Project Authors. All Rights Reserved.
Licensed under the Apache License 2.0 (the "License"). You may not use this file except in compliance with the License. You can obtain a copy in the file LICENSE in the source distribution or at <https://www.openssl.org/source/license.html>. | <urn:uuid:4ba420da-52ea-4d82-b38d-85e24537fa4e> | {
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Lung cancer kills almost 160,000 people yearly and is responsible for more deaths than breast, colon, prostate and pancreas cancers combined (1). More than 80 percent of patients with lung cancer are diagnosed at an advanced stage (2). The National Lung Screening Trial (NLST), which randomized high-risk patients to receive or not to receive low-dose computed tomography (LDCT) screening, demonstrated a 20 percent reduction in mortality among patients who received LDCT screening (3). Notably, LDCT is the first cancer screening test found to reduce overall mortality, not just cancer-specific mortality. After the results of the NLST were released in 2011, the United States Preventive Services Task Force officially recommended yearly LDCT screening for patients aged 55–77 with at least a 30 pack-year history who had smoked within the last 15 years (4). Soon thereafter, lung screening programs were created at various institutions across the country (5,6). But there is growing concern that the implementation of these programs has not been widespread. Reports using the Behavioral Risk Factor Surveillance System (BRFSS) survey data estimated that fewer than 5% of eligible patients receive LDCT screening (7). Our goals were to determine the frequency and geographic variability of LDCT screening in the United States in an insured population.
Source of data
After institutional review board approval was obtained from the Institutional Review Board Committee (IRB 17-109), a retrospective cohort study was performed using enrollment and claims data from Clinformatics Data Mart (CDM), one of the nation’s largest commercial health insurance databases with more than 18,000,000 enrollees (8). Data include the Member Eligibility Tables, which contains information on every member enrolled with the health plan during the specific period, and the Medical Claims Tables, which contains data for inpatient and outpatient professional services including outpatient surgery, laboratory, and radiology. The BRFSS data in 2016 was used to estimate the current smoking rate in each state. The University of Texas Medical Branch Institutional Review Board approved the research and waived informed consent.
We developed separate cohorts for 2016 and 2017. Each cohort included all beneficiaries aged 55–77 years on January 1 of that year, with complete insurance enrollment in that year. In analyses that included comorbidity we restricted the cohort to those with coverage for the prior year (n=2,809,801 for 2016 and 3,227,913 for 2017). The steps for the selection of the cohorts are outlined in the Figure S1.
Beneficiary and regional characteristics
Files provided information on beneficiary age, sex and state information. Chronic obstructive pulmonary disease (COPD) or emphysema was identified by ICD-9 codes 490, 491, 492, 496 or ICD-10 codes J41.1, J43.0, J43.1, J43.2, J43.8, J43.9, J44.0, J44.1, or J44.9 associated with inpatient or outpatient billing claims for the previous 12 months. Elixhauser comorbidity measures with COPD and emphysema excluded were generated from all claims in the 12 months before the date of the LDCT and categorized according to number of comorbidities (0, 1, 2, 3, 4+) (9). We also estimated the presence of smoking-related diagnoses in the 12 months prior to LDCT (not including the date of LDCT) defined by the code V15.82 (history of tobacco use), or ICD-9 codes 305.1 (tobacco use disorder) or 989.84 (toxic effect of tobacco).
The primary outcome measured was whether a patient underwent a LDCT (CPT G0297 or S8032).
The proportions of beneficiaries receiving LDCT were calculated for each month from January 2015 to December 2017. We then analyzed the time trends in LDCT using joinpoint analysis with a non-linear model to identify change points and 95% confidence intervals, and also slopes between the change points (10). Statistical significance for the joinpoint model analysis was present (P<0.01).
For 2016 and 2017, we calculated the proportions of enrollees stratified by patient characteristics. We estimated the relative risk (RR) of undergoing LDCT using odds ratio from logistic regression (11). Because of the size of the cohorts, the 95% confidence intervals for estimates were small, and small differences were statistically significant. Our focus was more on clinical meaningful differences. The proportions of patients with a charge of LDCT for each state in 2017 were calculated to evaluate the state-level variation. The current daily smoking rate in each state was estimated by all patients aged 55–80 from BRFSS in 2016. The correlation between LDCT and current smoking rates was tested by Spearman rank correlation.
All statistical analysis was performed using SAS/STAT software (SAS Institute Inc. 2008 SAS/STAT 9.2, SAS Institute Inc., Cary, NC, USA).
Table 1 shows characteristics of the enrollees, which differed slightly between 2016 and 2017. In 2017, 36.60% were under 65 years old and 53.84% were females; 25.03% were in a health maintenance organization (HMO), an organization in which enrollees pay a fee in return for a range of medical services from providers registered with the organization. Enrollees in 2017 had more comorbidities, a higher rate of prior tobacco diagnoses and more outpatient visits in the previous year. The South Atlantic region was overrepresented compared to the rest of the country.
Figure 1 shows the rate of LDCT screening for each month in 2016 and 2017. The rate rose throughout 2016 and early 2017, and appeared to plateau by approximately July 2017. Joinpoint analysis detected a significant increase in slope around January 2017, from a slope of 0.2 additional enrollees receiving LDCT per 1,000 enrollees per year prior to January 2017 to a slope of 0.4 enrollees per 1,000 per year between January 2017 and May 2017. Thereafter, there was a decrease from 0.4 enrollees per 1,000 per year to 0.1 enrollees per 1,000 per year.
Table 2 shows factors associated with the rate of LDCT screening among enrollees. In the multivariable analyses, enrollees aged 60 to 69 had the highest rates, with those aged 55–59 and 75–77 with the lowest rates. Women had 15% lower odds of receiving LDCT (RR =0.85; 0.81–0.87). There was no difference by whether the enrollee had an HMO vs. fee for service plan, defined as a plan in which medical services which are provided are unbundled and reimbursed separately. Enrollees with 3 or 4+ comorbidities were less likely to receive LDCT. A prior diagnosis of COPD or a diagnosis of current or past tobacco use were both strongly associated with LDCT.
There was also marked regional variation, with enrollees in the West South Central region only one fifth as likely as those in New England to receive LDCT (RR =0.20; 0.18–0.21). Figure 2 presents a map of the LDCT rates in 2017 by states, with rates varying from 1.1 per 1,000 enrollees per year in Oklahoma to 16.7 per 1,000 enrollees per year in Rhode Island.
Figure 3 present a scatter plot showing the LDCT rates in each state and the rates of daily smoking among those age 55–79 in each state estimated by 2016 BRFSS data. There was wide variation in both rates, but no correlation between LDCT rate in each state and the daily smoking rates (P=0.87).
Lung cancer has a poor overall prognosis, with a 5-year survival of only 18% (12). These poor outcomes occur largely because most diagnoses are made in advanced stages. LDCT screening combats this problem by diagnosing cancers at earlier stages. A lung cancer detected by LDCT screening will be discovered at an early stage 64% to 85% of the time (13,14). When comprehensive LDCT screening is implemented in a community, the rate of stage IV diagnoses for the entire community can drop below 15 percent (15). The benefits of LDCT screening have been demonstrated in numerous trials, but there has been difficulty in establishing effective programs which screen a high percentage of eligible patients (16).
To our knowledge, this current study is the first national study using health insurance claims data to estimate rates of LDCT screening. Prior reported rates of LDCT have utilized survey data, which depend on recall and also on a respondent distinguishing LDCT from other radiologic exams (17). Also, the number of subjects on whom there are data is much higher in claims data, allowing for more precise estimation of changes in LDCT rates over time and geographically.
To get an estimate of the percentage of eligible enrollees who underwent screening, we utilized a study from Jemal and Fedewa (18) which claimed that there were 8.4 million people eligible for LDCT screening in 2010. Using that statistic and United States Census data, 13.2% of adults aged 55 to 77 years nationwide are eligible for LDCT screening. If we accept that estimate and apply it to our data, then approximately 4.6% of eligible patients in our study received a LDCT. Other studies have shown similarly low rates of LDCT screening, and these low rates lag well behind screening rates for colon, prostate and breast cancer. While it might be expected that a new test would initially be underutilized and then gradually become more widespread, our data suggest very little increase in national LDCT rates after May of 2017.
The rate of LDCT screening in each state did not necessarily correlate with the rate of smoking. This was unexpected, because current daily smoking rates by state should correlate strongly with eligibility for LDCT screening. The New England states, which have relatively low rates of smoking, highlighted this discordance. One factor which may account for the high rate of screening in New England is the number of approved lung cancer registry sites by the American College of Radiology (ACR). New England is heavily concentrated with approved sites, compared to the rest of the country (7). Future studies could investigate other possible factors, such as the availability of primary care providers, academic medical centers, socioeconomic and racial/ethnic composition, and other elements which may influence LDCT screening rates.
Our study showed that the youngest and oldest groups of eligible patients—those aged 55–59 and 75–77—had the lowest rates of LDCT screening. It is possible that patients aged 55–59 have not accumulated enough smoking exposure to be eligible. But given that 90% of smokers begin by age 18 or younger (19), it is likely that there is a larger percentage of eligible patients in this range, compared to other ages, who are not being screened. One of the primary reasons for this trend may be a lack of awareness among people within this age group. Campaigns to increase awareness in younger patients should help to increase the percentage of patients overall who receive appropriate LDCT screening. Given that approximately 12,000 patients between the ages of 55 to 59 die each year from lung cancer (20), increasing screening in this age group could have a major impact in reducing overall lung cancer mortality.
We found no difference in LDCT screening rates by type of health plan, HMO vs. fee-for-service. Prior studies have found that patients in HMOs were more likely to receive recommended preventive medicine interventions (21). It may be that enrollees in HMOs have lower rates of eligibility for LDCT screening, which we cannot determine with our data.
The minimal increase in LDCT screening rates after May of 2017 suggests that additional measures are required to increase rates. Lack of awareness can be improved with more advertising promoting the benefits of screening. Increased awareness among patients would explain why patients with more outpatient visits in the prior year were more likely to undergo LDCT screening. Existing screening programs can be made more efficient and employ a multidisciplinary approach. And sharing of electronic medical record between screening programs and local hospitals/physicians will allow for more patients to be included in these screening programs (22).
There were some limitations to this study. The Clinformatics data do not include information on enrollee race/ethnicity. Certain regions such as the South Atlantic are over-represented in the data. The 55–64 age group selects for employed individuals and their families. A major limitation is the lack of information on eligibility for LDCT screening. The only information related to tobacco was the use of tobacco-related diagnoses in the prior year, such as “tobacco use disorder”. Such diagnoses are fairly specific in identifying tobacco use, but with low sensitivity (23). Also, there is no way to determine quantity or duration of smoking. Other criteria for LDCT, such as willingness to undergo surgery if a cancer is found, are also not available in these data.
Our review of enrollees aged 55–77 years in the CDM database revealed that the rate of LDCT screening is low, and is increasing only minimally over time. There are large geographic differences in screening rates which are independent of smoking exposure. The youngest enrollees are least likely to receive screening but may have the most potential to gain quality-adjusted life years. Patients who interact more with physicians are more likely to receive LDCT screening. The marked geographic variation provides an opportunity to study areas with high vs. low LDCT rates to determine factors associated with increased utilization.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The University of Texas Medical Branch Institutional Review Board approved the research and waived informed consent.
- National Cancer Institute Surveillance, Epidemiology and End Results Program. Available online: https://seer.cancer.gov/statfacts/html/lungb.html. Accessed August 14th, 2018.
- Gould MK. Clinical Practice. Lung cancer screening with low-dose computed tomography. N Engl J Med 2014;371:1813-20. [Crossref] [PubMed]
- National Lung Screening Trial Research Team, Church TR, Black WC, et al. Results of initial low-dose computed tomographic screening for lung cancer. N Engl J Med 2013;368:1980-91. [Crossref] [PubMed]
- Moyer VA. U.S. Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;160:330-8. [PubMed]
- Kinsinger LS, Anderson C, Kim J, et al. Implementation of lung cancer screening in the veterans health administration. JAMA Intern Med 2017;177:399-406. [Crossref] [PubMed]
- Armstrong K, Kim JJ, Halm EA, et al. Using lessons from breast, cervical and colorectal cancer screening to inform the development of lung cancer screening programs. Cancer 2016;122:1338-42. [Crossref] [PubMed]
- Charkhchi P, Kolenic GE, Carlos RC. Access to lung cancer screening services: preliminary analysis of geographic service distribution using the ACR lung cancer screening registry. J Am Coll Radiol 2017;14:1388-95. [Crossref] [PubMed]
- Gunaseelan V, Kenney B, Lee JS, et al. Invited commentary: databases for surgical health services research: Clinformatics Data Mart. Surgery 2019;165:669-71. [Crossref] [PubMed]
- Elixhauser A, Steiner C, Harris DR, et al. Comorbidity measures for use with administrative data. Med Care 1998;36:8-27. [Crossref] [PubMed]
- Smith PL. Splines as a useful and convenient statistical tool. The American Statistician 1979;33:57-62.
- Zhang J, Yu KF. What’s the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280:1690-1. [Crossref] [PubMed]
- Hubbard MO, Fu P, Margevicius S, et al. Five-year survival does not equal cure in non-small cell lung cancer: a Surveillance, Epidemiology and End Results-based analysis of variables affecting 10-to-18-year survival. J Thorac Cardiovasc Surg 2012;143:1307-13. [Crossref] [PubMed]
- Kanodra NM, Silvestri GA, Tanner NT. Screening and early detection efforts in lung cancer. Cancer 2015;121:1347-56. [Crossref] [PubMed]
- Deffebach ME, Humphrey L. Lung cancer screening. Surg Clin North Am 2015;95:967-78. [Crossref] [PubMed]
- Okereke IC, Bates MF, Jankowich MD, et al. Effects of implementation of lung cancer screening at one veterans affairs medical center. Chest 2016;150:1023-9. [Crossref] [PubMed]
- Fintelmann FJ, Bernheim A, Digumarthy SR, et al. The 10 pillars of lung cancer screening: rationale and logistics of a lung cancer screening program. Radiographics 2015;35:1893-8. [Crossref] [PubMed]
- Huo J, Shen C, Volk RJ, et al. Use of CT and chest radiography for lung cancer screening before and after publication of screening guidelines: intended and unintended uptake. JAMA Intern Med 2017;177:439-41. [Crossref] [PubMed]
- Jemal A, Fedawa S. Lung cancer screening with low-dose computed tomography in the United States-2010 to 2015. JAMA Oncol 2017;3:1278-81. [Crossref] [PubMed]
- U.S. Department of Health and Human Services. The health consequences of smoking-50 years of progress. A report of the surgeon general. Available online: https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf, Accessed August 16, 2018.
- Tanoue LT, Tanner NT, Gould MK, et al. Lung cancer screening. Am J Respir Crit Care Med 2015;191:19-33. [Crossref] [PubMed]
- Xiao Q, Savage GT. HMOs’ consumer-friendliness and preventive health care utilization: exploratory findings from the 2002 Medical Expenditure Panel survey. J Health Hum Serv Adm 2008;31:259-89. [PubMed]
- Raz DJ, Dunham R, Tiep B, et al. Augmented meaningful use criteria to identify patients eligible for lung cancer screening. Ann Thorac Surg 2014;98:996-1002. [Crossref] [PubMed]
- Rostron BL, Chang CM, Pechacek TF. Estimation of cigarette smoking-attributable morbidity in the United States. JAMA Intern Med 2014;174:1922-8. [Crossref] [PubMed] | <urn:uuid:8fe64271-aa38-404b-a925-79b8a60da9ea> | {
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A typewriter is a mechanical or electromechanical machine for typing characters similar to those produced by a printer's movable type. Typically, a typewriter has an array of keys, and each one causes a different single character to be produced on the paper, by means of a ribbon with dried ink struck against the paper by a type element similar to the sorts used in movable type letterpress printing.
On some typewriters, a separate type element (called a typebar) corresponds to each key; others use a single type element (such as a typeball or disc) with a different portion of it used for each character. At the end of the nineteenth century, the term typewriter was also applied to a person who used a typing machine.
The first commercial typewriters were introduced in 1874,but did not become common in offices until after the mid-1880s. The typewriter quickly became an indispensable tool for practically all writing other than personal handwritten correspondence. It was widely used by professional writers, in offices, business correspondence in private homes, and by students preparing term papers.
Typewriters were a standard fixture in most offices up to the 1980s. Thereafter, they began to be largely supplanted by computers. Nevertheless, typewriters remain common in some parts of the world, are required for a few specific applications, and are popular in certain subcultures. In many Indian cities and towns, typewriters are still used, especially in roadside and legal offices due to a lack of continuous, reliable electricity.The QWERTY keyboard layout, developed for typewriters, remains the standard for computer keyboards.
Notable typewriter manufacturers included E. Remington and Sons, IBM, Godrej,Imperial Typewriter Company, Oliver Typewriter Company, Olivetti, Royal Typewriter Company, Smith Corona, Underwood Typewriter Company, Adler Typewriter Company and Olympia Werke .
Although many modern typewriters have one of several similar designs, their invention was incremental, developed by numerous inventors working independently or in competition with each other over a series of decades. As with the automobile, telephone, and telegraph, a number of people contributed insights and inventions that eventually resulted in ever more commercially successful instruments. Historians have estimated that some form of typewriter was invented 52 times as thinkers tried to come up with a workable design.
Some early typing instruments include:
By the mid-19th century, the increasing pace of business communication had created a need for mechanization of the writing process. Stenographers and telegraphers could take down information at rates up to 130 words per minute, whereas a writer with a pen was limited to a maximum of 30 words per minute (the 1853 speed record).
From 1829 to 1870, many printing or typing machines were patented by inventors in Europe and America, but none went into commercial production.[ citation needed ]
In 1865, Rev. Rasmus Malling-Hansen of Denmark invented the Hansen Writing Ball, which went into commercial production in 1870 and was the first commercially sold typewriter. It was a success in Europe and was reported as being used in offices in London as late as 1909.Malling-Hansen used a solenoid escapement to return the carriage on some of his models which makes him a candidate for the title of inventor of the first "electric" typewriter.
According to the book Hvem er skrivekuglens opfinder? (English: Who is the inventor of the Writing Ball?), written by Malling-Hansen's daughter, Johanne Agerskov, in 1865, Malling-Hansen made a porcelain model of the keyboard of his writing ball and experimented with different placements of the letters to achieve the fastest writing speed. Malling-Hansen placed the letters on short pistons that went directly through the ball and down to the paper. This, together with the placement of the letters so that the fastest writing fingers struck the most frequently used letters, made the Hansen Writing Ball the first typewriter to produce text substantially faster than a person could write by hand.
The Hansen Writing Ball was produced with only upper-case characters. The Writing Ball was used as a template for inventor Frank Haven Hall to create a derivative that would produce letter prints cheaper and faster.
Malling-Hansen developed his typewriter further through the 1870s and 1880s and made many improvements, but the writing head remained the same. On the first model of the writing ball from 1870, the paper was attached to a cylinder inside a wooden box. In 1874, the cylinder was replaced by a carriage, moving beneath the writing head. Then, in 1875, the well-known "tall model" was patented, which was the first of the writing balls that worked without electricity. Malling-Hansen attended the world exhibitions in Vienna in 1873 and Paris in 1878 and he received the first-prize for his invention at both exhibitions.
The first typewriter to be commercially successful was patented in 1868 by Americans Christopher Latham Sholes, Frank Haven Hall, Carlos Glidden and Samuel W. Soule in Milwaukee, Wisconsin,although Sholes soon disowned the machine and refused to use or even recommend it. It looked "like something like a cross between a piano and a kitchen table". The working prototype was made by the machinist Matthias Schwalbach. The patent (US 79,265) was sold for $12,000 to Densmore and Yost, who made an agreement with E. Remington and Sons (then famous as a manufacturer of sewing machines) to commercialize the machine as the Sholes and Glidden Type-Writer .
This was the origin of the term typewriter. Remington began production of its first typewriter on March 1, 1873, in Ilion, New York. It had a QWERTY keyboard layout, which, because of the machine's success, was slowly adopted by other typewriter manufacturers. As with most other early typewriters, because the typebars strike upwards, the typist could not see the characters as they were typed.
Coming into the market in the early 1880s,the index typewriter uses a pointer or stylus to choose a letter from an index. The pointer is mechanically linked so that the letter chosen could then be printed, most often by the activation of a lever.
The index typewriter was briefly popular in niche markets. Although they were slower than keyboard type machines they were mechanically simpler and lighter,they were therefore marketed as being suitable for travellers, and because they could be produced more cheaply than keyboard machines, as budget machines for users who needed to produce small quantities of typed correspondence. The index typewriter's niche appeal however soon disappeared, as on the one hand new keyboard typewriters became lighter and more portable and on the other refurbished second hand machines began to become available. The last widely available western index machine was the Mignon typewriter produced by AEG which was produced until 1934. Considered one of the very best of the index typewriters, part of the Mignon's popularity was that it featured both interchangeable indexes and type, allowing the use of different fonts and character sets, something very few keyboard machines allowed and only at considerable added cost.
Although pushed out of the market in most of the world by keyboard machines, successful Japanese and Chinese typewriters are of the index type albeit with a very much larger index and number of type elements.
By about 1910, the "manual" or "mechanical" typewriter had reached a somewhat standardized design. There were minor variations from one manufacturer to another, but most typewriters followed the concept that each key was attached to a typebar that had the corresponding letter molded, in reverse, into its striking head. When a key was struck briskly and firmly, the typebar hit a ribbon (usually made of inked fabric), making a printed mark on the paper wrapped around a cylindrical platen.
The platen was mounted on a carriage that moved horizontally to the left, automatically advancing the typing position, after each character was typed. The carriage-return lever at the far left was then pressed to the right to return the carriage to its starting position and rotating the platen to advance the paper vertically. A small bell was struck a few characters before the right hand margin was reached to warn the operator to complete the word and then use the carriage-return lever.Typewriters for languages written right-to-left operate in the opposite direction.
In most of the early typewriters, the typebars struck upward against the paper, pressed against the bottom of the platen, so the typist could not see the text as it was typed. What was typed was not visible until a carriage return caused it to scroll into view. The difficulty with any other arrangement was ensuring the typebars fell back into place reliably when the key was released. This was eventually achieved with various ingenious mechanical designs and so-called "visible typewriters" which used frontstriking, in which the typebars struck forward against the front side of the platen, became standard.
One of the first was the Daugherty Visible, introduced in 1893, which also introduced the four-bank keyboard that became standard, although the Underwood which came out two years later was the first major typewriter with these features. [ citation needed ]However, older "nonvisible" models continued in production to as late as 1915.
A significant innovation was the shift key, introduced with the Remington No. 2 in 1878. This key physically "shifted" either the basket of typebars, in which case the typewriter is described as "basket shift", or the paper-holding carriage, in which case the typewriter is described as "carriage shift". Either mechanism caused a different portion of the typebar to come in contact with the ribbon/platen. The result is that each typebar could type two different characters, cutting the number of keys and typebars in half (and simplifying the internal mechanisms considerably). The obvious use for this was to allow letter keys to type both upper and lower case, but normally the number keys were also duplexed, allowing access to special symbols such as percent,, and ampersand, .
Before the shift key, typewriters had to have a separate key and typebar for upper-case letters; in essence, the typewriter had two keyboards, one above the other. With the shift key, manufacturing costs (and therefore purchase price) were greatly reduced, and typist operation was simplified; both factors contributed greatly to mass adoption of the technology. Certain models, such as the Barlet, had a double shift so that each key performed three functions. These little three-row machines were portable and could be used by journalists.
However, because the shift key required more force to push (its mechanism was moving a much larger mass than other keys), and was operated by the little finger (normally the weakest finger on the hand), it was difficult to hold the shift down for more than two or three consecutive strokes. The "shift lock" key (the precursor to the modern caps lock) allowed the shift operation to be maintained indefinitely.
To facilitate typewriter use in business settings, a tab (tabulator) key was added in the late nineteenth century. Before using the key, the operator had to set mechanical "tab stops", pre-designated locations to which the carriage would advance when the tab key was pressed. This facilitated the typing of columns of numbers, freeing the operator from the need to manually position the carriage. The first models had one tab stop and one tab key; later ones allowed as many stops as desired, and sometimes had multiple tab keys, each of which moved the carriage a different number of spaces ahead of the decimal point (the tab stop), to facilitate the typing of columns with numbers of different length ($1.00, $10.00, $100.00, etc.)
Languages such as French, Spanish, and German required diacritics, special signs attached to or on top of the base letter: for example, a combination of the acute accent ⟨é⟩, ⟨ñ⟩, and others were separate sorts. With mechanical typewriters, the number of whose characters (sorts) was constrained by the physical limits of the machine, the number of keys required was reduced by the use of dead keys. Diacritics such as (acute accent) would be assigned to a dead key, which did not move the platen forward, permitting another character to be imprinted at the same location; thus a single dead key such as the acute accent could be combined with , , , and to produce , , , and , reducing the number of sorts needed from 5 to 1. The typebars of "normal" characters struck a rod as they moved the metal character desired toward the ribbon and platen, and each rod depression moved the platen forward the width of one character. Dead keys had a typebar shaped so as not to strike the rod.plus produced ; plus produced . In metal typesetting,
The tilde character,, never seen in isolation in metal typesetting, became a separate character in ASCII as a result of its use on dead keys for Spanish and Portuguese (see Tilde#Role of mechanical typewriters).
In English-speaking countries, ordinary typewriters printing fixed-width characters were standardized to print six horizontal lines per vertical inch, and had either of two variants of character width, one called pica for ten characters per horizontal inch and the other elite, for twelve. This differed from the use of these terms in printing, where pica is a linear unit (approximately 1⁄6 of an inch) used for any measurement, the most common one being the height of a type face.
Some typewriters were designed to print extra-large type (commonly double height, double width) for labelling purposes. Classification numbers on books in libraries could be done this way.
Some ribbons were inked in black and red stripes, each being half the width and running the entire length of the ribbon. A lever on most machines allowed switching between colors, which was useful for bookkeeping entries where negative amounts were highlighted in red. The red color was also used on some selected characters in running text, for emphasis. When a typewriter had this facility, it could still be fitted with a solid black ribbon; the lever was then used to switch to fresh ribbon when the first stripe ran out of ink. Some typewriters also had a third position which stopped the ribbon being struck at all. This enabled the keys to hit the paper unobstructed, and was used for cutting stencils for stencil duplicators (aka mimeograph machines).
In the early part of the 20th century, a typewriter was marketed under the name Noiseless and advertised as "silent". It was developed by Wellington Parker Kidder and the first model was marketed by the Noiseless Typewriter Company in 1917. An agreement with Remington in 1924 saw production transferred to Remington, and a further agreement in 1929 allowed Underwood to produce it as well.Noiseless portables sold well in the 1930s and 1940s, and noiseless standards continued to be manufactured until the 1960s.
In a conventional typewriter the typebar reaches the end of its travel simply by striking the ribbon and paper. A "noiseless" typewriter has a complex lever mechanism that decelerates the typebar mechanically before pressing it against the ribbon and paper [ citation needed ]in an attempt to dampen the noise. It certainly reduced the high-frequency content of the sound, rendering it more of a "clunk" than a "clack" and arguably less intrusive, but such advertising claims as "A machine that can be operated a few feet away from your desk – And not be heard" were not true.
Although electric typewriters would not achieve widespread popularity until nearly a century later, the basic groundwork for the electric typewriter was laid by the Universal Stock Ticker, invented by Thomas Edison in 1870. This device remotely printed letters and numbers on a stream of paper tape from input generated by a specially designed typewriter at the other end of a telegraph line.
Some electric typewriters were patented in the 19th century, but the first machine known to be produced in series is the Cahill of 1900.
Another electric typewriter was produced by the Blickensderfer Manufacturing Company, of Stamford, Connecticut, in 1902. Like the manual Blickensderfer typewriters, it used a cylindrical typewheel rather than individual typebars. The machine was produced in several variants but apparently it was not a commercial success, for reasons that are unclear.
The next step in the development of the electric typewriter came in 1910, when Charles and Howard Krum filed a patent for the first practical teletypewriter.The Krums' machine, named the Morkrum Printing Telegraph, used a typewheel rather than individual typebars. This machine was used for the first commercial teletypewriter system on Postal Telegraph Company lines between Boston and New York City in 1910.
James Fields Smathers of Kansas City invented what is considered the first practical power-operated typewriter in 1914. In 1920, after returning from Army service, he produced a successful model and in 1923 turned it over to the Northeast Electric Company of Rochester for development. Northeast was interested in finding new markets for their electric motors and developed Smathers's design so that it could be marketed to typewriter manufacturers, and from 1925 Remington Electric typewriters were produced powered by Northeast's motors.
After some 2,500 electric typewriters had been produced, Northeast asked Remington for a firm contract for the next batch. However, Remington was engaged in merger talks, which would eventually result in the creation of Remington Rand and no executives were willing to commit to a firm order. Northeast instead decided to enter the typewriter business for itself, and in 1929 produced the first Electromatic Typewriter.
In 1928, Delco, a division of General Motors, purchased Northeast Electric, and the typewriter business was spun off as Electromatic Typewriters, Inc. In 1933, Electromatic was acquired by IBM, which then spent $1 million on a redesign of the Electromatic Typewriter, launching the IBM Electric Typewriter Model 01 in 1935. By 1958 IBM was deriving 8% of its revenue from the sale of electric typewriters.
In 1931, an electric typewriter was introduced by Varityper Corporation. It was called the Varityper, because a narrow cylinder-like wheel could be replaced to change the font.
Electrical typewriter designs removed the direct mechanical connection between the keys and the element that struck the paper. Not to be confused with later electronic typewriters, electric typewriters contained only a single electrical component — the motor. Where the keystroke had previously moved a typebar directly, now it engaged mechanical linkages that directed mechanical power from the motor into the typebar.
In 1941, IBM announced the Electromatic Model 04 electric typewriter, featuring the revolutionary concept of proportional spacing. By assigning varied rather than uniform spacing to different sized characters, the Type 4 recreated the appearance of a typeset page, an effect that was further enhanced by including the 1937 innovation of carbon-film ribbons that produced clearer, sharper words on the page.The proportional spacing feature became a staple of the IBM Executive series typewriters.
IBM and Remington Rand electric typewriters were the leading models until IBM introduced the IBM Selectric typewriter in 1961, which replaced the typebars with a spherical element (or typeball) slightly smaller than a golf ball, with reverse-image letters molded into its surface. The Selectric used a system of latches, metal tapes, and pulleys are driven by an electric motor to rotate the ball into the correct position and then strike it against the ribbon and platen. The typeball moved laterally in front of the paper, instead of the previous designs using a platen-carrying carriage moving the paper across a stationary print position.
Due to the physical similarity, the typeball was sometimes referred to as a "golfball".The typeball design had many advantages, especially the elimination of "jams" (when more than one key was struck at once and the typebars became entangled) and in the ability to change the typeball, allowing multiple fonts to be used in a single document.
The IBM Selectric became a commercial success, dominating the office typewriter market for at least two decades. [ citation needed ] By the 1970s, IBM had succeeded in establishing the Selectric as the de facto standard typewriter in mid- to high-end office environments, replacing the raucous "clack" of older typebar machines with the quieter sound of gyrating typeballs.IBM also gained an advantage by marketing more heavily to schools than did Remington, with the idea that students who learned to type on a Selectric would later choose IBM typewriters over the competition in the workplace as businesses replaced their old manual models.
Later models of IBM Executives and Selectrics replaced inked fabric ribbons with "carbon film" ribbons that had a dry black or colored powder on a clear plastic tape. These could be used only once, but later models used a cartridge that was simple to replace. A side effect of this technology was that the text typed on the machine could be easily read from the used ribbon, raising issues where the machines were used for preparing classified documents (ribbons had to be accounted for to ensure that typists did not carry them from the facility).
A variation known as "Correcting Selectrics" introduced a correction feature, where a sticky tape in front of the carbon film ribbon could remove the black-powdered image of a typed character, eliminating the need for little bottles of white dab-on correction fluid and for hard erasers that could tear the paper. These machines also introduced selectable "pitch" so that the typewriter could be switched between pica type (10 characters per inch) and elite type (12 per inch), even within one document. Even so, all Selectrics were monospaced—each character and letterspace was allotted the same width on the page, from a capital "W" to a period. Although IBM had produced a successful typebar-based machine with five levels of proportional spacing, called the IBM Executive,proportional spacing was not provided with the Selectric typewriter or its successors the Selectric II and Selectric III.
The only fully electromechanical Selectric Typewriter with fully proportional spacing and which used a Selectric type element was the expensive Selectric Composer, which was capable of right-margin justification (typing each line twice was required, once to calculate and again to print) and was considered a typesetting machine rather than a typewriter. Composer typeballs physically resembled those of the Selectric typewriter but were not interchangeable.
In addition to its electronic successors, the Magnetic Tape Selectric Composer (MT/SC), the Mag Card Selectric Composer, and the Electronic Selectric Composer, IBM also made electronic typewriters with proportional spacing using the Selectric element that were considered typewriters or word processors instead of typesetting machines.
The first of these was the relatively obscure Mag Card Executive, which used 88-character elements. Later, some of the same typestyles used for it were used on the 96-character elements used on the IBM Electronic Typewriter 50 and the later models 65 and 85.
By 1970, as offset printing began to replace letterpress printing, the Composer would be adapted as the output unit for a typesetting system. The system included a computer-driven input station to capture the key strokes on magnetic tape and insert the operator's format commands, and a Composer unit to read the tape and produce the formatted text for photo reproduction.
The IBM 2741 terminal was a popular example of a Selectric-based computer terminal, and similar mechanisms were employed as the console devices for many IBM System/360 computers. These mechanisms used "ruggedized" designs compared to those in standard office typewriters.
Some of IBM's advances were later adopted in less expensive machines from competitors. For example, Smith-Corona electric typewriters introduced in 1973 switched to interchangeable Coronamatic (SCM-patented) ribbon cartridges,including fabric, film, erasing, and two-color versions. At about the same time, the advent of photocopying meant that carbon copies, correction fluid and erasers were less and less necessary; only the original need be typed, and photocopies made from it.
Towards the end of the commercial popularity of typewriters in the 1970s, a number of hybrid designs combining features of printers were introduced. These often incorporated keyboards from existing models of typewriters and printing mechanisms of dot-matrix printers. The generation of teleprinters with impact pin-based printing engines was not adequate for the demanding quality required for typed output, and alternative thermal transfer technologies used in thermal label printers had become technically feasible for typewriters.
IBM produced a series of typewriters called Thermotronic with letter-quality output and correcting tape along with printers tagged Quietwriter. Brother extended the life of their typewriter product line with similar products. The development of these proprietary printing engines provided the vendors with exclusive markets in consumable ribbons and the ability to use standardized printing engines with varying degrees of electronic and software sophistication to develop product lines. Although these changes reduced prices—and greatly increased the convenience—of typewriters, the technological disruption posed by word processors left these improvements with only a short-term low-end market. To extend the life of these products, many examples were provided with communication ports to connect them to computers as printers.
The final major development of the typewriter was the electronic typewriter. Most of these replaced the typeball with a plastic or metal daisy wheel mechanism (a disk with the letters molded on the outside edge of the "petals"). The daisy wheel concept first emerged in printers developed by Diablo Systems in the 1970s. The first electronic daisywheel typewriter marketed in the world (in 1976) is the Olivetti Tes 501, and subsequently in 1978, the Olivetti ET101 (with function display) and Olivetti TES 401 (with text display and floppy disk for memory storage). This has allowed Olivetti to maintain the world record in the design of electronic typewriters, proposing increasingly advanced and performing models in the following years.In 1981, Xerox Corporation, who by then had bought Diablo Systems, introduced a line of electronic typewriters incorporating this technology (the Memorywriter product line). For a time, these products were quite successful as their daisy-wheel mechanism was much simpler and cheaper than either typebar or Selectric mechanisms, and their electronic memory and display allowed the user to easily see errors and correct them before they were actually printed. One problem with the plastic daisy wheel was that they were not always durable. To solve this problem, more durable metal daisy wheels were made available (but at a slightly higher price).
These and similar electronic typewriters were in essence dedicated word processors with either single-line LCD displays or multi-line CRT displays, built-in line editors in ROM, a spelling and grammar checker, a few kilobytes of internal RAM and optional cartridge, magnetic card or diskette external memory-storage devices for storing text and even document formats. Text could be entered a line or paragraph at a time and edited using the display and built-in software tools before being committed to paper.
Unlike the Selectrics and earlier models, these really were "electronic" and relied on integrated circuits and electromechanical components. These typewriters were sometimes called display typewriters,dedicated word processors or word-processing typewriters, though the latter term was also frequently applied to less sophisticated machines that featured only a tiny, sometimes just single-row display. Sophisticated models were also called word processors, though today that term almost always denotes a type of software program. Manufacturers of such machines included Olivetti (TES501, first totally electronic Olivetti word processor with daisywheel and floppy disk in 1976; TES621 in 1979 etc.), Brother (Brother WP1 and WP500 etc., where WP stood for word processor), Canon (Canon Cat), Smith-Corona (PWP, i.e. Personal Word Processor line) and Philips/Magnavox (VideoWriter).
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The 1970s and early 1980s were a time of transition for typewriters and word processors. At one point in time, most small-business offices would be completely "old-style", while large corporations and government departments would already be "new-style"; other offices would have a mixture.[ citation needed ] The pace of change was so rapid that it was common for clerical staff to have to learn several new systems, one after the other, in just a few years.[ citation needed ] While such rapid change is commonplace today, and is taken for granted, this was not always so; in fact, typewriting technology changed very little in its first 80 or 90 years.[ citation needed ]
Due to falling sales, IBM sold its typewriter division in 1991 to the newly formed Lexmark, completely exiting from a market it once dominated.
The increasing dominance of personal computers, desktop publishing, the introduction of low-cost, truly high-quality laser and inkjet printer technologies, and the pervasive use of web publishing, e-mail and other electronic communication techniques have largely replaced typewriters in the United States. Still, as of 2009 [update] , typewriters continued to be used by a number of government agencies and other institutions in the US, where they are primarily used to fill preprinted forms. According to a Boston typewriter repairman quoted by The Boston Globe , "Every maternity ward has a typewriter, as well as funeral homes". A fairly major typewriter user is the City of New York, which in 2008 purchased several thousand typewriters, mostly for use by the New York Police Department, at the total cost of $982,269. Another $99,570 was spent in 2009 for the maintenance of the existing typewriters. New York police officers would use the machines to type property and evidence vouchers on carbon paper forms.
A rather specialized market for typewriters exists due to the regulations of many correctional systems in the US, where prisoners are prohibited from having computers or telecommunication equipment, but are allowed to own typewriters. The Swintec corporation (headquartered in Moonachie, New Jersey), which, as of 2011, still produced typewriters at its overseas factories (in Japan, Indonesia, and/or Malaysia), manufactures a variety of typewriters for use in prisons, made of clear plastic (to make it harder for prisoners to hide prohibited items inside it). As of 2011, the company had contracts with prisons in 43 US states.
In April 2011, Godrej and Boyce, a Mumbai-based manufacturer of mechanical typewriters, closed its doors, leading to a flurry of news reports that the "world's last typewriter factory" had shut down.The reports were quickly contested, with opinions settling to agree that it was indeed the world's last producer of manual typewriters.
In November 2012, Brother's UK factory manufactured what it claimed to be the last typewriter ever made in the UK; the typewriter was donated to the London Science Museum.
Russian typewriters use Cyrillic, which has made the ongoing Azerbaijani reconversion from Cyrillic to Latin alphabet more difficult. In 1997, the government of Turkey offered to donate western typewriters to the Republic of Azerbaijan in exchange for more zealous and exclusive promotion of the Latin alphabet for the Azerbaijani language; this offer, however, was declined.
In Latin America and Africa, mechanical typewriters are still common because they can be used without electrical power. In Latin America, the typewriters used are most often Brazilian models; Brazil continues to produce mechanical (Facit) and electronic (Olivetti) typewriters to the present day.
The 21st century has seen a revival of interest in typewriters among certain subcultures, including makers, steampunks, hipsters, and street poets.
According to the standards taught in secretarial schools in the mid-20th century, a business letter was supposed to have no mistakes and no visible corrections.[ citation needed ] Accuracy was prized as much as speed. Indeed, typing speeds, as scored in proficiency tests and typewriting speed competitions, included a deduction of ten words for every mistake. Corrections were, of course, necessary, and many methods were developed.
In practice, several methods would often be combined. For example, if six extra copies of a letter were needed, the fluid-corrected original would be photocopied, but only for the two recipients getting a c.c.; the other four copies, the less-important file copies that stayed in various departments at the office, would be cheaper, hand-erased, less-distinct bond paper copies or even "flimsies" of different colors (tissue papers interleaved with black carbon paper) that were all typed as a "carbon pack" at the same time as the original.
In informal applications such as personal letters where low priority was placed on the appearance of the document, or conversely in highly formal applications in which it was important that any corrections be obvious, the backspace key could be used to back up over the error and then overstrike it with hyphens, slashes, Xs, or the like.
The traditional erasing method involved the use of a special typewriter eraser made of hard rubber that contained an abrasive material. Some were thin, flat disks, pink or gray, approximately 2 inches (51 mm) in diameter by 1⁄8 inch (3.2 mm) thick, with a brush attached from the center, while others looked like pink pencils, with a sharpenable eraser at the "lead" end and a stiff nylon brush at the other end. Either way, these tools made possible erasure of individual typed letters. Business letters were typed on heavyweight, high-rag-content bond paper, not merely to provide a luxurious appearance, but also to stand up to erasure.
Typewriter eraser brushes were necessary for clearing eraser crumbs and paper dust, and using the brush properly was an important element of typewriting skill; if erasure detritus fell into the typewriter, a small buildup could cause the typebars to jam in their narrow supporting grooves.
Erasing a set of carbon copies was particularly difficult, and called for the use of a device called an eraser shield (a thin stainless-steel rectangle about 2 by 3 inches (51 by 76 mm) with several tiny holes in it) to prevent the pressure of erasing on the upper copies from producing carbon smudges on the lower copies. To correct copies, typists had to go from carbon copy to carbon copy, trying not to get their fingers dirty as they leafed through the carbon papers, and moving and repositioning the eraser shield and eraser for each copy.
Paper companies produced a special form of typewriter paper called erasable bond (for example, Eaton's Corrasable Bond). This incorporated a thin layer of material that prevented ink from penetrating and was relatively soft and easy to remove from the page. An ordinary soft pencil eraser could quickly produce perfect erasures on this kind of paper. However, the same characteristics that made the paper erasable made the characters subject to smudging due to ordinary friction and deliberate alteration after the fact, making it unacceptable for business correspondence, contracts, or any archival use.
In the 1950s and 1960s, correction fluid made its appearance, under brand names such as Liquid Paper, Wite-Out and Tipp-Ex; it was invented by Bette Nesmith Graham. Correction fluid was a kind of opaque, white, fast-drying paint that produced a fresh white surface onto which, when dry, a correction could be retyped. However, when held to the light, the covered-up characters were visible, as was the patch of dry correction fluid (which was never perfectly flat, and frequently not a perfect match for the color, texture, and luster of the surrounding paper). The standard trick for solving this problem was photocopying the corrected page, but this was possible only with high quality photocopiers.
A different fluid was available for correcting stencils. It sealed up the stencil ready for retyping but did not attempt to color match.
Dry correction products (such as correction paper) under brand names such as "Ko-Rec-Type" were introduced in the 1970s and functioned like white carbon paper. A strip of the product was placed over the letters needing correction, and the incorrect letters were retyped, causing the black character to be overstruck with a white overcoat. Similar material was soon incorporated in carbon-film electric typewriter ribbons; like the traditional two-color black-and-red inked ribbon common on manual typewriters, a black and white correcting ribbon became commonplace on electric typewriters. But the black or white coating could be partly rubbed off with handling, so such corrections were generally not acceptable in legal documents.
The pinnacle of this kind of technology was the IBM Electronic Typewriter series. These machines, and similar products from other manufacturers, used a separate correction ribbon and a character memory. With a single keystroke, the typewriter was capable of automatically backspacing and then overstriking the previous characters with minimal marring of the paper. White cover-up ribbons were used with fabric ink ribbons, or an alternate premium design featured plastic lift-off correction ribbons which were used with carbon film typing ribbons. This latter technology actually lifted the carbon film forming a typed letter, leaving nothing more than a flattened depression in the surface of the paper, with the advantage that no color matching of the paper was needed.
The 1874 Sholes & Glidden typewriters established the "QWERTY" layout for the letter keys. During the period in which Sholes and his colleagues were experimenting with this invention, other keyboard arrangements were apparently tried, but these are poorly documented.The QWERTY layout of keys has become the de facto standard for English-language typewriter and computer keyboards. Other languages written in the Latin alphabet sometimes use variants of the QWERTY layouts, such as the French AZERTY, the Italian QZERTY and the German QWERTZ layouts.
The QWERTY layout is not the most efficient layout possible for the English language, since it requires a touch-typist to move his or her fingers between rows to type the most common letters. Although the QWERTY keyboard was the most commonly used layout in typewriters, a better, less strenuous keyboard was being searched for throughout the late 1900s.
One popular but unverifiedexplanation for the QWERTY arrangement is that it was designed to reduce the likelihood of internal clashing of typebars by placing commonly used combinations of letters farther from each other inside the machine.
A number of radically different layouts such as Dvorak have been proposed to reduce the perceived inefficiencies of QWERTY, but none have been able to displace the QWERTY layout; their proponents claim considerable advantages, but so far none has been widely used. The Blickensderfer typewriter with its DHIATENSOR layout may have possibly been the first attempt at optimizing the keyboard layout for efficiency advantages.
Many non-Latin alphabets have keyboard layouts that have nothing to do with QWERTY. The Russian layout, for instance, puts the common trigrams ыва, про, and ить on adjacent keys so that they can be typed by rolling the fingers. The Greek layout, on the other hand, is a variant of QWERTY.
Typewriters were also made for East Asian languages with thousands of characters, such as Chinese or Japanese. They were not easy to operate, but professional typists used them for a long time until the development of electronic word processors and laser printers in the 1980s.
On modern keyboards, the exclamation point is the shifted character on the 1 key, a direct result of the historical fact that these were the last characters to become "standard" on keyboards. Holding the spacebar pressed down usually suspended the carriage advance mechanism (a so-called "dead key" feature), allowing one to superimpose multiple keystrikes on a single location. The ¢ symbol (meaning cents) was located above the number 6 on electric typewriters, while ASCII computer keyboards have ^ instead.
A number of typographical conventions originate from the widespread use of the typewriter, based on the characteristics and limitations of the typewriter itself. For example, the QWERTY keyboard typewriter did not include keys for the en dash and the em dash. To overcome this limitation, users typically typed more than one adjacent hyphen to approximate these symbols. This typewriter convention is still sometimes used today, even though modern computer word processing applications can input the correct en and em dashes for each font type.Double hyphens are also standard in Western comics lettering despite historically being done by hand.
Other examples of typewriter practices that are sometimes still used in desktop publishing systems include inserting a double space between sentences,and the use of the typewriter apostrophe, , and straight quotes, , as quotation marks and prime marks. The practice of underlining text in place of italics and the use of all capitals to provide emphasis are additional examples of typographical conventions that derived from the limitations of the typewriter keyboard that still carry on today.
Many older typewriters did not include a separate key for the numeralor the exclamation point , and some even older ones also lacked the numeral zero, . Typists who trained on these machines learned the habit of using the lowercase letter ("ell") for the digit , and the uppercase ('oh') for the zero. A cents symbol, was created by combining (over-striking) a lower case with a slash character (typing , then backspace, then ).
Similarly, the exclamation point was created by combining an apostrophe and a period ('+. ≈ ). These characters were omitted to simplify design and reduce manufacturing and maintenance costs; they were chosen specifically because they were "redundant" and could be recreated using other keys.
Some terminology from the typewriter age has survived into the personal computer era. Examples include:
In the above listing, the two-letter codes in parentheses are abbreviations for the ASCII characters derived from typewriter usage.
When Remington started marketing typewriters, the company assumed the machine would not be used for composing but for transcribing dictation, and that the person typing would be a woman. The 1800s Sholes and Glidden typewriter had floral ornamentation on the case.
During World Wars I and II, increasing numbers of women were entering the workforce. In the United States, women often started in the professional workplace as typists. Questions about morals made a salacious businessman making sexual advances to a female typist into a cliché of office life, appearing in vaudeville and movies. Being a typist was considered the right choice for a "good girl", meaning women who present themselves as being chaste and having good conduct.According to the 1900 census, 94.9% of stenographers and typists were unmarried women.
The "Tijuana bibles" – adult comic books produced in Mexico for the American market, starting in the 1930s – often featured women typists. In one panel, a businessman in a three-piece suit, ogling his secretary's thigh, says, "Miss Higby, are you ready for—ahem!—er—dictation?"
The typewriter was a useful machine during the censorship era of the Soviet government, starting during the Russian Civil War (1917-1922). Samizdat was a form of self-publication used when the government was censoring what literature the public could access. The Soviet government signed a Decree on Press which prohibited the publishing of any written work that wasn't previously read over and approved.This work was copied by hand, most often on typewriters. There was a new law in 1983 that required any owner of a typewriter needed to get police permission to buy or keep, they would have to register a type sample of letters and numbers to ensure that any illegal literature typed with it could be traced back to its source. The typewriter became increasingly popular as the interest in prohibited books grew.
Typewritten documents may be examined by forensic document examiners. This is done primarily to determine 1) the make and/or model of the typewriter used to produce a document, or 2) whether or not a particular suspect typewriter might have been used to produce a document.In some situations, an ink or correction ribbon may also be examined.
The determination of a make and/or model of typewriter is a 'classification' problem and several systems have been developed for this purpose.These include the original Haas Typewriter Atlases (Pica version) and (Non-Pica version) and the TYPE system developed by Dr. Philip Bouffard, the Royal Canadian Mounted Police's Termatrex Typewriter classification system, and Interpol's typewriter classification system, among others.
Because of the tolerances of the mechanical parts, slight variation in the alignment of the letters and their uneven wear, each typewriter has an individual "signature" or "fingerprint", which may permit a typewritten document to be traced back to the typewriter on which it was produced. For devices utilizing replaceable components, such as a typeball element, any association may be restricted to a specific element, rather than to the typewriter as a whole.
The earliest reference in fictional literature to the potential identification of a typewriter as having produced a document was by Sir Arthur Conan Doyle, who wrote the Sherlock Holmes short story "A Case of Identity" in 1891.In non-fiction, the first document examiner to describe how a typewriter might be identified was William E. Hagan who wrote, in 1894, "All typewriter machines, even when using the same kind of type, become more or less peculiar by use as to the work done by them". Other early discussions of the topic were provided by A. S. Osborn in his 1908 treatise, Typewriting as Evidence, and again in his 1929 textbook, Questioned Documents. A modern description of the examination procedure is laid out in ASTM Standard E2494-08 (Standard Guide for Examination of Typewritten Items).
Typewriter examination was used in the Leopold and Loeb and Alger Hiss cases. In the Eastern Bloc, typewriters (together with printing presses, copy machines, and later computer printers) were a controlled technology, with secret police in charge of maintaining files of the typewriters and their owners. In the Soviet Union, the First Department of each organization sent data on organization's typewriters to the KGB. This posed a significant risk for dissidents and samizdat authors. In Romania, according to State Council Decree No. 98 of March 28, 1983, owning a typewriter, both by businesses or by private persons, was subject to an approval given by the local police authorities.People previously convicted of any crime or those who because of their behaviour were considered to be "a danger to public order or to the security of the state" were refused approval. In addition, once a year, typewriter owners had to take the typewriter to the local police station, where they would be asked to type a sample of all the typewriter's characters. It was also forbidden to borrow, lend, or repair typewriters other than at the places that had been authorized by the police.
The ribbon can be read, although only if it has not been typed over more than once. This is not as easy as reading text from a page as the ribbon does not include spaces, but can be done, giving every typewriter a "memory".
QWERTY is a keyboard design for Latin-script alphabets. The name comes from the order of the first six keys on the top left letter row of the keyboard. The QWERTY design is based on a layout created for the Sholes and Glidden typewriter and sold to E. Remington and Sons in 1873. It became popular with the success of the Remington No. 2 of 1878, and remains in ubiquitous use.
A word processor is an electronic device for composing, editing, formatting, and printing text.
Daisy wheel printing is an impact printing technology invented in 1970 by Dr Andrew Gabor at Diablo Data Systems. It uses interchangeable pre-formed type elements, each with typically 96 glyphs, to generate high-quality output comparable to premium typewriters such as the IBM Selectric, but two to three times faster. Daisy wheel printing was used in electronic typewriters, word processors and computers from 1972. The daisy wheel is considered to be so named because of its resemblance to the daisy flower.
The IBM Electric typewriters were a series of electric typewriters that IBM manufactured, starting in the mid-1930s. They used the conventional moving carriage and typebar mechanism, as opposed to the fixed carriage and type ball used in the IBM Selectric, introduced in 1961. After 1944, each model came in both "Standard" and "Executive" versions, the latter featuring proportional spacing.
Touch typing is a style of typing. Although the phrase refers to typing without using the sense of sight to find the keys—specifically, a touch typist will know their location on the keyboard through muscle memory—the term is often used to refer to a specific form of touch typing that involves placing the eight fingers in a horizontal row along the middle of the keyboard and having them reach for specific other keys. Both two-handed touch typing and one-handed touch typing are possible.
Caps Lock⇪ Caps Lock is a button on a computer keyboard that causes all letters of Latin and Cyrillic based scripts to be generated in capital letters. It is a toggle key: each press reverses the previous action. Some keyboards also implement a light, to give visual feedback about whether it is on or off. Exactly what Caps Lock does depends on the keyboard hardware, the operating system, the device driver, and the keyboard layout. Usually, the effect is limited to letter keys; letters of Latin-based scripts are capitalized, while letters of other texts and non-letter characters are generated normally. Whenever the key is engaged, the shift keys could be used to type lowercase letters on many operating systems, but not macOS.
The Friden Flexowriter was a teleprinter, a heavy-duty electric typewriter capable of being driven not only by a human typing, but also automatically by several methods, including direct attachment to a computer and by use of paper tape.
The space bar, spacebar, blank, or space keySpace bar is a key on a typewriter or alphanumeric keyboard in the form of a horizontal bar in the lowermost row, significantly wider than other keys. Its main purpose is to conveniently enter a space, e.g., between words during typing.
The Diablo 630 was a daisy wheel printer sold by the Diablo Data Systems division of the Xerox Corporation from 1980. The printer was capable of letter-quality printing; that is, its print quality was equivalent to the quality of an IBM Selectric typewriter, Selectric-based printer, or similar quality printer.
The Olivetti Lettera 22[oliˈvetti ˈlɛttera ventiˈdue] is a portable mechanical typewriter designed by Marcello Nizzoli in 1949 or, according to the company's current owner Telecom Italia, 1950. This typewriter was very popular in Italy, and it still has many fans. It was awarded the Compasso d'oro prize in 1954. In 1959 the Illinois Institute of Technology chose the Lettera 22 as the best design product of the last 100 years.
The Blickensderfer Typewriter was invented by George Canfield Blickensderfer (1850–1917) and patented on August 4, 1891. Blickensderfer was the nephew of the inventor of the stenotype John Celivergos Zachos. Two models were initially unveiled to the public at the 1893 World's Columbian Exposition in Chicago, the Model 1 and the Model 5. His machines were originally intended to compete with larger Remington, Hammond and Yost typewriters, and were the first truly portable, full-keyboard typewriters. The design also enabled the typist to see the typed work at a time when most typewriters were understrike machines that concealed the writing. When Blickensderfer unveiled his small Model 5 at the 1893 World's Fair, a stripped-down version of his larger more complex Model 1 machine, these revolutionary features attracted huge crowds and a full order book – many of them from Britain, Germany and France, whose business machine markets were more highly developed than the United States.
A letter-quality printer was a form of computer impact printer that was able to print with the quality typically expected from a business typewriter such as an IBM Selectric.
CPT Corporation was founded in 1971 by Dean Scheff in Minneapolis, Minnesota, with co-founders James Wienhold and Richard Eichhorn. CPT first designed, manufactured, and marketed the CPT 4200, a dual-cassette-tape machine that controlled a modified IBM Selectric typewriter to support text editing and word processing.
The Oliver Typewriter Company was an American typewriter manufacturer headquartered in Chicago, Illinois. The Oliver Typewriter was one of the first "visible print" typewriters, meaning text was visible to the typist as it was entered. Oliver typewriters were marketed heavily for home use, using local distributors and sales on credit. Oliver produced more than one million machines between 1895 and 1928 and licensed its designs to several international firms.
Lucien Stephen Crandall was an American inventor of typewriters, adding machines and electrical devices. Crandall gave his name to several typewriters, and he was also involved in the development of various machines, such as the project to produce the Hammond design at the Remington factory, or later the International typewriter.
The IBM Selectric typewriter was a highly successful line of electric typewriters introduced by IBM on 31 July 1961.
The Sholes and Glidden typewriter was the first commercially successful typewriter. Principally designed by the American inventor Christopher Latham Sholes, it was developed with the assistance of fellow printer Samuel W. Soule and amateur mechanic Carlos S. Glidden. Work began in 1867, but Soule left the enterprise shortly thereafter, replaced by James Densmore, who provided financial backing and the driving force behind the machine's continued development. After several short-lived attempts to manufacture the device, the machine was acquired by E. Remington and Sons in early 1873. An arms manufacturer seeking to diversify, Remington further refined the typewriter before finally placing it on the market on July 1, 1874.
Dvorak is a keyboard layout for English patented in 1936 by August Dvorak and his brother-in-law, William Dealey, as a faster and more ergonomic alternative to the QWERTY layout. Dvorak proponents claim that it requires less finger motion and as a result reduces errors, increases typing speed, reduces repetitive strain injuries, or is simply more comfortable than QWERTY.
A keyboard layout is any specific physical, visual or functional arrangement of the keys, legends, or key-meaning associations (respectively) of a computer keyboard, mobile phone, or other computer-controlled typographic keyboard.
A bit-paired keyboard is a keyboard where the layout of shifted keys corresponds to columns in the ASCII (1963) table, archetypally the Teletype Model 33 (1963) keyboard. This was later contrasted with a typewriter-paired keyboard, where the layout of shifted keys corresponds to electric typewriter layouts, notably the IBM Selectric (1961). The difference is most visible in the digits row : compared with mechanical typewriters, bit-paired keyboards remove the _ character from 6 and shift the remaining &* from 7890 to 6789, while typewriter-paired keyboards replace 3 characters: ⇧ Shift+2 from " to @⇧ Shift+6 from _ to ^ and ⇧ Shift+8 from ' to *. An important subtlety is that ASCII was based on mechanical typewriters, but electric typewriters became popular during the same period that ASCII was adopted, and made their own changes to layout. Thus differences between bit-paired and (electric) typewriter-paired keyboards are due to the differences of both of these from earlier mechanical typewriters.
A previous version of this story did not clearly state that Godrej & Boyce appears to be the world's last maker of mechanical typewriters, which operate solely on human power. Numerous other manufacturers continue to make several types of electric typewriters.
This article examines the history, economics, and ergonomics of the typewriter keyboard. We show that David's version of the history of the market's rejection of Dvorak does not report the true history, and we present evidence that the continued use of Qwerty is efficient given the current understanding of keyboard design.
QWERTY's effect, by reducing those annoying clashes, was to speed up typing rather than slow it down.
The earliest known reference to the identification potential of typewriting, curiously enough, appears in 'A Case of Identity', a Sherlock Holmes story by Sir Arthur Conan Doyle...
|Look up typewriter in Wiktionary, the free dictionary.|
|Look up typewriter in Wiktionary, the free dictionary.|
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InStat/MDR expects 32-bit microcontrollers to grow at a compound annual rate of 22.6 percent between 2001 and 2006. Two driving factors are contributing to that growth. One is the introduction of new applications that require higher performance, including gadgets like digital cameras, cell phones and MP3 players. Second, even such familiar applications as TV sets, car stereos and electronic toys are getting so advanced that they increasingly require performance and memory beyond the scope of 8-bit microcontrollers.
Before discussing the migration from 8 to 32 bits, it is important to clarify where the 16-bit microcontroller fits into the picture. Primary research with embedded engineers across many different markets suggests that most engineers who outgrow 8-bit MCUs move directly to 32-bit controllers. It seems that for most engineers, a 16-bit MCU is not a viable upgrade alternative.
This is particularly interesting in comparison with the massive migration from 4 to 8 bits that has taken place over the past decade. Clearly, history isn't repeating itself, since few designs were migrated directly from 4 to 16 bits. One reason for this break from the past is that the ARM7TDMI has established itself as a standard CPU core. Currently, more than 30 semiconductor vendors are shipping ARM7TDMI-based products, and the core has become even more of a de facto standard than the widely licensed 80C51. Such a dominant architecture was never conceived in the 16-bit world, which mostly consists of single-source proprietary cores.
Moreover, process geometry shrinks have almost erased the price difference between 16- and 32-bit MCUs. On-chip memory and peripherals take up so much silicon real estate that the cost of the core nearly disappears in the budget. For most applications, upgrading from a 4-bit MCU to a 16-bit alternative was not even considered, because of big price differences.
So what specific fac tors are fueling the shift from 8- to 32-bit architectures? One is the growing need for a broader addressing range. Many 8-bit architectures today are limited to 64k of addressing range. Some microcontroller families are unable to address external program memory, thus limiting the address range to whatever memory is implemented on the chip. A few 8-bit architectures are able to address up to a few megabytes of off-chip memory, and in some cases, extended address range is achieved by adding to an existing architecture. But often the solutions vary by company and are not code-compatible, and the extended addressing capabilities still lack the efficiency of a 32-bit architecture. An 8-bit microcontroller is still only 8-bit, and the arithmetic involved in calculating addresses wider than 16-bits imposes a heavy load on most 8-bit architectures. Many 32-bit microcontrollers feature a synchronous DRAM, which dramatically lowers the cost of larger data memories. By comparison, 8-bitters can address SRAM only.
The need for more performance is also driving the move to 32-bit controllers. Not only do applications demand more raw CPU power in terms of clock speed, but the proliferation of communications interfaces such as Ethernet and USB in embedded applications increases the need for advanced on-chip peripherals. The availability of 8-bit MCUs with on-chip Ethernet MAC is sparse for a good reason: TCP/IP is too complex a protocol to run properly on most 8-bit architectures.
In cases where the MCU runs TCP/IP or other protocols in addition to handling application control functions, the need for an RTOS quickly becomes reality. Most 8-bit microcontrollers are not architected for real-time task switching, and few good real-time operating systems are available. Also, DMA controllers are common on 32-bit MCUs and are used to offload the CPU when the controller is receiving or transmitting large amounts of data.
It's also worth noting that there is a growing tendency among customers to avoid single-so urce architectures. With the exception of the 80C51, single-source architectures dominate the 8-bit MCU market. That implies a significant tool investment and a substantial amount of work every time code is ported from one architecture to another. With the ARM7TDMI becoming the de facto standard architecture for the lower end of the 32-bit embedded space, embedded engineers have regained the freedom to choose among microcontrollers from different vendors without losing the investment in code base and development tools.
Nonetheless, migrating from 8 to 32 bits involves far more than just code recompilation and board relayout. Whereas the 32-bit MCU opens up a new world in terms of possibilities, it also introduces a new set of real and perceived issues to deal with.
The myth of higher component cost is one that should be addressed. There is a perception that "more bits cost more," but this is not always valid, since many 32-bit MCUs are manufactured in a 0.18-micron proces s. Also, one has to consider the application's total bill of materials. In many cases one 32-bit MCU can replace several components because of extra performance and on-chip peripherals. Often, engineers compare only the price of the microcontroller instead of the entire system cost-and that prevents many engineers from even contemplating the move.
The cost analysis of a networked image device, for example, with a 32-bit MCU reveals a $2 higher component cost for the 32-bit solution-a small price to pay considering that JPEG decompression and faster, 100-Mbit/second Ethernet connection speeds can be included. The added market value of the added functionality by far outweighs the increase in component cost. Not only that, but the redesign provides plenty of performance overhead that can be used for future expansions.
Memory usage could be viewed as another barrier. Few 32-bit MCUs feature on-chip code memory, although that is changing. The main issues with off-chip memory are EMI, power consump tion, access time and security.
The cost of development tools is not necessarily a real barrier. An 8-bit development suite includes a compiler and an emulator/debugger, which could cost as much as $4,000. In some cases, one can get by with much less; but few free compilers are available, and almost all 8-bit devices require a dedicated emulator. Often, using several derivatives based on a single architecture requires the use of several emulators.
When investing in 32-bit development tools, one can easily spend far more than $4,000. However, since free GNU debuggers and compilers are available and since most 32-bit MCUs do not require an emulator for real-time debugging, one can get started with a modest investment in development tools. That, of course, requires silicon vendors to make the effort of porting, testing and supporting the free tool chain.
In some cases, fear of complexity could be enough to make engineers hesitate to move to 32-bit. Developers of 8-bit microcontrollers ge nerally have little experience with RTOSes and programming. Fear that the learning curve is too steep or too long will be a barrier to many 8-bit design engineers. But when the performance requirements reach the physical limits of what an 8-bit microcontroller can do, the design tweaking involved in adding more features becomes extremely resource-demanding. At this point it is always better to make the leap.
Embarrassment of riches
Then there's the sheer number of devices to consider. The 8-bit MCU offering comprised approximately 1,300 devices from more than 40 vendors. A similar number of vendors have offered 240 devices in the 32-bit category. Although the difference in device selection is expected to have shrunk somewhat over a two-year period, it is still substantial. That is why configurable devices such as those offered by Altera and Triscend have success in the 32-bit market space.
Engineers struggling with the decision to upgrade to the 32-bit MCU, must take a look at the total system cost, since often the performance of the application can be increased by an order of magnitude for a minimal increase in cost. There's extra work involved in learning a new architecture and a new tool set, but squeezing the last Mips out of an already bogged-down 8-bitter could also easily burn few late hours in the lab.
Geir Kjosavik is director of business development at Triscend Corp.
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Introduced along with the Mac II in March 1987, the SE came with 1 MB of RAM, one or two double-sided 800K floppies, and space to mount an internal SCSI hard drive (the second drive bay held either a hard drive or second floppy – no room for both, although that didn’t stop some people from creating a bracket to mount a hard drive in a two-floppy SE). The SE was the first compact Mac with a built-in fan.
The SE is sometimes referred to as the SE/20, SE 1/40, 4/80, etc. “SE/20″ is not an official designation, often leads to confusion, and should not be used. These are not different models, nor should an “SE/20″ be confused with the more powerful SE/30. These numbers refer to the amount of memory and size of the internal hard drive, so an “SE/20″ would have a 20 MB hard drive and an SE 4/40 would have 4 MB of RAM and a 40 MB hard drive.
Although Apple officially rates SCSI on the SE at 1.25 MBps, real world testing finds it to be considerably lower at about half the rated speed. This is also roughly 2.5x faster than the SCSI on the Mac Plus.
In August 1989 Apple began to ship the SE with their high density floppy drive, known as the FDHD (floppy drive, high density) or SuperDrive (for its ability to read and write IBM-format floppies with additional software). Not only did this provide 1.4 MB capacity, but also the ability to read and write 3.5″ DOS disks using special software.
Olders SEs with their original ROMs do not support high density floppies. However, they can be used with FDHD drives as long as the disks used are 800K floppies.
The SE was introduced as the low-end cousin of the hot new 16 MHz Mac II. The SE was the first compact Mac with an expansion slot. One of the first add-in cards was an MS-DOS card. Over time, video, ethernet, and accelerator cards became popular accessories.
- Got a compact Mac? Join our Vintage Macs Group.
- LEM’s System 6 Group is for anyone using Mac System 6.
It’s not generally known, but the SE supports color, although not on the internal display. It’s only 3-bit color, but it supports output to the ImageWriter II printer’s color ribbon, and as least one company made a SCSI video output device that let the SE display 3-bit color on an external color monitor.
Color display? Aura Systems made ScuzzyGraph II, a SCSI peripheral that provided 8-color video for people who didn’t want to buy (or couldn’t afford) a Mac II. 1989 cost was $995 to $2,495, depending on resolution.
- If you have less than 4 MB installed, upgrade to 4 MB. You can often find pulled 1 MB SIMMs (removed from other Macs during upgrade) inexpensively.
- The SE cannot use two-chip 1 MB SIMMs.
- Memory permitting, set the disk cache to 128k.
- To use HD floppies on a pre-SuperDrive SE, look into the Applied Engineering AE HD+ external floppy drive. They may be available from Que Computers for $99 (612-623-0903). Note that the “plus” is important – the AE HD will not do the job.
- Because of limited SCSI throughput, older hard drives with no data buffer should usually be formatted with a 2:1 interleave for use in the SE. (Unfortunately, other Macs may find it difficult or impossible to work with this interleave.) This is not an issue with newer drives that have a data buffer.
- If you need to create the smallest possible System file, you can delete Chicago 12, Geneva 9 and 12, and Monaco 9, since these fonts are in the SE ROMs.
- To remove the hard drive: find the two screws holding the drive bracket in place. They will be facing the rear of the computer and underneath the drive itself. You’ll need a fairly long Phillips screwdriver to reach them – and you’ll need to disconnect the power and data cables before you can get to them. Once the screws are loose, lift the back and it should come out easily.
- SE introduced 1987.03.02 at $2,900 (dual floppy) or $3,700 (with 20 MB hard drive); discontinued 1989.08.01
- SE FDHD (1.4 MB floppy) introduced 1989.08.01; discontinued 1990.10.15
- code names: Plus Plus, Maui, Aladdin, Chablis, Freeport
- configurations included dual-floppy or one floppy plus 20 or, 40 MB hard drive
- Gestalt ID: 5
- Order no.: M5010 (SE), M5011 (SE FDHD)
- upgrade path: SE/30 motherboard
- requires System 4.1 (System 4.0 and Finder 5.4) to 7.5.5, although we have a report of one user running System 1.1 on the SE)
- addressing: 24-bit only
- CPU: 8 MHz 68000
- ROM: 256 KB
- RAM: 1 MB, expandable 4 MB using pairs of 256 KB or 1 MB 150ns 30-pin SIMMs (will not work with two-chip 1 MB SIMMs)
- 1.0, relative to SE
- 0.37, MacBench 2.0
- 0.98, Speedometer 3
- 0.7 MIPS
- see Benchmarks: SE for more details
- 9″ b&w screen, 512 x 342 pixels
- ADB ports: 2
- serial ports: 2 DIN-8 RS-422 ports on back of computer
- SCSI ports: 1 DB-25 connector on back of computer, maximum throughput of 5,248 kbps
- floppy drive: 800 KB, 1.4 MB double-sided on FDHD version
- floppy connector on back of computer
- Hard drive: none or 20 MB
- expansion slots: 1 SE PDS
- size (HxWxD): 13.6″ x 9.6″ x 10.9″
- Weight: 17 lb.
- PRAM battery: 3.6V half-AA
- power supply: 100W
Accelerators & Upgrades
Some accelerators have onboard SIMM slots, allowing them to use more than 4 MB of RAM.
- Brainstorm accelerator (16 MHz 68000), long discontinued. See review in Macworld, 1995.03.
- Macintosh SE/30 motherboard (16 MHz 68030), but it probably costs less to buy a whole SE/30 than just a motherboard.
- MicroMac Multispeed (16, 25, or 32 MHz 68030), optional 32 MHz 68882 FPU
- MicroMac Performer (16 MHz 68030), optional 25 MHz 68882 FPU
- MicroMac Performer Pro (32 MHz 68030), 64 KB cache, optional 68882 FPU
- Sonnet Technologies Allegro SE (33 MHz 68030), 33 MHz 68882 FPU, discontinued
Discontinued accelerators (68030 unless otherwise noted) include the Applied Engineering TransWarp (16, 40 MHz), Dove Marathon Racer (16 MHz), Extreme Systems Vandal (50 MHz), Harris Performer2 (16 MHz 68000), MacProducts Railgun (33 MHz), Mobius (25 MHz), NewLife Accelerator! (16, 25, 33 MHz), Novy ImagePro (16, 25, 33 MHz), and Total Systems Mercury (16 MHz), Gemini Integra (50 MHz), and Gemini Ultra (33, 50 MHz).
Color? Aura Systems made ScuzzyGraph II, a SCSI peripheral that provided 8-color video for people who didn’t want to buy (or couldn’t afford) a Mac II. 1989 cost was $995-2,495, depending on resolution.
- Guide to Compact Macs, a quick overview of Apple’s 10 compact Macs.
- Golden Apples: The 25 best Macs to date, Michelle Klein-Häss, Geek Speak, 2009.01.27. The best Macs from 1984 through 2009, including a couple that aren’t technically Macs.
- Creating Classic Mac Boot Floppies in OS X, Paul Brierley, The ‘Book Beat, 2008.08.07. Yes, it is possible to create a boot floppy for the Classic Mac OS using an OS X Mac that doesn’t have Classic. Here’s how.
- Know Your Mac’s Upgrade Options, Phil Herlihy, The Usefulness Equation, 2008.08.26. Any Mac can be upgraded, but it’s a question of what can be upgraded – RAM, hard drive, video, CPU – and how far it can be upgraded.
- Why You Should Partition Your Mac’s Hard Drive, Dan Knight, Mac Musings, 2008.12.11. “At the very least, it makes sense to have a second partition with a bootable version of the Mac OS, so if you have problems with your work partition, you can boot from the ‘emergency’ partition to run Disk Utility and other diagnostics.”
- Antique Macs are still useful computers, Charles Moore, From the MacCave, 2008.09.09. Charles Moore’s first online article looks at the utility of compact Macs – and foreshadows his longterm affection for PowerBooks.
- The Compressed Air Keyboard Repair, Charles Moore, Miscellaneous Ramblings, 2008.07.24. If your keyboard isn’t working as well as it once did, blasting under the keys with compressed air may be the cure.
- Tales of old Mac data retrieval, Adam Rosen, Adam’s Apple, 2008.06.13. Getting apps and documents off 400K floppies, old disk images, and a Mac running System 5.
- A Vintage Mac Network Can Be as Useful as a Modern One, Carl Nygren, My Turn, 2008.04.08. Old Macs can exchange data and share an Internet connection very nicely using Apple’s old LocalTalk networking.
- Low End Mac’s Best Classic Mac OS Deals. Best online prices for System 6, 7.1, 7.5.x, Mac OS 7.6, 8.0, 8.1, 8.5, 9.0, 9.2.2, and other versions.
- Vintage Mac Networking and File Exchange, Adam Rosen, Adam’s Apple, 2007.12.19. How to network vintage Macs with modern Macs and tips on exchanging files using floppies, Zip disks, and other media.
- Getting Inside Vintage Macs and Swapping Out Bad Parts, Adam Rosen, Adam’s Apple, 2007.12.14. When an old Mac dies, the best source of parts is usually another dead Mac with different failed parts.
- Solving Mac Startup Problems, Adam Rosen, Adam’s Apple, 2007.12.12. When your old Mac won’t boot, the most likely culprits are a dead PRAM battery or a failed (or failing) hard drive.
- Better and Safer Surfing with Internet Explorer and the Classic Mac OS, Max Wallgren, Mac Daniel, 2007.11.06. Tips on which browsers work best with different Mac OS versions plus extra software to clean cookies and caches, detect viruses, handle downloads, etc.
- A (Mac) classic spookfest, Tommy Thomas, Welcome to Macintosh, 2007.10.31. How to set up those old compact Macs with screen savers to enhance your Halloween experience.
- Simple Macs for Simple Tasks, Tommy Thomas, Welcome to Macintosh, 2007.10.19. Long live 680×0 Macs and the classic Mac OS. For simple tasks such as writing, they can provide a great, low distraction environment.
- Interchangeabilty and Compatibility of Apple 1.4 MB Floppy SuperDrives, Sonic Purity, Mac Daniel, 2007.09.26. Apple used two kinds of high-density floppy drives on Macs, auto-inject and manual inject. Can they be swapped?
- 4 steps for resurrecting old Macs, Sonic Purity, Mac Daniel, 2007.07.18. Hardware problems may be solved with a thorough cleaning, deoxidizing electrical contacts, replacing failed capacitors, and/or repairing broken solder joints.
- Leopard compatibility list, bad capacitors kill Macs, 1 GHz G3 upgrade resurrected, and more, Dan Knight, Low End Mac Mailbag, 2007.06.26. Also tips for troublesome OS X installs, ‘About This Mac’ sometimes lies, PowerBook advice, and aluminum PowerBook design.
- My first mobile Mac: A Classic II, Jacek A. Rochacki, Miscellaneous Ramblings, 2007.06.25. When a PowerBook 100 was beyond the author’s means, he bought a second-hand Mac Classic II and fabricated his own carrying case to make it mobile.
- Mac System 7.5.5 Can Do Anything Mac OS 7.6.1 Can, Tyler Sable, Classic Restorations, 2007.06.04. Yes, it is possible to run Internet Explorer 5.1.7 and SoundJam with System 7.5.5. You just need to have all the updates – and make one modification for SoundJam.
- The Truth About CRTs and Shock Danger, Tom Lee, Online Tech Journal, 2007.05.22. You’ve been warned that CRT voltage can injure and even kill. The truth is that this danger is overstated – and takes attention away from a greater danger.
- Format Any Drive for Older Macs with Patched Apple Tools, Tyler Sable, Classic Restorations, 2007.04.25. Apple HD SC Setup and Drive Setup only work with Apple branded hard drives – until you apply the patches linked to this article.
- Making floppies and CDs for older Macs using modern Macs, Windows, and Linux PCs, Tyler Sable, Classic Restorations, 2007.03.15. Older Macs use HFS floppies and CDs. Here are the free resources you’ll need to write floppies or CDs for vintage Macs using your modern computer.
- The First Expandable Macs: Mac II and SE, Dan Knight, Mac Musings, 2007.03.02. Until March 2, 1987, Macs were closed boxes with no internal expansion slots, no support for color, and no internal hard drives. The Mac II and SE changed all that.
- The legendary Apple Extended Keyboard, Tommy Thomas, Welcome to Macintosh, 2006.10.13. Introduced in 1987, this extended keyboard was well designed and very solidly built. It remains a favorite of long-time Mac users.
- Jag’s House, where older Macs still rock, Tommy Thomas, Welcome to Macintosh, 2006.09.25. Over a decade old, Jag’s House is the oldest Mac website supporting classic Macs and remains a great resource for vintage Mac users.
- 30 days of old school computing: Setting up a Mac Classic II, Ted Hodges, Vintage Mac Living, 2006.09.07. Fond memories of using a Classic II in elementary school lead to it being the first Mac set up for a month of vintage, very low-end computing.
- Vintage Macs with System 6 run circles around 3 GHz Windows 2000 PC, Tyler Sable, Classic Restorations, 2006.07.06. Which grows faster, hardware speed or software bloat? These benchmarks show vintage Macs let you be productive much more quickly than modern Windows PCs.
- Floppy drive observations: A compleat guide to Mac floppy drives and disk formats, Scott Baret, Online Tech Journal, 2006.06.29. A history of the Mac floppy from the 400K drive in the Mac 128K through the manual-inject 1.4M SuperDrives used in the late 1990s.
- Compact Flash with SCSI Macs, PB 1400 CD-RW upgrade problems, and Web incompatibilities, Dan Knight, Low End Mac Mailbag, 2006.06.16. Suggested ways to use Compact Flash with vintage Macs and PowerBooks, problems getting CD-RW to work with a PowerBook 1400, and more thoughts on website incompatibilities.
- Moving files from your new Mac to your vintage Mac, Paul Brierley, The ‘Book Beat, 2006.06.13. Old Macs use floppies; new ones don’t. Old Macs use AppleTalk; Tiger doesn’t support it. New Macs can burn CDs, but old CD drives can’t always read CD-R. So how do you move the files?
- DOS cards, x86 emulation, Boot Camp, and the future of Windows on Macs, Adam Robert Guha, Apple Archive, 2006.04.07. Macs have had DOS compatibility since 1987, and software emulators followed in a few years. With Boot Camp, Intel Macs can now run Windows XP. Where next?
- System 7.5 and Mac OS 7.6: The beginning and end of an era, Tyler Sable, Classic Restorations, 2006.02.15. System 7.5 and Mac OS 7.6 introduced many new features and greater modernity while staying within reach of most early Macintosh models.
- System 7: Bigger, better, more expandable, and a bit slower than System 6, Tyler Sable, Classic Restorations, 2006.01.04. The early versions of System 7 provide broader capability for modern tasks than System 6 while still being practical for even the lowliest Macs.
- Web browser tips for the classic Mac OS, Nathan Thompson, Embracing Obsolescence, 2006.01.03. Tips on getting the most out of WaMCom, Mozilla, Internet Explorer, iCab, Opera, and WannaBe using the classic Mac OS.
- The Joy of Six: Apple’s fast, svelte, reliable, and still usable System 6, Tyler Sable, Classic Restorations, 2005.12.06. System 6 was small enough to run quickly from an 800K floppy yet powerful enough to support 2 GB partitions, 24-bit video, and the Internet.
- 10 things new classic Mac owners should know, Paul Brierley, The ‘Book Beat, 2005.12.06. New to compact Macs? Ten things you really should know before you get too confused.
- How to set up your own Mac Plus (or later) web server, Joe Rivera, Mac Fallout Shelter, 2005.11.29. All you need is an old Mac Plus with 4 MB of RAM, a hard drive, System 7 or later, some free software, and an Internet connection.
- Which system software is best for my vintage Mac?, Tyler Sable, Classic Restorations, 2005.11.22. Which system software works best depends to a great extent on just which Mac you have and how much RAM is installed.
- A Macintosh SE that Uses DSL?, Mark Looper. “…how I have been able to set up my network so that any of my Macs, including the SE with dual 800 kB floppies and no hard drive (but with Ethernet!), can connect to the Internet via DSL, without having to use another Mac (or *shudder* a PC) to handle the PPPoE!”
- Mac SE alive and kicking on Web, Leander Kahney, Wired, 2004.05.19. “…a pair of German Web designers has created a working simulation of Apple Computer’s classic Mac SE on the Web.” Very cool.
- The compact Macs, Matthew Glidden, Profiles in Networking, ATPM, 2002.06. LocalTalk and ethernet networking for compact Macs.
- My emailing Mac Plus, Jeff Garrison. A Mac Plus, a second floppy, a modem, System 6, Eudora Lite – email on the cheap.
- The compact Mac trio: Hardware upgrades, Dan Knight, The Old Gray Mac, 2001.07.31. Hardware upgrades for the Mac Plus, SE, and Classic.
- The compact Mac trio: Hardware overview, Dan Knight, The Old Gray Mac, 2001.07.30. Introduction to and hardware overview of the Mac Plus, SE, and Classic.
- The original Macintosh, Dan Knight, Online Tech Journal, 2001.05.29. An in-depth look at the original Macintosh and how it shaped future Macs.
- Macintosh SE Support Pages, Chris Adams
- Video cards for SE & Classic
- Making a video adjustment tool, Chris Lawson, Mac Daniel, 2000.03.24. Would you believe you can craft one from an old toothbrush?
- Networking a Mac Plus to an iMac, Jag’s House. Key component is a SCSI-ethernet adapter.
- System 6 for the Macintosh, Ruud Dingemans. If you have an older, slower, memory-limited Mac, System 6 is fast, stable, and still very usable.
- Cruising the web in black & white, John C. Foster, MacWeek, 1999.10.20
- Applied Engineering AE HD+ FAQ, Adam Takessian. The ins and outs of Applied Engineering’s 1.4 MB floppy for the 512Ke, Plus, and 800 KB SE.
- Mac SE Upgrade Page, MacSpeedZone
- Transparent SE, a very rare edition
- Faster browsing on older Macs, Online Tech Journal
- Old Macs on the internet, The Web Toolbox
- SE saga, Steve Wood, View from the Classroom
- Email lists: Classic Macs Digest, Vintage Macs
- System6, the email list for those who choose to use System 6.0.x.
- Memory upgrade guide
- Links to System 6.0.8 and 7.0.1
- Review of MicroMac Performer accelerator.
- Obsolete Computer Museum
- Software Compatible with 68000 CPU
- Get your compact Mac on the web with tips from JAG’s House.
- Macintosh SE Technical Specifications, Apple Knowledge Base Archive
- Macintosh SE FDHD Technical Specifications, Apple Knowledge Base Archive
- Never connect an Apple II 5.25″ floppy drive to the Mac’s floppy port. Doing so can ruin the floppy controller, meaning you can’t even use the internal drive any longer.
- That monitor packs a lot of voltage. Read Compact Mac CRT Energy before working inside.
- Macs with black-and-white only displays (1-bit, no grays) may find Netscape Navigator 3 makes it impossible to view some pages and sites. The workaround is to use Navigator 2.
- Some early SEs had noisy fans; MacUser (1992.11) recommends replacing them.
- Reliably supports serial speeds to 19.2 kbps, although default is 9600 bps. May have better throughput at 28.8 kbps despite some dropped and retransmitted packets. Throughput with a 56k modem may be limited. See 56k modem page. For more information on Mac serial ports, read Macintosh Serial Throughput.
- Apple discontinued support and parts orders for the Plus on 1998.08.31. You may be able to find dealers with parts inventory either locally or on our parts and service list.
Keywords: #macse #macintoshse
Short link: http://goo.gl/cR4aMw
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Choosing the right PIC
Choosing a PIC according to your needs is sometimes a headache. There are people of course that hate headaches and therefore they use just 2-3 types of PICs and that's all. That is a solution of course, absolutely inefficient though.
The selection needs to have some criteria. Those criteria come along with the type of application you have in mind to make. That is the reason why i cannot set a numbered list of choosing criteria from highest to lowest, but i can only think a list of them. Within this list, all items are equal to each other.
Now, let's see what should be your considerations when choosing the right PIC:
The bit length of the PIC:
You can choose between 8, 16 and 32 bit micro controllers. My advice is to choose the smallest possible. If you do not have to deal with large numbers, larger than 8-bits, then you should stick with the 8-bit family. If you need to measure pulses for example that would exceed the 8-bits, then there are ways to do this with -bit uControllers. Some of them are equipped with one or more 16-bit counter/timers that does the job easy. Also, you may use two or more 8-bit bytes to represent a larger number. What i want to say is that you should always try to use the simplest one for your job. It is cheaper after all.
The memory size:
One word: The more, the better. The only frontier here is the price. Strangely (not really), Microchip has a pricing policy that may surprise you. You may find for example a PIC that has small memory and fewer capabilities from another one, but instead of being cheaper it is more expensive. I suppose that this comes with the selling quantities. More memory does not always mean more money.
Keep in mind that there are actually 3 types of basic memories within one PIC. First the programm memory. It is usually 1 to 32 K Bytes. This part of memory will hold the program itself. If you are thinking of a long assembly sheet, think also of a long program memory.
The second type is the RAM. This is usually 1K Byte but it can get some wild numbers! Especially in 32bit systems that can have up to 32KBytes of RAM. This memory is used for temporarily storing variables and parameter values. This memory, like the RAM of the PC, will blank each time the power of the PIC is turned off.
The third type is EEPROM memory. This is the "Hard Disk Storage" of your PIC. This memory is read and written using a specific program flow and the values stored there are kept even if the PIC is completely out of power. The size is up to 4K and it has a negative effect to the price of the PIC. Use those bytes wisely.
The pin count:
Although i said on the beginning that all the items are equally between them, the pin count of a PIC is usually the first and most important that will determine the selection. there are tiny 4 I/O ports PICs, and some titans with 85 I/O ports! The price is analog to the ports of course. The most common are the 16 I/O (18 pins) pics and the 38 I/O (40 pins). You should keep in mind that there are ways to expand the I/O ports with SIPO and PISO blocks by using just 3 ports of the PIC.
The maximum frequency:
Up to 120MHz is the frequency that those beauties can reach. A standard 20Mhz though, is usually enough for an amateur and an advanced person. You need to have in mind that the fastest the clock, the faster the program flows. There are plenty of situations that a fast clock is completely inappropriate. If for example you make an RPM meter for slow turning motors or PC fans, then you will discover that the clock should be slow to avoid unnecessary divisions and avoid big numbers. It may not make any sense to you right now. If it does not indeed, then just go for a 4 to 20MHz PIC.
Along with the maximum external clock of the PIC, comes also the internal oscillator. This is an internal oscillator that some PICs are equipped with. Using this feature, the PIC can work with no external crystal or other oscillator. This saves space on the PCB, money on the construction and of course it saves power. This is usually a 32KHz clock but can go up to 32MHz in some cases. Although it cannot achieve the fidelity of a quartz, i advise to use it whenever this is possible.
The debugging feature:
I have used several different cheap and not so cheap PIC programmers. Right now, i use an ICD 2.2. This programmer is compartible with the MPLAB debug feature. The PIC16F88 supports this debugger. The debugging is sometimes a life-jacket during a boat sinking. Although it is a S-L-O-W procedure, although sometimes it is technically impossible to debug, i must admit that it has saved me plenty of hours laying face to face with the monitor. For a beginner, i vote YES. If your budget permits that, select one of the possible PIC programmers that are also debuggers and compartible with MPLAB. And if you respect your time, choose a USB one and not a parallel port programmer. Here is a good beginning to your search:
Microchip ICD 2 programmer / Debugger
Communication, analog and digital peripherals:
I've kept the best part for the end. Almost every PIC has at least one of those features embedded. If you are thinking of using them, then this will be the number #1 search criteria. Here is a list of those features, so you know with what you're dealing with:
Hopefully, i have not forgotten any...
Inside every PIC, there is at least one timer/counter. These are modules used to measure pulses from several sources. They could measure pulses from an encoder, from an rtc, from the engine distributor, from the PIC's clock itself... Those timers are 8, 16 or 32 bit length. An 8 bit micro controller does not mean that it will only have 8-bit timer. This is not true. An 8-bit uController may have up to 3 16-bit timers inside, along with some 8-bit timers. But no 8-bit PIC has a 32-bit timer.
Selecting a PIC using this parameter as criteria, require experience. Therefore, if you are an amateur, just leave this feature aside. One 16-bit counter for an 8-bit PIC is far enough for your starting projects.
It's not that bad after all
... as you may have already thought. Yes, there are thousands of PICs. Yes, each one may be used for sophisticated applications. yes you need to gain experience before being a PIC-selector guru. But Microchip has make a big step forward. They recently introduced the MAPS. It means Microchip Advanced Part Selector. What it does, is that you enter your criteria, and it returns the available PICs that fits to your needs, along with the datasheets and a budgetary pricing. You can find the MIPS at the following link:
Microchip Advanced Part Selector (MIPS)
I must say that this tools is WOW!
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Summary: Bookmarks is a new-generation research guide built on the assumption that students need to appreciate both conventional methods of research and techniques associated with rapidly developing electronic technologies.. "Bookmarks is designed as a bridge between old and new traditions - a guide for the college writers working in both print and electronic environments. It invites them to think of themselves, perhaps for the first time, as serious researchers.
Summary: Bookmarks is a new-generation research guide built on the assumption that students need to appreciate both conventional methods of research and techniques associated with rapidly developing electronic technologies.. "Bookmarks is designed as a bridge between old and new traditions - a guide for the college writers working in both print and electronic environments. It invites them to think of themselves, perhaps for the first time, as serious researchers. ...show less
Edition/Copyright:3RD 06 Cover: Paperback Publisher:Longman, Inc. Published: 04/06/2005 International: No
View Table of Contents
Table of Contents Preface To the Writer Pt. I Beginning Research 1 1 Sizing Up Your Research Project 2 2 Managing Your Project 9 3 Finding a Topic 19 4 Establishing a Purpose 27 5 Narrowing Your Topic 35 Pt. II Gathering Ideas and Information 43 6 Finding Information 44 7 Doing Keyword Searches 65 8 Conducting Field Research 73 9 Keeping Track of Information 81 Pt. III Working with Sources 87 10 Choosing Appropriate Sources 88 11 Evaluating Sources 97 12 Reviewing and Positioning Sources 102 13 Annotating Research Materials 108 14 Summarizing and Paraphrasing Sources 112 15 Understanding Academic Responsibility and Intellectual Property 123 Pt. IV Developing the Project 133 16 Refining Your Claim 134 17 Organizing Your Project 139 18 Drafting Your Project 150 19 Documenting Your Project 156 20 Handling Quotations 163 21 Completing Your Project 173 Authoring Your Own Web Site 185 Pt. V Documentation 201 22 COS Documentation 205 23 MLA Documentation 235 24 APA Documentation 275 25 CMS Documentation 307 26 CBE Documentation 327 Credits 333 Index 335 Glossary 354
2005 Paperback Fair Books rated "Acceptable" may have significant wear & tear; may have significant amounts of underlining, highlighting, or notes; may have creases, or tears; may have cracked spi...show morenes or loose pages; may have the previous owner's name, stamp, sticker, or gift inscription; or may be library discards. ...show less
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This chapter explains what is meant by a psychiatric diagnosis, methods for making diagnoses, and aspects of diagnostic reliability, validity, and utility. Psychiatric and somatic comorbidities are elucidated. It includes a section on the influence of traditional medicine for most of the world’s population. It provides an overview of diagnostic interviews and screening questionnaires.
Historical development of psychiatric diagnosesEdit
What is a diagnosis? The word stems from dia (Greek) meaning through and gnosis (Greek) meaning knowledge, or the establishing of the nature of a disease. Making diagnoses is as old as medical history.
Diagnoses described in ancient times still hold, for example clinical depression was described by Aretaeus (81-138), who practiced medicine in Rome and Alexandria. The physician Ibn Zohr-Avenzoar (1092-1162) in Morocco described in his clinical treatment guideline acute delirium, melancholia and dementia among other psychiatric disorders, and also reported the first known account of suicide in melancholics. In 1286, Le Maristane (hospital) Sidi Frej was built in Fes, Morocco, for psychiatric patients, and was a model for the first mental asylum in the western world in Valencia, Spain, in 1410.
The term neurosis was created by the Scottish neurologist William Cullen in 1769 to label patients with nervous symptoms without an obvious organic cause. Chronic alcoholism was described by Magnus Huss in Stockholm in 1849. The German psychiatrist and neuropathologist Wilhelm Griesinger (1817-1868) laid the modern foundation of psychiatric classification in 1845, publishing a monograph on diseases of the brain. He proposed a unitary concept of psychosis. Subsequently Emil Kraepelin in Munich (1856-1926), the forefather of contemporary scientific psychiatry, split this unitary psychosis into two distinct forms based on symptom patterns that he called manic depression and dementia praecox. The Swiss psychiatrist Eugen Bleuler (1857-1939) renamed the latter schizophrenia, having determined that this disorder did not necessarily progress to dementia.
French psychiatrists made important early contributions to psychiatric diagnoses, such as Tourette’s syndrome, first described in 1885 by the neurologist Giles de la Tourette (1857-1904). He also described anorexia nervosa in 1890. Paul Hartenberg (1871-1949) eloquently described social anxiety disorder in his monograph Les Timides et la timidité in 1901.
After the second world war, the validity of psychiatric diagnoses was questioned by the United States military, since many recruits had been considered unfit for soldier duty by psychiatrists. Many combat soldiers were discharged on psychiatric grounds. There was no consensus on how to make psychiatric diagnoses. In the absence of an agreed classification, epidemiological research was not possible.
There were many thought leaders on the merits of making diagnoses. Sigmund Freud (1856-1939) postulated unconscious conflicts as the source of mental ill health, while the Swiss-born psychiatrist Adolf Meyer (1866-1950), influential in the United States, advocated that such ill health was a personality reaction to psychological, social, and biological factors. In Scotland, Ronald Laing (1927-1989) launched the "antipsychiatric" idea in 1955 that psychosis was a reaction to a cold family environment that produced a false "id," for example the case of the schizophrenogenic mother. He argued that psychiatric diagnoses rested on false grounds in that it was solely based on the patient’s conduct without external validators. The Hungarian-born American psychoanalyst Thomas Szasz (1920-) advanced the idea that psychiatric disorders are a myth, or social branding. He was embraced by the scientology movement in 1968 whose originator L. Ron Hubbard (1911-1986) in 1950 created the business of dianetics, the doctrine of the Church of Scientology, as an alternative to psychoanalysis.
The 1950s and 1960s brought critique of psychiatric diagnoses, a movement that coincided with the civil rights movement of the 1960s, and that particularly targeted the grounds for involuntary commitment to psychiatric care by means of diagnoses. When, in an experiment, several psychiatrists were asked to diagnose the same patient, it was obvious that they represented different schools of thought that did not share a common set of definitions. This challenging of the intellectual ground of psychiatry had profound effects on the allocation of resources, shifting from institutionalization to outpatient voluntary care in the United States and in Europe. In Italy all involuntary care was declared unlawful in 1978.
Two psychiatrists at Washington University in St. Louis then decided to bring sense into psychiatric diagnoses: Samuel Guze (1923-2000) and Eli Robins (1921-1995). In 1970 they published a paper on a criteria-based diagnosis of schizophrenia. This seminal paper became the intellectual basis for the 3rd version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) that was published in 1980 by the American Psychiatric Association. This fundamentally new classification was based on a consensus of clinical criteria. Also, the DSM-III did not assume etiological factors; it was based on a consensus among academic psychiatrists about the typical symptoms of a disorder and its prognosis. In 1987 and in 1994 this classification was revised, based on 150 literature surveys, and 12 field studies with more than 6000 diagnostic interviews. Work on its 5th version is ongoing, and it is to be published in 2012 (http://www.psych.org/MainMenu/Research/DSMIV/DSMV.aspx).
The DSM classification applies 5 perspectives on a patient: Axis 1 disorders (for example major depressive episode, anorexia nervosa), Axis 2 personality disorders, and neurodevelopmental disorders), Axis 3 somatic disorders (for example diabetes mellitus, traumatic brain injury), Axis 4 current stressors (for example having been raped, bereavement), and Axis 5 global assessment of function.
One current ambition in revising the DSM classification is to pay more attention to ethnicity in understanding how symptoms may present. Gender differences will also be elucidated. The most important change in DSM-V will be the inclusion of dimensions in diagnoses; for example, how severely ill is a patient with schizophrenia or depression.
By international convention most countries use the International Classification of Diseases (ICD) in making all diagnoses (somatic and psychiatric) in routine health care. This classification is produced by the World Health Organization. The current ICD-10 classification is quite similar to that of DSM-IV. The WHO is currently working its 11th revision of the ICD. With regard to the psychiatric diagnoses there is a joint effort with the DSM-V developers to use similar principles and standards. The revision process was formulated in 2007 and the draft version will be tested in field trials (http://www.who.int/classifications/icd/ICDRevision/en/index.html).
These efforts have advanced the reliability of psychiatric diagnoses to standards similar to those of other disciplines. Methods for external validation have emerged in recent years. For example, functional magnetic resonance imaging (fMRI), and other in vivo imaging techniques, allow one to study how the amygdala reacts to an anxiety provocation in a subject with an anxiety disorder. Imaging techniques reveal disturbed CNS networks in subjects with schizophrenia, and pronounced structural aberrations in the lateral and medial parts of the temporal and frontal lobe. Untreated depression has been shown to cause cerebral shrinking. The efficacy of serotonergic medications depends on neurogenesis. Latency to rapid eye movement sleep is correlated to clinical symptoms of depression. Amyloid, a protein in the plaques in Alzheimers disease, has been detected in vivo in patients in a PET study. The effect of antipsychotic and antidepressant drug treatments can be correlated to symptom reduction, cerebral blood flow, and brain metabolite ratios.
The criteria in the DSM-IV classification are not always specific for the disorder. Therefore, epidemiological studies produce high rates of comorbid psychiatric conditions, especially if subjects are monitored longitudinally rather than cross-sectionally (lifetime or 12-month prevalence vs. point prevalence). These are consequences of criteria-based classification that need to be accounted for in selecting subjects for research and treatment.
Subjects with a primary anxiety disorder may develop a secondary depression, causing them to seek treatment. Treating the depression uncovers the underlying primary disorder. Anxiety subjects may also self-medicate with alcohol and other substances that are anxiolytic and be diagnosed with a substance use disorder. A patient with schizophrenia may develop a depression, and unless that is properly diagnosed the antipsychotic medication may be unnecessarily increased. A patient with recurring depressive episodes may eventually develop a manic episode, thus altering the diagnosis from unipolar depression to bipolar disorder. Subjects with substance use disorders may develop psychotic reactions to e.g., cannabis or amphetamine that may mimic schizophrenia. Since subjects with schizophrenia tend to seek various drug effects, the effects of cannabis or alcohol may cause psychiatric symptoms per se. There are many more instances of comorbidity that need to be understood.
An issue with the DSM-IV classification is the distinction between axis I disorders and axis II personality disorders. Personality, cognitive style, and social attitudes are moderately or highly heritable according to adoption and twin studies. There is even a genetic contribution to being religious or antisocial, and to the amount of time spent watching television! Personality traits are stable and genetically determined throughout life, and are modifiable only by serious effects such as a neurodegenerative disease, severe substance use, a traumatic brain injury, a brain tumor, or a severe generalized medical condition. One such famous case is Phineas Gage, a railroad worker who survived an iron rod that passed through his frontal lobes in 1848 and caused a pronounced personality change.
There have been many theories since Hippocrates to explain how personalities are shaped. The current explanatory model is the 5-factor model. That decribes a person along 5 different dimensions, e.g., being curious or rigid, dependable or careless, as well as degrees of self-confidence, stubbornness, shyness, and extrovertness. In the DSM-IV classification, personality disorders are assessed categorically, based on clinical assessments of cognition, affectivity, interpersonal functioning, and impulse control. If a person exhibits stable traits that deviate from the norms of the subject’s ethnic group, they may be deemed a personality disorder. There are 11 DSM-IV personality disorders divided into 3 clusters. Personality disorders occur in about 10 per cent of population samples, and in about a third of clinical samples.
The distinction between axis 1 and axis 2 disorders is sometimes unclear. A patient with a serious axis I disorder may qualify for a personality disorder diagnosis, e.g., long-standing social anxiety disorder may be regarded as a phobic personality disorder if sufficiently impaired. Yet, such a patient may respond well to treatment. A subject with high-functioning autism or Asperger syndrome may be regarded as having a schizotypal personality disorder. Attention Deficit Hyperactivity Disorder (ADHD) may be confused with antisocial personality disorder. In the work groups for the DSM-V, these issues may cause a fundamental change in dealing with axis II personality disorders.
Somatic disease may cause or aggravate psychiatric disorders. For example, a patient with diabetes mellitus who has taken too much insulin may present confused or agitated in the emergency room because his blood sugar is too low. A patient with hypothyroidism or hyperthyroidism or hyperparathyroidism usually has anxious or depressive symptoms. Patients with acute intermittent porphyria may become psychotic, and are always anxious. Depression is known as a risk factor for acute myocardial infarction, and can add to the risk of cardiovascular complications. Patients with stroke often develop anxiety and depression. Such manifestations of somatic disease are important to recognize, and they are diagnosed on axis III in the DSM-IV.
Premenstrual dysphoria is an intermittent cluster of symptoms among which irritability and dysphoria are the most disturbing. It develops following ovulation and reaches a peak until menstruation occurs, obviously governed by hormonal variations across the menstrual cycle.
Multiple sclerosis can present with psychotic symptoms and mood elevations including euphoria. Wilson’s disease is a disorder of copper metabolism that can cause rapid mood swings and cognitive dysfunction. Systemic lupus (SLE) can present with confusion and psychotic symptoms. Pernicious anemia (deficiency of vitamin B12) may present with depressive symptoms, memory deficits and sometimes confusion.
The medical model – is it useful?Edit
The scientific community assumes that there is a molecular basis for psychopathology, and that symptoms are produced that can be elicited, quantified and classified by interviewing and observing a subject. This medical model was critiqued in the 1950s and 1960s, causing thought leaders to argue for external causation rather than disorders of the brain. Psychiatry was also abused for political purposes. Sane political dissidents in the Sovjet Union were sentenced by courts to be diagnosed and incarcerated in mental asylums and given tranquilizers (for some this may have been a better alternative than imprisonment).
Early support for the medical model came from twin studies that showed a strong genetic contribution to schizophrenia and bipolar disorder. Neurosyphilis, first defined in 1672, and thought to be an immoral disease, was determined to be an infectious disease in 1913. The Austrian psychiatrist Julius Wagner-Jauregg was awarded the Nobel Prize in 1927 for having shown that neurosyphilis could be treated by infecting the patient with malaria, and in 1943 patients began treatment with penicillin. The dramatic effects of lithium on mania were elucidated in the 1950s. The equally dramatic effect of chlorpromazine on delusions and hallucinations in schizophrenia was also discovered in the 1950s. With regard to anxiety, a break-through in 1964 was the finding by Donald F. Klein that imipramine could extinguish panic attacks, previously believed to stem from unconscious parental conflicts.
In recent years, the medical model has gained support from neuroimaging studies. The model has proven useful in that the benefits and hazards of psychotherapies and psychotropic medications have been shown in randomized controlled trials for which subjects with these diagnoses have been selected. The regulatory bodies of the world base their research protocols and marketing approvals on the ICD-10 and DSM-IV nosologies. Good Clinical Practice, the code by which treatment studies are undertaken, assumes that subjects are selected based on structured diagnostic interviews and that validated measures of changes in symptoms and functioning are applied (see below). The courts pronounce verdicts on forensic psychiatric assessments that are based on the medical model. The medical model is the basis for clinical research into the genetics, etiology, pathogenesis, epidemiology, treatments, and outcomes of psychiatric disorders.
The medical model is often poorly understood by lay persons in politics, administration and the media. It is attacked by the scientology movement and other antipsychiatric movements that refuse to acknowledge the scientific basis for psychiatric disorders. No wonder that the public is so confused, and that stigma against psychiatric disorders is so prevalent in many societies. Traditional medicine This paragraph is a brief excursion into the domain of traditional medicine and how it relates to psychiatric diagnoses. Examples of this interface are given.
The overwhelming majority of the world population will primarily be diagnosed and treated in traditional medicine that was developed locally by indigenous peoples:
Traditional medicine is the sum total of the knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness. (World Health Organization, 2000).
Complementary and Alternative Medicine (CAM) are recently developed therapies, often in opposition to evidence-based medicine:
… a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period (The Cochrane Collaboration, 2000).
There are approximately 500 000 certified practitioners of Traditional Chinese Medicine (TCM) in China, and additionally folk herbalists and "magic witch doctors," serving 56 ethnic nationalities with widely differing beliefs about illness causation, and with much stigma toward psychiatric disorders. While patients with obviously disorganized behavior will be admitted to psychiatric hospitals, those with lesser morbidities are primarily dealt with in TCM. Diagnoses are flexible from one day to another, and based on listening, observing, questioning, and pulse-taking. Religious healers, although forbidden, may apply fortune-telling, handwriting analysis, and palm-reading. They try to counteract evil spirits and repair relationships with ancestors. There is a Chinese Classification of Mental Disorders (CCMD-3) written in Chinese and in English in 2001, that includes about 40 ethnic diagnoses. One is shenjing shuairuo which emphasizes somatic complaints and fatigue, as in the ICD diagnosis neuroasthenia. Another is koro (an excessive fear of genitals and breasts shrinking back into the body).
At healing shrines in India, e.g., at the temples of Balaji in Rajasthan, most subjects have a diagnosable psychiatric illness including psychosis and severe depressive episodes. Healers name it spirit illness, and prescribe offerings and rituals at the temple and at home.
In Japan, Morita therapy was devised by a psychiatrist, and draws from Zen Buddhism, aiming to make people accept their destiny, and live with the symptoms that are similar to social anxiety disorder in the DSM-IV. There is a period of absolute rest, then a period of light work, followed by a period of normal work. In studies more than one half of all patients, including those with schizophrenia, had seen a traditional healer or shaman (yuta) before seeking psychiatric treatment. Taijin Kyofosho (anthropophobia, phobia of eye contact) is a culture-bound syndrome, rooted in consideration for others, loyalty to the group, protecting a vertical society, mutual dependence, a sense of obligation, and empathy.
In the Xhosa tribe in South Africa, amafufuynana and ukuthwasa are culture-bound syndromes that overlap with the DSM-IV criteria for schizophrenia. Both include delusions, hallucinations, and bizarre behaviour. A young person with ukuthwasa is a candidate to become a traditional healer, as he/she can communicate with ancestors, and resisting such a calling may cause illness. There is often a family history of schizophrenia and other psychiatric disorders among those with ukuthwasa. Amafufuynana is believed to be caused by sorcery.
In Quichuas, an Amerindian nation in South America, someone who suffers from anxiety or depression according to the DSM classification is diagnosed as the victim of sorcery or bad spirits.
In the United Kingdom, South Asian patients, including Muslims from Pakistan, frequently seek traditional healers (hakims), practicing Unani Tibbia that stems from Jundishapur south of Teheran. Psychiatric disorders are treated with herbs, diets, and amulets with holy words from the Koran, or the patient is referred to a mullah. Such treatments are often conducted in tandem with biomedical treatments. African-Caribbean patients employ counter-measures including religious rituals and magic (Obeah - witchcraft), having consulted divine healers from the Pentecostal or other churches.
In Italy, the Catholic Charismatic Renewal, sanctioned by the Pope, stems from the Pentecostal cult and includes 300 000 believers. Illness, according to the Catholic doctrine of 2000, is closely related to Evil; it can be God’s punishment for sins, and healing by God can be obtained by collective prayer that produces exalting salvation and jubilation.
These are some brief examples of the multitude of traditional explanations and treatments that are used for the large majority of the world’s population. Traditional healers are a major force in global mental health, as about 40 per cent of their clients suffer from mental illnesses. A psychiatrist trained in evidence-based medicine thus needs to develop an understanding of the large influence of such faiths on patients with psychiatric disorders, even in technologically advanced societies, and need to adjust for it to establish a therapeutic alliance and improve the chances of a favorable outcome.
Structured diagnostic interviews and screening questionnairesEdit
Many structured diagnostic interviews have been tested over the years. The first was the Present State Examination (PSE) in Great Britain in the 1950s that was integrated into the Schedules for Clinical Assessment in Neuropsychiatry (SCAN, see below). The Mental Status Examination was developed in the United States in the 1960s.
Diagnostic interviews differ in scope and the qualifications of the interviewer, and in being based on ICD or DSM classification. Some are comprehensive and designed to find all psychiatric morbidity in general population samples, in primary care, or in tertiary care. Others deal primarily with e.g., affective disorders, substance use disorders, or personality disorders. Web-based case finding questionnaires are being developed to encourage people to seek treatment, as most individuals with conditions (such as substance use disorders, anxiety disorders, depression) amenable to treatment are not receiving any kind of treatment. Self-rating symptom scales are available for case-finding in e.g., the reception area of an outpatient unit, or to assess symptom changes in treatment studies.
Below are short descriptions of some currently used instruments.
The MINI Neuropsychiatric Interview was developed by David Sheehan and Yves Lecrubier as an efficient tool for the experienced mental health worker to look for 15 psychiatric diagnoses in an interview that takes about 30 minutes: Affective, anxiety, psychotic, substance use, eating, and antisocial personality disorders as well as current suicidality. The subject is instructed to simply answer yes or no to each question. Each section has one or a few lead-in questions, and in-depth questions in case there is a positive response. It is essential that the subject understands the questions, so the interviewer may have to repeat them or explain them. The questions are purposely overinclusive (false positives) so that cases will not be missed. It is critical that the interviewer has clinical judgment to assess the value of the subject’s responses. Since somatic diseases may have caused the symptoms (such as a brain tumor, thyroid disease, or adverse effects of medications and substances), a physician must validate the interview results. An experienced nurse or psychologist or mental health worker may do the actual interview. The MINI is the most common interview in drug treatment studies, and is available in over 40 languages. The English MINI version 6.0 was updated in 2009. It can be down-loaded without charge from www.medical-outcomes.com.
The Composite International Diagnostic Interview 3.0 (CIDI) is a fully structured non-clinical interview intended for use in general population surveys .
The CIDI-SAM (SAM is for Substance Abuse Module) is a structured interview that ascertains DSM-III, DSM-III-R, Feighner, RDC and ICD-10 diagnoses for alcohol, tobacco and nine classes of psychoactive drugs. It was designed at the request of the World Health Organization to expand the substance abuse sections of the CIDI. The SAM module takes an average of 45 minutes to complete.
The Schedules for Clinical Assessments in Neuropsychiatry (SCAN) is a semi-structured clinical interview to assess major mental disorders in clinical settings.
Schedules for Affective Disorders and Schizophrenia (SADS) has been produced in several versions since 1975, and can take up to 3 hours to complete by a trained clinician. It is the basis for the Structured Clinical Interview for Diagnosis (SCID I and SCID II) that is also an expert instrument.
The Personality Diagnostic Questionnaire (PDQ-4) holds 99 true/false items to screen for 11 DSM-IV personality disorders .
The General Health Questionnaire (GHQ-12) was developed in the 1970s for self-screening in primary care, public health surveys, and other settings with lower degrees of psycho-pathology. GHQ-12 asks if 12 symptoms have been present in recent weeks much more than usual, rather more than usual, no more than usual or not at all. Total scores derived using the Likert method (3-2-1-0) range from 36 to zero with higher scores denoting greater morbidity. It has proved reliable, stable and valid when tested in numerous primary care and hospital settings with a sensitivity and specificity versus CIDI of 79% and 77% respectively at cutpoint 11/12.
Another self-screen questionnaire is the Hospital Anxiety Depression Scale (HADS), developed in the UK to find cases with symptoms of anxiety and depression. It consists of 14 items that a subject can respond to within a few minutes, for example prior to a physician visit.
The Clinical Interview Schedule (CIS) was developed to assess anxiety, depression and somatization. The revised version (CIS-R) has been used in population surveys by lay interviewers.
The Kessler Psychological Distress Scale (K-10) checks if 10 mental symptoms have been present in the last 4 weeks for all, most, some, a little or none of the time. It was designed for use in general health surveys and has proved reliable and valid in surveys in the United States and in Australia .
Legal issues and psychiatric diagnosesEdit
The courts in most societies take a diagnosis of a psychiatric disorder into account before passing sentence. Usually the court will order that a subject undergoes a forensic psychiatric examination to determine whether there is a severe psychiatric disorder, and whether the subject can be held accountable for his actions. Does a subject with schizophrenia or antisocial personality disorder understand the consequences of his actions for other people and for society? Did the mother kill her child because of a depression, or because she was under the influence of auditory hallucinations? If there is an indisputable organic brain disease is the subject to be held accountable for a crime? These are evaluations that require an experienced, professional, thorough and highly regulated psychiatric assessment. The law varies between nations, and the court may order commitment to psychiatric care, or a prison term or both.
In many societies doctors are responsible by law to report if a patient is deemed unfit to possess a fire arm, or unfit to have a driver’s license, or to have custody of a child. Such reports require a careful psychiatric diagnosis.
In most countries, the history and mental health status examination should result in a clinical evaluation of the patient and at least one psychiatric diagnosis, all of which make up the core of the patient’s medical record (chart). This may be a preliminary or definite diagnosis. For example, a patient presenting with typical symptoms of schizophrenia can be given a preliminary diagnosis that is confirmed after 6 months, because of the duration criterion in DSM-IV.
The physician can be held accountable to a disciplinary board if the diagnostic procedure is not properly recorded. The diagnosis is the basis for justifying treatments and perhaps involuntary care.
Records are still written by hand or typed in many countries. Increasingly in Europe and in the United States there is a move to electronic medical records. This is in the interest of administrators and regulators to hold physicians accountable and to increase patient safety. Insurers have a stake in psychiatric diagnoses to assess the risk of a potential subject for a health insurance or retirement plan. If records contain valid and reliable information about the patient’s diagnosis, treatments, suicidal risk, and risk for aggression it will increase the quality of care. If all of the patient’s health care contacts (the emergency room, primary care unit, psychiatric clinic) are eligible to read the patient’s record it will increase patient safety, and reduce unnecessary investigatory procedures. There are opportunities for longitudinal case studies, research, and allocation of health care resources.
The potential drawback with a unifying electronic medical record is that it will be at the expense of person integrity and privacy. Particularly, a psychiatric record will contain highly sensitive information that should not be accessible to insurers and employers. Patients should have the option to decline such a unifying medical record that can otherwise be read by all eligible users of a computerized record system.
Anne Farmer, Peter McGuffin, Julie Williams. Measuring Psychopathology. Oxford University Press 2002.
Samuel B. Guze. Why Psychiatry is a Branch of Medicine. Oxford University Press, 1992.
Mario Incayawar, Ronald Wintrob, Lise Bouchard, Goffredo Bartocci (eds.). Psychiatrists and Traditional Healers. Unwitting Partners in Global Mental Health. Wiley-Blackwell, 2009.
Donald W. Goodwin, Samuel B. Guze. Psychiatric Diagnosis - 4th Edition. Oxford University Press, 1989. | <urn:uuid:242acd52-ed5a-4134-a37d-12e236c5f060> | {
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Dr. Norman A Garrison Jr has the following 2 specialties
- Emergency Medicine
An emergency physician is a doctor who is an expert in handling conditions of an urgent and extremely dangerous nature. These specialists work in the emergency room (ER) departments of hospitals where they oversee cases involving cardiac distress, trauma, fractures, lacerations and other acute conditions.
Emergency physicians are specially trained to make urgent life-saving decisions to treat patients during an emergency medical crisis. These doctors diagnose and stabilize patients before they are either well enough to be discharged, or transferred to the appropriate department for long-term care.
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Norman A Garrison Jr has the following 3 expertise
Showing 5 of 11
Patients' Choice Award (2013, 2017, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2011, 2013, 2017, 2018)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
On-Time Doctor Award (2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Top 10 Doctor - State (2014)
Top 10 Doctors are chosen by the millions of patients who visit Vitals each year to find a new doctor and share their experiences by providing ratings and reviews. In order to differentiate highly-regarded doctors from the rest for patients in search of quality care, Vitals awards Top 10 Doctor honors to those physicians within a certain specialty and geographic area who are consistently given top ratings by their patients.
49 Years Experience
University Of Mississippi School Of Medicine
Graduated in 1969
Dr. Norman A Garrison Jr accepts the following insurance providers.
- BCBS AL PPO
BCBS Blue Card
- BCBS Blue Card PPO
- First Health PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsFamily And Industrial Health Services, 4725 Mobile Hwy, Montgomery, AL
Take a minute to learn about Dr. Norman A Garrison Jr in this video.
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CAUSES OF DEATH
Causes of death statistics are key to understanding Australian society and health. The use of these statistics for demographic and health purposes provides significant information for the formulation and monitoring of health and other social policies. For example, causes of death information provide insights into the diseases and factors contributing to reduced life expectancy.
In Australia causes of death statistics are recorded as both underlying cause i.e. the disease or injury which initiated the train of morbid events leading directly to death; and multiple cause i.e. all causes and conditions reported on the death certificate that contributed, were associated with or were the underlying cause of the death (see Glossary for further details).
Causes of death data in this publication are classified using the 10th revision of the International Classification of Diseases (ICD-10). For further information see Explanatory Notes 30-34.
This data can be presented by using varying types of aggregation depending on the requirements of the data user. In this publication, data are presented in a number of ways to allow different types of analysis.
Chapter 2 of this publication presents data ranked by Leading Causes of Death. The methodology for the listing used is based on research presented in the Bulletin of the World Health Organization, see Explanatory Note 47. Data presented by leading cause is useful when comparing causes of death in different populations and/or over time.
Chapter 3 of this publication presents Underlying Cause of Death data commentary. Data presented in this manner is used to analyse particular causes or groups of similar causes. Information on median age at death and changes over time for selected causes is presented in this chapter with further data presented by ICD-10 chapter in the data cubes associated with this publication.
Chapter 4 presents data on Multiple Causes of Death. Multiple cause of death data is useful in the analysis of all the associated conditions that led to death, rather than the underlying cause alone.
Chapter 5 on Suicides and Chapter 6 on Deaths of Aboriginal and Torres Strait Islander people present summary data on these specific areas of public interest.
Chapter 7 presents Perinatal Deaths data. Perinatal deaths comprise stillbirths (fetal deaths) and deaths of infants within the first 28 days of life (neonatal deaths).
Chapter 8 presents data by Year of Occurrence.
In 2010, there were 143,473 deaths registered in Australia, 2,713 (1.9%) more than the number registered in 2009 (140,760). The standardised death rate (SDR) decreased to 5.7 deaths per 1,000 standard population in 2010, down from 5.8 in 2009. Standardised death rates are calculated using the 2001 total population of Australia as the standard population (see Glossary for more information).
In 2010, males accounted for 51.2% (73,484) of registered deaths, a slightly higher proportion than females who accounted for 48.8% of registered deaths (69,989).
The number of deaths for both males and females has increased since 2001 (66,835 and 61,709 respectively), but the increase has been larger for females. In 2001 there were 108 male deaths per 100 females. in 2010 this sex ratio dropped to 105 male deaths per 100 females.
Further details on numbers of deaths registered can be found in Deaths, Australia 2010 (cat. no. 3302.0).
Leading Cause of Death
In 2010, Ischaemic heart disease, defined as ICD-10 codes I20-I25, was the leading underlying cause of death in Australia. Ischaemic heart disease includes angina, blocked arteries (heart) and heart attacks. It was the underlying cause of 15.1% of all registered deaths in Australia. It accounted for 15.9% of all male deaths, and 14.3% of all female deaths registered in 2010. Ischaemic heart disease has been the leading cause of death in Australia since 2000.
Underlying Cause of Death
The table below presents summary causes of death data for each major chapter of the ICD-10. Further information on selected causes for 2010 is presented in Chapter 3 of this publication.
Multiple Cause of Death
1.1 DEATHS, by ICD-10 CHAPTER LEVEL - 2010(a)(b)
Proportion of total deaths
Standardised Death Rate(c)
|Cause of death and ICD code |
|Certain infectious and parasitic diseases (A00-B99) |
|Neoplasms (C00-D48) |
|Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) |
|Endocrine, nutritional and metabolic diseases (E00-E90) |
|Mental and behavioural disorders (F00-F99) |
|Diseases of the nervous system (G00-G99) |
|Diseases of the circulatory system (I00-I99) |
|Diseases of the respiratory system (J00-J99) |
|Diseases of the digestive system (K00-K93) |
|Diseases of the skin and subcutaneous tissue (L00-L99) |
|Diseases of the musculoskeletal system and connective tissue (M00-M99) |
|Diseases of the genitourinary system (N00-N99) |
|Certain conditions originating in the perinatal period (P00-P96) |
|Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) |
|Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) |
|External causes of morbidity and mortality (V01-Y98) |
|All Causes(d) |
|(a) Causes of death data for 2010 are preliminary and subject to a revisions process. See Explanatory Notes 35-39 and Technical Notes, Causes of Death Revisoins, 2006 and Causes of Death Revisions, 2008 and 2009 |
|(b) See Explanatory Notes 89-104 for further information on specific issues relating to 2010 data. |
|(c) Standardised Death Rate per 100,000 persons. See Glossary for further information. |
|(d) Includes deaths due to Diseases of the eye and adnexa (H00-H59), Diseases of the ear and mastoid processes (H60-H95) and Pregnancy, childbirth and the puerperium (O00-O99). |
For the 143,473 deaths registered in Australia in 2010, there were 453,319 causes reported giving a mean of 3.2 causes per death. The mean number of causes reported per death varies with age, sex and underlying cause of death. In 18.1% of all deaths, only one cause was reported, while 37.1% of deaths were reported with three or more causes. For further detail on multiple cause, see Chapter 4
of this publication.
Causes of Death Revisions Process
All coroner certified deaths registered after 1 January 2006 are now subject to a revisions process. Where presented, this publication contains final 2006, 2007 and 2008 data and revised 2009 cause of death data. Final 2006, 2007 and 2008 data and revised 2009 data are also presented in the associated data cubes. Data released in this publication for 2010 are preliminary data. All coroner certified deaths registered in 2010 will be subject to the revisions process. For further information, see Explanatory Notes
35-39 and Technical Notes, Causes of Death Revisions 2006
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Presenting The Information You Need...
Notebook Computer Guide*
*Become An Educated Buyer & Save
Handy Checklist For Buying A New Computer or Laptop
(Don't Enter That Computer Store Without It!)
Compiled and Written by Titus Hoskins
Computer technology is changing so fast it is sometimes very hard for the average consumer to keep up. New products and systems are coming on stream at such a blistering pace even some die-hard techies are probably falling behind...
With this thought in mind, here's a whole checklist of quick, fast facts you might want to consider before you buy your next computer. Some are very common basic computer facts you probably already know; while others deal with more recent technologies and products that you should check or be aware of when buying your new computer.
Remember, an educated buyer will always get the best deal by knowing exactly what you want in your computer and discarding the things you don't need or will never use. Prepare yourself before you enter that computer store or shop online for your next laptop/PC and save yourself some money.
Use This Fast Checklist Before Buying A New Computer or Laptop:
What Type of Processor? - This is the brand and type of processor included in your system, such as Intel i3, i5 or i7 Quad Core, Intel Core 2, AMD Phenom... this is the heart of your computer; also called the CPU (Central Processing Unit) and it runs your computer, performing tasks and running calculations. You must also check your processor speed - which is measured in Megahertz (MHz) or Gigahertz (GHZ) and determines how fast your computer can perform tasks. Usually, the higher the processor speed, the faster your CPU will perform. Remember, one GHz is equal to 1000 MHz. Many machines now have Duo or even Quad processors to achieve maximum performance. You should also check your Processor's Cache - this is the amount of memory you have in your computer for short term storage during processing. A lot of cache will allow you to work and process bigger and more complex files without crashing your system.
How Much RAM? - Random Access Memory is temporary memory your computer uses to run applications and data on your operating system. Generally the more RAM you have, the faster your computer will run. You need at least 256MB for Windows XP and Mac OS X. You need at least 1 Gig of RAM for Windows Vista but 2 Gigs or more will make it run smoother. However, 32-bit Operating Systems ONLY recognizes up to 3GB of RAM, while you need 64-bit systems to take full advantage of 4GB of RAM. Obviously, gaming machines will need a lot of dedicated video RAM.
Hard Drive Speed and Capacity? - Your hard drive is your computer's primary storage area where your data and files are stored. Most hard drives are now quite large at 100GB - 300GB or more. You might also want to check the rotational speed - a 7,200rpm hard drive is faster than a 5,400rpm model. How fast the disk spins will also determine the performance level of your computer or laptop. Many people also prefer a SATA (Serial Advanced Technology Architecture) hard drive. It was developed by a whole group of companies including Seagate, Intel, Maxtor, Dell and others. SATA transmits data in a serially (in a single stream) as opposed to PATA or Parallel ATA which is commonly referred to as an IDE hard drive.
Graphics Card? - Your graphics card or video card handles all your computer graphics, visuals and videos. Some computer systems have a motherboard chipset that handles your graphics, while other systems use a separate graphics card. Which card you decide for your system will largely depend upon what you're using your computer for... if you want to do video gaming or handle large high-resolution graphics then you will want a dedicated video card which will run faster and perform better than integrated graphics. Most new video cards use AGP (Accelerated Graphics Port) which is a dedicated connection that comes in different speeds - 2X 4X and 8X. To play video games and run complex multi-media applications you will need a high speed AGP 8X video card with at least 128MB or more of dedicated memory. Most gamers prefer high-end Graphics Cards from NVIDIA or ATI. To achieve maximum performance two or more graphics cards can be connected in a SLI configuration.
Dedicated Video Memory - This dedicated video memory is separate from your main system memory. In many computers the main memory is shared or integrated to help supplement your system's memory when it's needed. In others systems it is completely dedicated memory. Still others use a hybrid of both technologies.
Shared Video Memory - The portion of your system's memory that's shared to the graphics chipset to perform tasks like 3D gaming.
Video Memory - Shows how much total video memory is available to the video chipset/card - both dedicated and shared.
Pre-loaded Operating System? - What kind of OS (Operating System) is pre-installed on your computer. Usually this will be Windows XP or Windows Vista. There are different versions of Vista such as:
Windows Vista Home Basic... Similar to Windows XP Home Edition and intended for simple home use and budget buyers. The Windows Aero theme and translucent effects not included with this edition.
Windows Vista Home Premium... Similar to Windows XP Media Center Edition with support for more advanced multimedia and entertainment features. Includes support for premium games, mobile and tablet PC, Network Projector, Windows Aero, Touch Screen, and has auxiliary display (via Windows Side Show) support.
Windows Vista Business... Similar to Windows XP Professional and targeted towards the business market. Includes all the features of Home Premium except for Windows Media Center and related technologies.
Windows Vista Enterprise... A more robust version of the Business edition. (Microsoft Windows NT 6.0.6000.0) Includes multilingual user interface, BitLocker Drive Encryption & UNIX application support. This version is not available thru retail or OEM channels.
Windows Vista Ultimate ... Combines all the features of Home Premium and Enterprise editions.
Many computer users like to keep using Windows XP or install it. This is simply done, however - some current laptops/PCs won't accept XP so check this out BEFORE you buy your machine. Wins XP is no longer supported by Microsoft.
Most current laptops/computers come with Windows 7 or Windows 8/8.1/8.2 and keep in mind Windows 10 is coming soon.
Intel Centrino - This is a platform promoted by Intel which covers mainboard chipset, mobile CPU and wireless network interface in laptop designs. Intel's Core Duo processor offers dual-core performance while keeping the power consumption low.
Intel Centrino 2 - Fifth-generation Centrino Platform (codename Montevina) which supports Penryn Core 2 Duo processors.
What Optical Drives? - These are removable drives that write and read data using lasers. Common ones include CD ROM, DVD ROM, CD R/RW and DVD R/RW drives. The speed at which these optical drives work is measured in "150kb per second" units. Factors of "x" are used such as 4X, 8X... remember that DVD drives can use both DVDs and CDs.
Screen Size & Type? - Display size and type on your laptop or computer. Most screens are now LCD but not all. Check the resolution of your display as follows: 1600×1200 UXGA, 1400×1050 SXGA+, wide screens like 1280×720 WXGA, 1680×1050 WSXGA+ and 1920×1200 WUXGA.
TFT Active Matrix Display - TFT stands for thin-film transistors and many high-end notebook computers use (TFT) active matrix liquid crystal displays. Most notebooks have LCD (liquid crystal display) screens - this is different from your desktop CRT (cathode-ray tube) monitor but most people are familiar with LCD displays since they are commonly found in digital cameras and video recorders.
Native Screen Resolution - Refers to fixed pixel displays such as LCD, DLP and Plasma TVs. Native resolution is the fixed pixel display resolution, such as 1920 x 1080 (interlaced or progressive scan) for HD or High Definition TV.
Sound Card - Also known as an audio card is an independent expansion that controls Inp ut/output of audio signals. Important component for multimedia applications such as video gaming, music composition...
TV Tuner - Lets your computer tune TV or HDTV signals so that you can watch live television thru your PC.
FireWire (IEEE 1394) - Firewire is a high speed port for large and fast transfer of data - used with hard drives, video cameras and scanners.
Ethernet Port - This lets you connect your computer to a wired ethernet network. (Group of computers working together.)
Integrated Bluetooth - Bluetooth is a standard wireless networking system which lets you connect wirelessly to your computer's peripherals such as mouse, keyboards, headsets, printers...
Integrated WiFi - Integrated Wifi gives you wireless network access.
HDCP Compliant - HDCP compliance assures that the digital outputs on the computer are secure and the HDCP copy protection system is supported.
Audio Output - Audio output whether mono, stereo or surround and showing how many channels can be output.
Digital Input - Digital inputs lets multi-channel digital audio outputs to be streamed.
Digital Output - A digital output allows for multi-channel digital audio output.
Integrated Microphone - An integrated microphone lets you record audio into your computer.
Microphone Input - A connection for a standard stereo microphone.
Speaker Wattage - Total wattage output of your speakers, sometimes listed as peak power or total power depending on the speaker's maker.
Card Reader - This is used for reading memory cards.
Component output - This enables analog HD signals to be shown by your PC on a compatible display.
Composite Output - This shows whether or not your system supports composite video connections.
DVI Output - Provides a connector for DVI panels.
E-SATA - Is a high speed data port mainly used for connecting E-SATA hard drives.
HDMI - Whether or not your system supports HDMI connectivity - important for High Definition playback/visuals.
Keyboard - Input device for your computer - if you're buying a laptop, check to see if it's a full size standard keyboard.
Touchpad - An input device commonly found on notebook computers. Along with other input devices such as the Track Stick, Keyboards, and mouse.
Modem - A device which allows you to transmit data over phone lines. A fax modem lets you transmit to another fax modem or fax machine.
Mouse - An input device which uses hand movements and a corresponding screen cursor.
Remote - Some computers now have remote controls... handy if you use your computer for watching TV or DVDs.
S-Video Output - This supports S-video connections.
USB 2.0 - Check your system's USB 2.0 ports which are used for connecting USB (USB 1.0, 1.1 and 2.0) devices.
VGA Output - A connector for VGA (Video Graphics Array) panels.
Webcam - A webcam is a simple camera that records or transmits images to your computer.
Available AGP Slots? - These are used to install AGP expansion Cards.
Available Hard Drive Bays? - This is an open slot inside your system where you can install extra components such as optical or hard drives. Often referred to as an expansion bay. These come in two sizes - floppy drive (3.5 inches) and CD drive 5.25 inches and can handle any device that is the same size.
Available Memory Slots? - Tells you how many Memory Slots you have in your system. Usually you can upgrade your RAM if there are slots available.
Available Optical Bays? - For installing Optical Drives like the DVD drive.
Available PCI Slots? - These are available expansion slots for special cards such as video or network cards... to increase the performance or capabilities of your PC.
Available PCI-E Slots? - Available Slots to install PCI-E expansion Cards.
PCI-Express - Peripheral Component Interconnect Express, aka PCI-E is a computer expansion card interface format that was introduced in 2004 by Intel. Unlike the other PC expansion interfaces, PCI Express uses point-to-point serial links/lanes instead of a bus. There are different versions - such as x16, x1 which will be followed with x4 and x8.
What is SLI? - SLI stands for "Scalable Link Interface". Of interest mostly to Gamers and Gaming machines, NVIDIA SLI technology lets you use a couple of graphics cards together with PCI Express X16. Basically, SLI will speed up graphics on a single monitor by deploying two graphics cards. An alternative system would be ATI's CrossFire which is an SLI-like configuration using 'Master' and 'Slave' cards to combine two Radeon GPUs for improved and faster graphics.
Power Supply - Shows the wattage of your installed power supply.
Battery Life - The Lithium ion battery is the major type of battery found in most notebook computers because they have a longer battery life than regular batteries. Laptop batteries can be 4-cell, 6-cell, 9-cell... if long battery life is important to you - get the highest numbered cell battery. Also, it might be wise to purchase a second battery if you do a lot of traveling or 'in-the-field' work.
Removable Storage - Lets you read/write data to and from a removable floppy disk. Not used much anymore but still handy for troubleshooting or quick file transfers.
Pre-loaded Software? - Always check to see what software is pre-loaded on your computer system. This software will use up your system's resources... you can always remove these programs after you have bought your system to free up space.
System Bus - Your System Bus is measured in MHz ((megahertz) and is the path which connects all your computer components to the processor. Obviously, the higher your bus speed, the faster your system will process information.
English/French Software - Compatible with both English and French. Some systems will have French Kits, mainly for the Canadian marketplace.
Tower Size - Check to see the dimensions of your PC Tower system.
Laptop Size - Size is more important when buying a laptop. Check the size and weight of your laptop system - some desktop replacement laptops weight more than 10 pounds and are not really portable.
Check Warranty for Labor & Parts?- You must check the length of your warranty for Labor & Parts - how many years is each covered?
Extended Warranty? - Many manufacturers and retail stores will try to sell you extended warranties on any computer system you're considering. These warranties can be expensive so it is up to the individual buyer whether or not to purchase them. It will depend upon your own resources but if you're buying an expensive unit going with an extended warranty is a real option - especially when you consider replacement costs and the "peace of mind" such things supposedly brings.
What Computer to Buy? - Unless vanity is your thing or you have a serious "keeping up with the Joneses" complex - you should only buy a computer to meet your needs. Ask yourself what you will be using your computer for? If it's for simple email tasks or surfing the web - you don't need a big expensive machine with all the costy extras. If you're into video gaming or editing large video/graphic files you may need a more expensive fast computer with high-end quality graphics. In other words, choose the computer or laptop that will take care of your needs and tasks. Save your money by buying only what you need.
Where to Buy your Computer? - More and more computer buyers are ordering their systems online - either directly from the manufacturer or from online retail merchants. The main benefits of going with an online purchase are: 1) you're dealing directly with the maker, 2) you can configure your computer or laptop from the comfort of your own home, 3) you can often take advantage of special online discounts and deals... the main disadvantage is you can't physically see and handle the computer system you're buying. For this reason many buyers like buying their systems at their local computer store, where despite sometimes pushy salespeople who are usually working on commission - it does give you the chance to test-run the computer you're considering. It also gives you the chance to ask questions about the computer or laptop you're buying. Regardless of the route you take - Happy Shopping!
The Notebook Guide
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What is CRPS? that the ischemia that occurs Lifting the veil CRPS generally occurs after a when the blood flow to living tis- fracture, sprain or soft tissue dam- sue is stopped for a few or more on complex age to an arm or leg. "In the days hours, and the reperfusion that following the injury, the limb follows when the blood re-enters
NEDA TOOLKIT for Parents
Table of Contents
Common myths about eating disorders………………………………………………………………………….6 Eating disorder signs, symptoms and behaviors………………………………………………………….9 Ways to start a discussion with a loved one…………………….………………….………………………13 Advice from other parents: What to expect and how to respond………………………….17 Why parent-school communications may be difficult…………………………………………….20 Useful online resources for eating disorders……………………………………………………………. 21 Treatments available for eating disorders………………………………………………………………….24 The evidence on what treatment works………………………………………………………………………30 How to find a suitable treatment setting…………………………………………………………………….56 Treatment settings and levels of care………………………………………………………………………….59 Questions to ask the care team at a facility……………………………………………………………….61 Questions to ask when interviewing a therapist……………………………………………………….62 Questions parents may want to ask treatment providers privately…………………….63 Online databases to find suitable treatment………………………………………………………………64 How to take care of yourself while caring for a loved one…………………………………….65 Navigating and understanding insurance issues……………………………………………………….68 Sample letters to use with insurance companies………………………………………………………75 How to manage an appeals process…………………………………………………………………………….83
NEDA TOOLKIT for Parents
The NEDA Educational Toolkits Story
Parents and Educators.the starting point
In September 2007 the Board of Directors of NEDA Using the core questions we decided the Parent and officially approved the organization's new strategic Educators Toolkits would be created first. Additional priorities, listing educational toolkits as a new NEDA target audiences will include Coaches and Trainers, priority fitting the new mission Health Care Providers, and Individual Patients. We then hired ECRI Institute, a recognized expert in providing "To support those affected by eating disorders and be a publications, information and consulting services catalyst for prevention, cures, and access to quality internationally for healthcare assessments. Their ability care." Educational Toolkits were created to strengthen to translate work on behalf of the eating disorders existing materials and provide vital information to community into useful, real world tools established an targeted audiences. A list of audiences was prioritized excellent partnership for creating the content of the by the board and acts as a reference for ongoing materials and toolkit development. Parents and Educators.the process
The toolkit concept
ECRI initially created two separate toolsets with a The initial concept of the toolkits was to tie together consistent tone. We brought together two focus groups existing information along with the development of to guide us in the types of information to be included new materials to create complete packages that would for each of the audiences – parents and educators. help targeted audiences during critical moments in ECRI conducted additional interviews with interested their search for help, hope and healing. They are elementary and high school teachers and families. intended for guidance, not for standards of care and Next, ECRI researched and revised existing NEDA would be based on information available at the time of educational materials and handouts (as needed) and created new materials as appropriate for each kit. The result was a draft set of "tools" for each toolkit. Some Creation of the toolkits took thoughtful consideration. basic information is common to each; other tools are We identified several key questions as we began unique to each toolkit. As with all our materials, we working on this project. First: "What is a NEDA want to increase the outreach and support to our Educational Toolkit?" led us to ask ourselves these constituents while providing reliable information to the general public about the unique and complex nature of eating disorders. Who is the audience we are trying to reach? All focus groups agreed that an electronic toolkit, How many different toolkits will we develop? accessible via the NEDA website, would be the easiest, What should a toolkit contain? most up-to-date way to make the toolkits available. How do we include our stakeholders in the NEDA researched and reviewed several online toolkits, development of the toolkits? looking for the best elements of each that could be How does our audience want to receive the toolkit used to inform the design concept. The final design once it's developed? plan for the organization of each kit was created by How do we market the toolkits? designer, David Owens Hastings. ECRI then produced What is the plan to revise and enhance the toolkits the final documents that are the body of each of the first toolkits. The focus groups reviewed materials one more time and made suggestions for revisions. Their excellent edits and useful comments were integrated into the drafts. Joel Yager, MD, and additional clinical advisors were final reviewers on all documents. ECRI then submitted the Toolkit documents to NEDA.
NEDA TOOLKIT for Parents
Beyond parent and educators toolkits
We fully recognize that not all the information within each toolkit will be able to address the diversity and the nuances of each person's and/or families unique circumstances. Our intent is to provide a one-stop place for a comprehensive overview relating to eating disorders for each audience. We have included resources for further information and will be going deeper as funding permits with each audience. We are imagining at this point in the project Parent and Educator toolkits version 1.0, then version 2.0 and so on. The lifecycle of the toolkits is an important aspect in managing this strategic priority for the organization. Our goal is to maintain the usefulness of the toolkits by reviewing and revising each at two-year intervals and including the most up-to-date research and information. NEDA's clinical advisors will be primary reviewers, along with others invited by NEDA, including members of professional organizations that will be disseminating the toolkits. We are currently seeking funding for the ongoing development of toolkits, as well as distribution and marketing. If you or anyone you know may be interested in contributing to, sponsoring or providing a grant to support these efforts, please be sure to contact our Development Office at 212-575-6200, ext. 307; We hope you'll find these toolkits useful and will share this resource with others.
NEDA TOOLKIT for Parents
NEDA TOOLKIT for Parents
Common myths about eating disorders
This information is intended to help dispel all-too-common misunderstandings about eating disorders and those
affected by them. If your family member has an eating disorder, you may wish to share this information with others (i.e., other family members, friends, teachers, coaches, family physician).
Eating disorders are not an illness
because females are more likely to seek help, and health practitioners are more likely to consider an Eating disorders are a complex medical/psychiatric eating disorder diagnosis in females. Differences in illness. Eating disorders are classified as a mental symptoms exist between males and females: females illness in the American Psychiatric Association's are more likely to focus on weight loss; males are more Diagnostic and Statistical Manual of Mental Health likely to focus on muscle mass. Although issues such as Disorders (DSM-IV), are considered to often have a altering diet to increase muscle mass, over-exercise, or biologic basis, and co-occur with other mental illness steroid misuse are not yet criteria for eating disorders, such as major depression, anxiety, or obsessive- a growing body of research indicates that these factors compulsive disorder are associated with many, but not all, males with eating Eating disorders are uncommon
Men who suffer from eating disorders tend to
They are common. Anorexia nervosa, bulimia nervosa, and binge-eating disorder are on the rise in the United States and worldwide. Among U.S. females in their Sexual preference has no correlation with developing teens and 20s, the prevalence of clinical and an eating disorder. subclinical anorexia may be as high as 15%. Anorexia nervosa ranks as the 3rd most common chronic illness Anorexia nervosa is the only serious eating
among adolescent U.S. females. Recent studies suggest disorder
that up to 7% of U.S. females have had bulimia at some time in their lives. At any given time an estimated 5% of All eating disorders can have damaging physical and the U.S. population has undiagnosed bulimia. Current psychological consequences. Although excess weight findings suggest that binge-eating disorder affects 0.7% loss is a feature of anorexia nervosa, effects of other to 4% of the general population. eating disorders can also be serious or life threatening, such as the electrolyte imbalance associated with Eating disorders are a choice
People do not choose to have eating disorders. They A person cannot die from bulimia
develop over time and require appropriate treatment to address the complex medical/psychiatric symptoms While the rate of death from bulimia nervosa is much and underlying issues. lower than that seen with anorexia nervosa, a person with bulimia can be at high risk for death and sudden Eating disorders occur only in females
death because of purging and its impact on the heart and electrolyte imbalances. Laxative use and excessive Eating disorders occur in males. Few solid statistics are exercise can increase risk of death in individuals who available on the prevalence of eating disorders in are actively bulimic. males, but the disorders are believed to be more common than currently reflected in statistics because Subclinical eating disorders are not serious
of under-diagnosis. An estimated one-fourth of anorexia diagnoses in children are in males. The Although a person may not fulfill the diagnostic criteria National Collegiate Athletic Association carried out for an eating disorder, the consequences associated studies on the incidence of eating-disordered behavior with disordered eating (e.g., frequent vomiting, among athletes in the 1990s, and reported that of those excessive exercise, anxiety) can have long-term athletes who reported having an eating disorder, 7% consequences and requires intervention. Early were male. For binge-eating disorder, preliminary intervention may also prevent progression to a full- research suggests equal prevalence among males and blown clinical eating disorder. females. Incidence in males may be underreported
NEDA TOOLKIT for Parents
Dieting is normal adolescent behavior
Eating disorders are about appearance and
While fad dieting or body image concerns have become "normal" features of adolescent life in Western Eating disorders are a mental illness and have little to cultures, dieting or frequent and/or extreme dieting do with food, eating, appearance, or beauty. This is can be a risk factor for developing an eating disorder. It indicated by the continuation of the illness long after a is especially a risk factor for young people with family person has reached his or her initial ‘target' weight. histories of eating disorders and depression, anxiety, or Eating disorders are usually related to emotional issues obsessive-compulsive disorder. A focus on health, such as control and low self-esteem and often exist as wellbeing, and healthy body image and acceptance is part of a "dual" diagnosis of major depression, anxiety, preferable. Any dieting should be monitored. or obsessive-compulsive disorder. Anorexia is "dieting gone bad"
Eating disorders are caused by unhealthy and
unrealistic images in the media
Anorexia has nothing to do with dieting. It is a life- threatening medical/psychiatric disorder. While sociocultural factors (such as the ‘thin ideal') can contribute or trigger development of eating disorders, A person with anorexia never eats at all
research has shown that the causes are multifactorial and include biologic, social, and environmental Most anorexics do eat; however, they tend to eat contributors. Not everyone who is exposed to media smaller portions, low-calorie foods, or strange food images of thin "ideal" body images develops an eating combinations. Some may eat candy bars in the morning disorder. Eating disorders such as anorexia nervosa and nothing else all day. Others may eat lettuce and have been documented in the medical literature since mustard every 2 hours or only condiments. The the 1800s, when social concepts of an ideal body shape disordered eating behaviors are very individualized. for women and men differed significantly from today— Total cessation of all food intakes is rare and would long before mass media promoted thin body images for result in death from malnutrition in a matter of weeks. women or lean muscular body images for men. Only people of high socioeconomic status get
Recovery from eating disorders is rare
Recovery can take months or years, but many people People in all socioeconomic levels have eating eventually recover after treatment. Recovery rates vary disorders. The disorders have been identified across all widely among individuals and the different eating socioeconomic groups, age groups, disorders. Early intervention with appropriate care can improve the outcome regardless of the eating disorder. Although anorexia nervosa is associated with the You can tell if a person has an eating disorder
highest death rate of all psychiatric disorders, research simply by appearance
suggests that about half of people with anorexia nervosa recover, about 20% continue to experience You can't. Anorexia may be easier to detect visually, issues with food, and about 20% die in the longer term although individuals may wear loose clothing to due to medical or psychological complications. conceal their body. Bulimia is harder to "see" because individuals often have normal weight or may even be overweight. Some people may have obvious signs, such as sudden weight loss or gain; others may not. People with an eating disorder can become very effective at hiding the signs and symptoms. Thus, eating disorders can be undetected for months, years, or a lifetime.
NEDA TOOLKIT for Parents
Eating disorders are an attempt to seek
You're not sick until you're emaciated
Only a small percentage of people with eating disorders reach the state of emaciation often portrayed The causes of eating disorders are complex and in the media. The common belief that a person is only typically include socio economic, environmental, truly ill if he or she becomes abnormally thin cultural, and biologic factors. People who experience compounds the affected individuals' perceptions of eating disorders often go to great lengths to conceal it body image and not being "good" at being "sick due to feelings of shame or a desire to persist in enough." This can interfere with seeking treatment and behavior perceived to afford the sufferer control in life. can trigger intensification of self-destructive eating Eating disorders are often symptomatic of deeper disorder behaviors. psychological issues such as low self-esteem and the desire to feel in control. The behaviors associated with Kids under age 15 are too young to have an
eating disorders may sometimes be interpreted as eating disorder
‘attention seeking"; however, they indicate that the affected person has very serious struggles and needs Eating disorders have been diagnosed in children as young as seven or eight years of age. Often the precursor behaviors are not recognized until middle to Purging is only throwing up
late teens. The average age at onset for anorexia nervosa is 17 years; the disorder rarely begins before The definition of purging is to evacuate the contents of puberty. Bulimia nervosa is usually diagnosed in mid- the stomach or bowels by any of several means. In to-late teens or early 20s, although some people do not bulimia, purging is used to compensate for excessive seek treatment until even later in life (30s or 40s). food intake. Methods of purging include vomiting, enemas and laxative abuse, insulin abuse, fasting, and You can't suffer from more than one eating
excessive exercise. Any of these behaviors can be disorder
dangerous and lead to a serious medical emergency or death. Purging by throwing up also can affect the teeth Individuals often suffer from more than one eating and esophagus because of the acidity of purged disorder at a time. Bulimarexia is a term that was coined to describe individuals who go back and forth between bulimia and anorexia. Bulimia and anorexia Purging will help lose weight
can occur independently of each other, although about half of all anorexics become bulimic. Many people Purging does not result in ridding the body of ingested suffer from an eating disorders not otherwise specified food. Half of what is consumed during a binge typically (EDNOS), which can include any combination of signs remains in the body after self-induced vomiting. Laxatives result in weight loss through fluids/water and the effect is temporary. For these reasons, many people Achieving normal weight means the anorexia
with bulimia are average or above-average weight. Weight recovery is essential to enabling a person with anorexia to participate meaningfully in further treatment, such as psychological therapy. Recovering to normal weight does not in and of itself signify a cure, because eating disorders are complex medical/psychiatric illnesses.
NEDA TOOLKIT for Parents
Eating Disorder Signs, Symptoms, and Behaviors
Dramatic weight loss Has intense fear of others without eating weight gain or being Dresses in layers to hide "fat," even though Consistently makes excuses to avoid Is preoccupied with weight, food, calories, fat situations involving experience of body grams, and dieting weight or shape, undue influence of Refuses to eat certain weight or shape on foods, progressing to excessive, rigid self-evaluation, or restrictions against exercise regimen – whole categories of food despite weather, seriousness of low (e.g., no carbohydrates, fatigue, illness, or injury, the need to "burn off " calories Postpuberty female feeling "fat" or Withdraws from usual overweight despite friends and activities Feels ineffective and becomes more isolated, withdrawn, Has strong need for constipation, abdominal pain, cold intolerance, lethargy, and excess Shows inflexible about eating in public Has limited social Denies feeling hungry Develops food rituals restrained initiative Resists maintaining (e.g., eating foods in body weight at or certain orders, excessive above a minimally chewing, rearranging normal weight for food on a plate)
NEDA TOOLKIT for Parents
In general, behaviors and Steals or hoards food Looks bloated from attitudes indicate that in strange places weight loss, dieting, and control of food are Drinks excessive Frequently diets amounts of water becoming primary concerns Shows extreme Evidence of binge eating, concern with body including disappearance of weight and shape large amounts of food in mouthwash, mints, and short periods of time or lots Has secret recurring of empty wrappers and Hides body with baggy containers indicating binge eating (eating consumption of large period of time an Maintains excessive, amount of food that rigid exercise regimen Evidence of purging is much larger than behaviors, including – despite weather, most individuals frequent trips to the fatigue, illness, or bathroom after meals, signs injury, the need to and/ or smells of vomiting, "burn off " calories circumstances); feels presence of wrappers or lack of control over packages of laxatives or Shows unusual ability to stop eating swelling of the cheeks Purges after a binge Appears uncomfortable (e.g., self-induced eating around others Has calluses on the vomiting, abuse of back of the hands and laxatives, diet pills knuckles from self- Develops food rituals (e.g., and/or diuretics, eats only a particular food induced vomiting excessive exercise, or food group [e.g., Teeth are discolored, condiments], excessive chewing, doesn't allow Body weight is foods to touch) Creates lifestyle typically within the schedules or rituals to normal weight range; Skips meals or takes small make time for binge- may be overweight portions of food at regular and-purge sessions Withdraws from usual friends and activities
NEDA TOOLKIT for Parents
Binge Eating Disorder (Compulsive Eating Disorder)
Evidence of binge eating, Steals or hoards food in Has periods of including disappearance of large amounts of food in short periods of time or lots Hides body with baggy continuous eating of empty wrappers and beyond the point of containers indicating feeling comfortably consumption of large Creates lifestyle schedules or rituals to make time for binge- Does not purge Develops food rituals (e.g., eats only a particular food or Engages in sporadic food group [e.g., condiments], Skips meals or takes fasting or repetitive excessive chewing, doesn't small portions of food allow foods to touch) at regular meals Body weight varies from normal to mild, moderate, or severe obesity
Other Eating Disorders
Any combination of the above
NEDA TOOLKIT for Parents
How to be supportive
Accuse or cause feelings of guilt Educate yourself on eating disorders; learn the jargon Invade privacy and contact the patient's doctors or others to check up behind his/her back Learn the differences between facts and myths about weight, nutrition, and exercise Demand weight changes (even if clinically necessary for health) Ask what you can do to help Insist the person eat every type of food at the Listen openly and reflectively Be patient and nonjudgmental Invite the person out for social occasions where Talk with the person in a kind way when you are the main focus is food calm and not angry, frustrated, or upset Invite the person to go clothes shopping Have compassion when the person brings up painful issues about underlying problems Make eating, food, clothes, or appearance the focus of conversation Let him/her know you only want the best for Make promises or rules you cannot or will not follow (e.g., promising not to tell anyone) Remind the person that he/she has people who care and support him/her Threaten (e.g., if you do this once more I'll…) Offer more help than you are qualified to give Suggest professional help in a gentle way Create guilt or place blame on the person Offer to go along Put timetables on recovery Be flexible and open with your support Take the person's actions personally Try to change the person's attitudes about Compliment the person's personality, successes, eating or nag about food and accomplishments Try to control the person's life Encourage all activities suggested by the treating care team, such as keeping Use scare tactics to get the person into appointments and medication compliance treatment, but do call 911 if you believe the person's condition is life-threatening Encourage social activities that don't involve food Encourage the person to buy foods that he/she will want to eat (as opposed to only "healthy" Help the person to be patient Help with the person's household chores (e.g., laundry, cleaning) as needed Remember: recovery takes time and food may always be a difficult issue Remember: recovery work is up to the affected Show care, concern, and understanding Ask how he/she is feeling Try to be a good role model Understand that the person is not looking for attention or pity
NEDA TOOLKIT for Parents
Ways to start a discussion with a loved one who might
have an eating disorder
The following guidance presumes that the situation is serious, that it is not immediately life threatening, and that it does not require emergency medical care or a call to 911.
Learn all you can about eating disorders
Explain the reasons for your concerns, without
mentioning eating behavior
Then, prepare yourself to listen with compassion and no judgment. Have a list handy of the resources to offer The person may den the situation because of overwhelming feelings, such as shame and guilt. Avoid expressing frustration with the person. Stay calm. Be Remember that even though you are
gently persistent as you go on expressing your informed about the eating disorder, only a
concerns. Ask, "Are you willing to consider the professional trained in diagnosing eating
possibility that something is wrong?" Be prepared with disorders can make a diagnosis
resources to offer if the person seems to be listening—or leave a list of resources behind for the person to Avoid using your knowledge to nag or scare the person. look at on his/her own. Expressing your concerns may The goal of a discussion should be to express your be awkward at first, but such efforts can provide the concerns about what you've observed and persuade, bridge to help the person. Even if the person does not but not force, the person to accept help. acknowledge a problem during your discussion, you have raised awareness that you are paying attention, Plan a private, uninterrupted time and place
are concerned, and want to be a support. to start a discussion
Ask if he/she is willing to explore these
Be calm, caring, and nonjudgmental. Directly express, concerns with a healthcare professional who
in a caring way, your observations and concerns about understands eating disorders
the person's behavior. Use a formula like "I am concerned about you and what's going on for you when Remember that only appropriately trained I see you [fill in the blank]." Cite specific days/times, professionals can offer appropriate options and guide situations, and behaviors that have raised your concern. treatment. Your job is to express concern and offer Share your wonder about whether the behavior might support. Ask if he/she will share the feelings that come indicate an eating disorder that requires treatment. from the behavior you've observed. Does it provide a Share what you've observed about the person's mood, sense of control, relief, satisfaction, or pleasure? Let depression, health, addiction recovery, or relationships. your loved one know there are other ways to feel Avoid words and body language that could imply better that don't take such a physical and emotional blame. Avoid discussing food and eating behavior, which can lead to power struggles. Leave those issues for the therapist to handle. Comments like "You're Remind your loved one that many people
putting on weight" or "You look thinner," may be have successfully recovered from an eating
perceived as encouraging disordered eating. disorder
Offer to help find a treatment center and offer to go along to a therapist or intake appointment. Offer encouragement and support, but, understand that in the long run, recovery is up to the person.
NEDA TOOLKIT for Parents
Take a break if your loved one continues to
deny the problem
Revisit the subject again soon, but not in a confrontational way. It's frustrating and scary to see someone you love suffering and be unable to do much about it. Remember that control is often a big issue. You cannot successfully control another person's behavior. Many patients and families interviewed about these issues discussed "control" as a key issue they had to come to terms with. If your child is older than 18, treatment cannot be forced or discussed with any health professional without written permission from your child. Even if your child is younger than age 18 years of age, he/she must be willing to acknowledge the problem and want to participate in treatment. In some cases, enlisting the support of others whom the person likes and respects may help—like a teacher, coach, guidance counselor, or other mentor who can share your concerns. Lastly, being a good support means that you
also have to take good care of yourself and
attend to the stresses you feel from the
This is important not only for your wellbeing, but also to serve as a model of healthy behavior for the person you are trying to support. Don't let your loved one's eating disorder completely rule your life.
NEDA TOOLKIT for Parents
First steps to getting help
These steps are intended for use in a nonemergency situation. If the situation is a medical or psychiatric emergency in which the patient is at risk of suicide or is medically unstable, call 911 immediately. Early detection, initial evaluation, and ongoing Medical assessment should include the following:
management can play a significant role in recovery and in preventing an eating disorder from progressing to a Physical exam including weight, height, body more severe or chronic state. The following mass index (BMI), cardiovascular and assessments are recommended as first steps to peripheral vascular function, dermatologic diagnosis and will help determine the level of care symptoms (e.g., health of skin, hair growth), needed for your family member. Receiving appropriate and evidence of self-injurious behaviors treatment at the earliest opportunity can aid in long- term recovery. The following assessments are Laboratory tests (see list below) recommended as first steps to diagnosis and will help determine the level of care your child or family Dental examination if a history of purging behaviors exists Patient assessment by a physician experienced in
Establishment of the diagnosis along with a eating disorders should include the following:
determination of eating disorder severity Patient history, including screening questions about eating patterns Laboratory Testing Used for Diagnosis of Eating
Disorders and Monitoring Response to Treatment
Medical, nutritional, and psychological and social functioning (if possible, an eating Standard Work-Up
disorder expert should assess the mental health of your child) Complete Blood Count (CBC) with differential Attitudes toward eating, exercise, and Complete Metabolic Profile: sodium, chloride, potassium, glucose, blood urea nitrogen, Family history of eating disorders or other psychiatric disorders, including alcohol and Creatinine, total protein, albumin, globulin, other substance use disorders calcium, carbon dioxide, asat, alkaline Family history of obesity Phosphates, total bilirubin Assessment of how the patient interacts with Serum magnesium people regarding food-related feelings and Thyroid Screen (T3, T4, TSH) Assessment of attitudes toward eating, Electrocardiogram (ECG) exercise, and appearance
NEDA TOOLKIT for Parents
Level of Care
If uncertain of diagnosis: Once a diagnosis is made, a level of care will be recommended based on the physical, psychiatric, and Erythrocyte sedimentation rate laboratory findings. Pursue the level of care that is recommended for your child. This may include Radiographic studies (computed tomography inpatient, outpatient, intensive outpatient, partial or magnetic resonance imaging of the brain or hospital, or residential treatment. upper or lower gastrointestinal system) If patient has been amenorrheic for 6 months: Urine pregnancy, luteinizing and follicle- stimulating hormone, and prolactin tests If patient is 15% or more below ideal body weight Complement 3 (C3) 24 Creatinine Clearance If patient is 15% or more below IBW lasting 6 months or longer at any time during course of eating disorder: Dual Energy X-Ray Absorptiometry (DEXA) to assess bone mineral density Estradiol Level (or testosterone in male) If patient is 20% or more below IBW or any neurologic If patient is 20% or more below IBW or sign of mitral Echocardiogram If patient is 30% or more below IBW: Skin Testing for Immune Functioning
NEDA TOOLKIT for Parents
Advice from other parents: What to expect and how to
Well-meaning people who have no idea about what
Can I give you some advice?
your family is going through can sometimes say insensitive things. Others who need to be part of the I appreciate your thoughtfulness and desire to help, care and communication plan—like schools, coaches, and it's good to know I have your support. I'd really other family members—need to know certain things. prefer to rely on the advice of our care team right Avoid responding to intrusive questions that are none now. We are getting lots of input from lots of of the asker's business. On the other hand, some directions and it's really a little overwhelming. Thanks questions provide an opportunity to educate and enlighten if you feel so inclined. Some days you may just feel too drained to respond to questions—let the Why do you think he/she has an eating
asker know it's not a great day to be asking questions. Parents of adolescents and young adults with an disorder?
eating disorder offer the advice below about possible No one knows exactly what causes eating disorders. ways to respond to questions, based on their own Right now I'm concerned with supporting my child through treatment and not focusing on the how and whys. Aren't eating disorders just the new disease
fad? I hear about them all over the media.
How can he/she be sick? He/she doesn't look
Not at all. An eating disorder is not a "fad" or a "phase." People don't just "catch" it and get over it. Individuals with bulimia nervosa typically are within Eating disorders are complex and devastating the normal weight range, and some may be conditions that can have serious consequences for underweight or overweight. Individuals with anorexia physical and emotional health, quality of life, and may not look it outwardly until the disorder becomes so severe that it is life threatening. An eating disorder? That's not really an
illness is it? It's just dieting gone bad
Why did he/she tell a teacher [coach, nurse,
[anorexia]. It's just an excuse to get sympathy
counselor—any other adult] first?
for being overweight [bulimia; binge eating
Kids often are hesitant to tell their parents something they feel really bad about. We're happy and relieved It's a recognized and real illness, identified by the that he/she at least told someone who then told us so National Institute of Mental Health. It's also serious – we can get him/her the care he/she needs. anorexia is the largest cause of death among teenage What are you doing to help your child?
He's/she's only in middle school. Isn't that too
We're listening to our child, educating ourselves about young to have an eating disorder?
it, and getting the best, most comprehensive care possible to address all the aspects of a really complex No. Eating disorders are diagnosed in people as young illness. It's exhausting.
NEDA TOOLKIT for Parents
Can't you just make her eat?
Why didn't you do anything sooner?
Like many behavioral problems, it is hard to make The scariest thing about eating disorders is how changes unless there is a consistent, persistent, and secretive they are and how well a person can hide the clinically informed way of going about it. Although condition. Hindsight is 20/20. Had we known the signs you can't just "make them eat," you can, as parents and symptoms back then that we know now, we might working with a professional who supports your efforts, have suspected it sooner and would have sought help find effective ways to disrupt starvation and over right away. Even then, the person has to be willing to exercise. In fact, studies in the UK and US suggest that accept treatment after the initial medical crisis is putting parents in charge of weight restoration is over—and the nature of the illness makes that hard. effective for most adolescents with anorexia nervosa. What can I do to help?
Will he/she be cured after treatment?
Thanks very much for asking. Life has been very We're hopeful for a full recovery over time. It can be a draining lately just trying to make sure my child is very long haul. Getting the right treatment is key and getting the care he/she needs. It leaves little time for that's a significant part of what I'm trying to the mundane. I keep my "to-do" list handy. (Pull out your list.) If you're serious, I could use help with (assign a task with a date and time that it's needed). Is there a chance that he/she could die?
Why aren't you letting me help you?
Eating disorders can be life-threatening. They affect a person's physical and emotional health. Some people Our child's illness is serious and I'm relying on have died from them. It's very scary, but we are professional help to treat his/her condition. The help I hopeful and doing everything we can to make sure need from family and friends is your continued he/she gets care that will prevent that. support and ongoing friendship. I appreciate your asking. If I think of something our family needs that Do you want us to help the child make-up
you can do for us, I'll let you know. work (flexible schedule) or should we leave
him/her back a grade? Do you want us to
Why didn't you tell me about this earlier?
provide a tutor?
It's private and our focus initially was on educating Let's schedule a meeting with my child's therapist and ourselves and getting our child the best care. We the principal, key teachers, nurse, and school weren't even sure it would be helpful to share with psychologist to create the education plan. others. So when we were ready, we decided that now is the right time for us to share this with friends and What kind of support do you want the school
How are you coping with this?
Have a specific list from the treatment team: Mealtime Thanks for asking. It's very draining and very stressful support; excuse from physical education or other on our entire family. We really appreciate the activities as needed; communication expected from understanding and support coming from friends. school and with whom.
NEDA TOOLKIT for Parents
Can I go with you to the support group?
Can't you just make him/her go to the
The response depends on the context: If the person is being nosy and is not close to the family or patient, it The use of hospitalization to treat anorexia nervosa may be inappropriate to attend a support group. In varies from country to country. In the US, that case, here is a response: The support group is hospitalization for medical complications for intended for people who are closest to the situation. If adolescents with AN is a common intervention. you want to learn more about eating disorders, that's Depending on individual state law, a parent may be terrific. Community information seminars are given able to admit their minor children for medical locally sometimes on eating disorders and that might hospitalization against the minor's wishes. Laws be a more comfortable setting—these are often governing psychiatric hospitalization of minors also offered through local hospital outreach programs or vary from state to state, but in many, parents cannot eating disorder advocacy groups. require their minor children to stay in a psychiatric facility if a judge determines they are not a danger to Is he/she going to have to be hospitalized?
themselves or others, or cannot care for themselves. That depends on the progress he/she makes as an How long will he/she be in treatment?
outpatient. We'll just have to see how it goes. Hospitalization is sometimes necessary with this Everyone's treatment process and progress is different. illness because of the serious medical consequences it It could be months; it could be years. Why are you going to family therapy?
Why is he/she returning to the hospital
We're hoping to better understand the problem, our role in the recovery process, how best to encourage Recovery is a hard and not always predictable road. A and support our son/daughter, and how to help few steps forward and a step back. Sometimes events manage the symptoms. or stresses can trigger a relapse. But keeping a positive outlook is important and knowing that many How long will he/she be in recovery?
people recover keeps us going. Don't put timetables on recovery. Every patient Why can't you stop this destructive behavior?
progresses at his/ her own speed. Be patient with therapy, finding the right medication, and the process Recovery is ultimately up to the patient. The care of the entire treatment plan. team and all of us in the family are doing everything we can to give her/him the care and support needed for recovery. But no one can force or speed up Is your child on any medications that I should
treatment and recovery. be aware of? What are the side effects I
should be looking out for?
How much school is your child going to miss?
The school and coaches and anyone your child spends That isn't entirely clear right now, but based on the significant time with should be given this information treatment team's recommendation for the near term, in case of an adverse event. Be prepared with copies here is what we know… of a sheet that summarizes medication names, dosing regimen, and the prescribing physician's contact
NEDA TOOLKIT for Parents
Why parent-school communications may be difficult:
Regulatory constraints and confidentiality issues
This information is intended to help both parents and school staff understand each other's perspectives about
communication and the factors that affect their communications.
Parents of children with an eating disorder (diagnosed Teachers explain that sometimes the student considers or undiagnosed) sometimes express frustration about the problem to be the parent, so contacting the parent what they perceive as a lack of communication about about a concern can make a student's problem worse their child's behavior from school teachers, coaches, in the students' eyes. Conversely, a student can also guidance counselors, and other school administrative prohibit a teacher from talking with parents about the personnel. From the parents' perspective, feelings have teachers' concerns without evidence from direct been expressed that "my child is in school and at observations of behavior. school activities more waking hours a day than they are home. Why didn't the school staff notice something The following link presents the position statement from was wrong? Why don't they contact us about our child the professional association of school counselors: to tell us what they think?" It states the professional From a teacher's perspective, feelings have been responsibilities of school counselors, emphasizing expressed that "my hands are tied by laws and rights to privacy, defining the meaning of regulations about what and how we are allowed to confidentiality in a school setting, and describing the communicate concerns to parents. Also, it's often the role of the school counselor. The position statement's case that a given teacher sees a student less than an summary is as follows: hour a day in a class full of kids. So no school staff person is seeing the child for a prolonged period. Kids "A counseling relationship requires an atmosphere of
are good at hiding things when they want to. " trust and confidence between student and counselor. A
student has the right to privacy and confidentiality. The
While rules vary from state to state, the Position responsibility to protect confidentiality extends to the
Statement on Confidentiality from The American student's parent or guardian and staff in confidential
School Counselor Association may help both sides relationships. Professional school counselors must
better understand why communications between adhere to P.L. 93-380."
family members and school personnel may be difficult at times. The rationale behind this position is that an atmosphere of trust is important to the counseling relationship. In addition, schools may be bound by strict protocols generated by state regulations about how teachers and staff are required to channel observations and concerns. For example, school districts in a state may be required to have a "student assistance program" team to handle student nonacademic issues. Teacher concerns are submitted on a standard form to the team that then meets to develop a "student action plan." Privacy laws can prohibit a teacher from discussing their concerns with a student without parent permission.
NEDA TOOLKIT for Parents
Useful online resources for eating disorders
Academy for Eating Disorders
Eating Disorders Coalition for Research,
Policy & Action
An organization for healthcare professionals in the eating disorders field. The academy promotes A coalition with representatives of various eating research, treatment, and prevention of eating disorder groups. This organization focuses on lobbying disorders. Their Web site lists current clinical trials and the federal government to recognize eating disorders general information about eating disorders. as a public health priority. A Chance to Heal Foundation
ECRI Institute Bulimia Resource Guide for
This foundation was established to provide financial assistance to individuals with eating disorders who might not otherwise receive treatment or reach full ECRI Institute, an independent, nonprofit healthcare recovery due to their financial circumstances. The research organization, researching the best ways to organization's mission also focuses on increasing improve patient care. ECRI Institute produces public awareness and education about eating evidence-based information about healthcare for disorders and advocating for change to improve patients and families, including the Web site listed access to quality care for eating disorders. above. The Institute is designated an Evidence-based Practice Center by the U.S. Agency for Healthcare Anna Westin Foundation
Research and Quality and a Collaborating Center of the World Health Organization. Maudsley Parents
This organization was founded in memory of a child who died from bulimia complications. It performs advocacy, education, and speakers, and provides resources about eating disorders, treatment, and Maudsley Parents is an independent, nonprofit, navigating the health insurance system. The volunteer organization of parents. The Maudsley Anna Westin Foundation and Methodist Hospital approach is an evidence-based treatment for eating Eating Disorders Institute partnered to establish a disorders. In Maudsley treatment, parents play a key long-term residential eating disorder treatment role in helping their child recover. program for women in Minnesota. National Alliance on Mental Illness
Anorexia Nervosa and Related Eating
A national grassroots mental health organization dedicated to improving the lives of people living with serious mental illness and their families. This organization provides information about anorexia, bulimia, binge-eating disorder, and other lesser-known food and weight disorders, including self-help tips and information about recovery and
NEDA TOOLKIT for Parents
National Association of Anorexia Nervosa
and Associated Disorders (ANAD)
This Web site gives detailed information on most aspects of eating disorders: defining them, preventing This organization seeks to alleviate the problems of them, finding treatments, and paying for recovery. eating disorders by educating the public and Useful links to related articles and stories are healthcare professionals, encouraging research, and sharing resources on all aspects of these disorders. ANAD's Web site includes information on finding support groups, referrals, treatment centers, advocacy, Voices not Bodies
and background on eating disorders. National Eating Disorders Association
An all-volunteer organization dedicated to eating disorders awareness and prevention. This organization is the largest non-profit organization in the United States dedicated to supporting those affected by eating disorders and being a catalyst for prevention, cures and access to quality care. NEDA develops support programs for a wide range of audiences, publishes and distributes educational materials, operates a toll-free eating disorders Information and Referral Helpline which links callers to vital information and treatment. The searchable database of treatment providers throughout the U.S. and Canada is also available on the website. Eating Disorder Referral and Information
This is a sponsored site with a large archive of information on eating disorders and referral information to treatment centers.
These Public Broadcasting System web pages are based on a NOVA television program documentary. The site provides information on eating disorders with personal stories and links.
NEDA TOOLKIT for Parents
NEDA TOOLKIT for Parents
Treatments available for eating disorders
Standard treatments include medications (prescription alleviate depression, but may also play a role in drugs), various psychotherapies, nutrition therapy, making an individual feel full and possibly prevent other nondrug therapies, and supportive or adjunct binge eating in patients with bulimia or binge eating interventions such as yoga, art, massage, and disorder. FDA has issued a warning and labeling to movement therapy. Some novel treatments are prevent prescription of one particular antidepressant currently under research, such as implantation of a for eating disorders Wellbutrin, which is available in device called a vagus nerve stimulator implanted at several brand and generic formulations— because it the base of the neck. This stimulator is currently in use leads to higher risk of epileptic seizures in these to treat some forms of depression, and it is under research for treating obesity. Psychological Therapy
The most commonly used treatments—psychotherapy and medication—are delivered at various levels of Several types of psychotherapy are used in individual inpatient and outpatient care, and in various settings and group settings and with families. Patients must be depending on the severity of the illness and the medically stable to be able to participate meaningfully treatment plan that has been developed for a in any type of psychological therapy. Thus, a patient particular patient. Bulimia nervosa and binge eating who has required hospitalization for refeeding and to disorders can often be treated on an outpatient basis, stabilize his/her medical condition will ordinarily not although more severe cases may require inpatient or be able to participate in therapy until after he/she has residential treatment. The levels of care and types of recovered sufficiently to enable cognitive function to treatment centers are discussed in separate documents return to normal. in the tool kit. The treatment plan should be developed by a multidisciplinary team in consultation with the A given psychologist or psychiatrist may use several patient, and family members as deemed appropriate by different approaches tailored to the situation. The the patient and his/her team. types of psychotherapy used are listed here in a chart and defined below. Cognitive behavior therapy (CBT) Medication
and behavior therapy (BT) have been used for many years as first-line treatment, and they are the most- Biochemical abnormalities in the brain and body have used types of psychotherapy for bulimia. CBT involves been associated with eating disorders. Many types of three overlapping phases. The first phase focuses on prescription drugs have been used in treatment of helping people to resist the urge to engage in the cycle eating disorders; however, only one prescription drug of behavior by educating them about the dangers. The (fluoxetine) actually has a labeled indication for one second phase introduces procedures to reduce dietary eating disorder, bulimia nervosa. (This means that the restraint and increase eating regularity. The last phase manufacturer requested permission from the U.S. Food involves teaching people relapse-prevention strategies and Drug Administration (FDA) to market the drug to help prepare them for possible setbacks. A course of specifically for treatment of bulimia nervosa and that individual CBT for bulimia nervosa usually involves 16- FDA approved this request based on the evidence the to 20-hour-long sessions over a period of 4 to 5 months. manufacturer provided about the drug's efficacy for BT uses principles of learning to increase the frequency bulimia nervosa.) of desired behavior and decrease the frequency of problem behavior. When used to treat bulimia nervosa, Most prescription drug therapy used for treatment of BT focuses on teaching relaxation techniques and the disorder is aimed at alleviating major depression, coping strategies that individuals can use instead of anxiety, or obsessive-compulsive disorder (OCD), which binge eating and purging or excessive exercise or often coexist with an eating disorder. Some prescription drug therapies are intended to make individuals feel full to try to prevent binge eating. Self-help groups are listed here because they may be Generic and brand names of prescription drugs that the only option available to people who have no have been used to treat eating disorders are listed in insurance. However, self-help groups can also have the chart. Some of these antidepressants also can exert negative effects on a person with an eating disorder if other effects. Selective serotonin reuptake inhibitors they are not well-moderated by a trained professional.
NEDA TOOLKIT for Parents
Medication names: Generic (Brand)
Naltrexone (Nalorex) (Intended to alleviate Amitriptyline (Elavil) addictive behaviors such as the addictive drives to Clomipramine (Anafranil) eat or binge eat.) Desipramine (Norpramin, Pertofrane) Imipramine (Janimine, Tofranil) Antiemetic
Nortriptyline (Aventyl, Pamelor) Modified Cyclic Antidepressants
Ondansetron (Zofran) (Used to give sensation of Trazodone (Desyrel) satiety and fullness.) Selective Serotonin Reuptake Inhibitors (SSRIS)
Citalopram (Celexa) Escitalopram (Lexapro) Topiramate (Topamax) (May help regulate feeding Fluoxetine (Prozac, Sarafem) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Aminoketone
Lithium carbonate (Carbolith, Cibalith-S, Duralith, Bupropion (Wellbutrin, Zyban): Now Eskalith, Lithane, Lithizine, Lithobid, Lithonate, contraindicated for treatment of eating disorders Lithotabs) (Used for patients who also have because of several reports of drug-related bipolar disorder, but may be contraindicated for patients with substantial purging.) Monoamine Oxidase Inhibitors
Brofaromine (Consonar) Isocarboxazide (Benazide) Moclobemide (Manerix) Phenelzine (Nardil) Tranylcipromine (Parnate) Serotonin And Noradepinephrine Reuptake Inhibitor
Duloxetine (Cymbalta) Venlafaxine (Effexor) Mianserin (Bolvidon) Mirtazapine (Remeron)
NEDA TOOLKIT for Parents
Other Adjunctive and Alternative Treatments
Creative Art Therapies
Behavior therapy Exposure with response prevention Movement Therapy Hypnobehavior therapy Cognitive therapy Cognitive analytic therapy Nutritional Counseling
Cognitive behavior therapy (all forms) Individual, group, family, and mealtime-support Cognitive remediation therapies Scheme-based cognitive therapy Self-guided cognitive behavioral therapy Other Therapies
Dialectical behavior therapy Although little research exists to support the use of Guided imagery the following interventions, individual patients have Psychodynamic therapy sometimes found some of these approaches to be Self psychology useful, particularly as adjuncts to conventional Psychoanalysis treatments. However, these approaches should not be Interpersonal psychotherapy used in place of evidence-based treatments where the Motivational enhancement therapy latter are available. Psychoeducation Supportive therapy Emailing for support or coaching Family therapy
Eye movement desensitization Involving family members in psychotherapy sessions with and without the patient Group psychotherapy
Cognitive behavioral therapy Psychodynamic Relaxation training Psychoeducational Interpersonal Self-Help groups
ANAD (Anorexia Nervosa and Associated 12-step approaches Eating Disorders Anonymous Web-based on-line programs
NEDA TOOLKIT for Parents
Antidepressants Prescription drugs used for treatment
Cognitive Remediation Therapy (CRT) Since patients
of eating disorders and aimed at alleviating major with anorexia nervosa (AN) have a tendency to get depression, anxiety, or obsessive-compulsive disorder, trapped in detail rather than seeing the big picture, and which often coexist with an eating disorder. have difficulty shifting thinking among perspectives, this newly investigated brief psychotherapeutic Behavior Therapy (BT) A type of psychotherapy that
approach targets these specific thinking styles and uses principles of learning to increase the frequency of their role in the development and maintenance of an desired behaviors and/or decrease the frequency of eating disorder. Currently, it's usually conducted side problem behaviors. Subtypes of BT include dialectical by side with other forms of psychotherapies. behavior therapy (DBT), exposure and response prevention (ERP), and hypnobehavioral therapy. Dialectical Behavior Therapy (DBT) A type of
behavioral therapy that views emotional deregulation Cognitive Therapy (CT) A type of psychotherapeutic
as the core problem in eating disorders. It involves treatment that attempts to change a patient's feelings teaching people new skills to regulate negative and behaviors by changing the way the patient thinks emotions and replace dysfunctional behavior. (See also about or perceives his/her significant life experiences. Behavioral Therapy.) Subtypes include cognitive analytic therapy and cognitive orientation therapy. Equine/Animal-assisted Therapy A treatment program
in which people interact with horses and become Cognitive Analytic Therapy (CAT) A type of cognitive
aware of their own emotional states through the therapy that focuses its attention on discovering how a reactions of the horse to their behavior. patient's problems have evolved and how the procedures the patient has devised to cope with them Exercise Therapy An individualized exercise plan that is
may be ineffective or even harmful. CAT is designed to written by a doctor or rehabilitation specialist, such as enable people to gain an understanding of how the a clinical exercise physiologist, physical therapist, or difficulties they experience may be made worse by nurse. The plan takes into account an individual's their habitual coping mechanisms. Problems are current medical condition and provides advice for what understood in the light of a person's personal history type of exercise to perform, how hard to exercise, how and life experiences. The focus is on recognizing how long, and how many times per week. these coping procedures originated and how they can Exposure with Response Prevention (ERP) A type of
behavior therapy strategy that is based on the theory Cognitive Behavior Therapy (CBT) CBT is a goal-
that purging serves to decrease the anxiety associated oriented, short-term treatment that addresses the with eating. Purging is therefore negatively reinforced psychological, familial, and societal factors associated via anxiety reduction. The goal of ERP is to modify the with eating disorders. Therapy is centered on the association between anxiety and purging by preventing principle that there are both behavioral and attitudinal purging following eating until the anxiety associated disturbances regarding eating, weight, and shape. with eating subsides.(See also Behavioral Therapy.) Cognitive Orientation Therapy (COT) A type of
Expressive Therapy A nondrug, nonpsychotherapy form
cognitive therapy that uses a systematic procedure to of treatment that uses the performing and/or visual understand the meaning of a patient's behavior by arts to help people express their thoughts and exploring certain themes such as aggression and emotions. Whether through dance, movement, art, avoidance. The procedure for modifying behavior then drama, drawing, painting, etc., expressive therapy focuses on systematically changing the patient's beliefs provides an opportunity for communication that might related to the themes, not beliefs that refer directly to otherwise remain repressed. eating behavior.
NEDA TOOLKIT for Parents
Eye Movement Desensitization and Reprocessing
Mandometer Therapy Treatment program for eating
(EMDR) A nondrug and nonpsychotherapy form of
disorders based on the idea that psychiatric symptoms treatment in which a therapist waves his or her fingers of people with eating disorders emerge as a result of back and forth in front of the patient's eyes, and the poor nutrition and are not a cause of the eating patient tracks the movements while also focusing on a disorder. A mandometer is a computer that measures traumatic event. It is thought that the act of tracking food intake and is used to determine a course of while concentrating allows a different level of processing to occur in the brain so that the patient can review the event more calmly or more completely than Massage Therapy A generic term for any of a number of
various types of therapeutic touch in which the practitioner massages, applies pressure to, or Family Therapy A form of psychotherapy that involves
manipulates muscles, certain points on the body, or members of an immediate or extended family. Some other soft tissues to improve health and well-being. forms of family therapy are based on behavioral or Massage therapy is thought to relieve anxiety and psychodynamic principles; the most common form is depression in patients with eating disorders. based on family systems theory. This approach regards the family as the unit of treatment and emphasizes Maudsley Method A family-centered treatment
factors such as relationships and communication program with three distinct phases. During the first patterns. With eating disorders, the focus is on the phase parents are placed in charge of the child's eating eating disorder and how the disorder affects family patterns in hopes to break the cycle of not eating, or of relationships. Family therapies may also be binge eating and purging. The second phase begins educational and behavioral in approach. once the child's refeeding and eating is under control with a goal of returning independent eating to the Hypnobehavioral Therapy A type of behavioral therapy
child. The goal of the third and final phase is to address that uses a combination of behavioral techniques such the broader concerns of the child's development. as self-monitoring to change maladaptive eating disorders and hypnotic techniques intended to Mealtime Support Therapy Treatment program
reinforce and encourage behavior change. developed to help patients with eating disorders eat healthfully and with less emotional upset. Interpersonal Therapy (IPT) IPT (also called
interpersonal psychotherapy) is designed to help Motivational Enhancement Therapy (MET) A treatment
people with eating disorders identify and address their based on a model of change, with focus on the stages interpersonal problems, specifically those involving of change. Stages of change represent constellations of grief, interpersonal role conflicts, role transitions, and intentions and behaviors through which individuals interpersonal deficits. In this therapy, no emphasis is pass as they move from having a problem to doing placed directly on modifying eating habits. Instead, the something to resolve it. The stages of change move expectation is that the therapy enables people to from "pre-contemplation," in which individuals show no change as their interpersonal functioning improves. IPT intention of changing, to the "action" stage, in which usually involves 16 to 20 hour-long, one-on-one they are actively engaged in overcoming their problem. treatment sessions over a period of 4 to 5 months. Transition from one stage to the next is sequential, but not linear. The aim of MET is to help individuals move Light therapy (also called phototherapy) Treatment
from earlier stages into the action stage using cognitive that involves regular use of a certain spectrum of lights and emotional strategies. in a light panel or light screen that bathes the person in that light. Light therapy is also used to treat conditions Movement/Dance Therapy
such as seasonal affective disorder (seasonal The psychotherapeutic use of movement as a process that furthers the emotional, cognitive, social, and physical integration of the individual, according to the American Dance Therapy Association.
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Nutritional Therapy Therapy that provides patients
Psychotherapy The treatment of mental and emotional
with information on the effects of eating disorders, disorders through the use of psychological techniques techniques to avoid binge eating, and advice about designed to encourage communication of conflicts and making meals and eating. For example, the goals of insight into problems, with the goal being symptom nutrition therapy for individuals with bulimia nervosa relief, changes in behavior leading to improved social are to help individuals maintain blood sugar levels, and vocational functioning, and personality growth. help individuals maintain a diet that provides them with enough nutrients, and help restore overall Psychoeducational Therapy A treatment intended to
physical health. teach people about their problem, how to treat it, and how to recognize signs of relapse so that they can get Opioid Antagonists A type of drug therapy that
necessary treatment before their difficulty worsens or interferes with the brain's opioid receptors and is recurs. Family psychoeducation includes teaching sometimes used to treat eating disorders. coping strategies and problem-solving skills to families, friends, and/or caregivers to help them deal more Pharmacotherapy Treatment of a disease or condition
effectively with the individual. using clinician-prescribed drugs. Self-guided Cognitive Behavior Therapy A modified
Progressive Muscle Relaxation A deep relaxation
form of cognitive behavior therapy in which a technique based on the simple practice of tensing or treatment manual is provided for people to proceed tightening one muscle group at a time followed by a with treatment on their own, or with support from a relaxation phase with release of the tension. This nonprofessional. Guided self-help usually implies that technique has been purported to reduce symptoms the support person may or may not have some associated with night eating syndrome. professional training, but is usually not a specialist in eating disorders. The important characteristics of the Psychoanalysis An intensive, nondirective form of
self-help approach are the use of a highly structured psychodynamic therapy in which the focus of and detailed manual-based CBT, with guidance as to treatment is exploration of a person's mind and the appropriateness of self-help, and advice on where habitual thought patterns. It is insight oriented, to seek additional help. meaning that the goal of treatment is for the patient to increase understanding of the sources of his/her inner Self Psychology A type of psychoanalysis that views
conflicts and emotional problems. anorexia and bulimia as specific cases of pathology of the self. According to this viewpoint, people with eating Psychodrama A method of psychotherapy in which
disorders cannot rely on human beings to fulfill their patients enact the relevant events in their lives instead self-object needs (e.g., regulation of self-esteem, of simply talking about them. calming, soothing, vitalizing). Instead, they rely on food (its consumption or avoidance) to fulfill these needs. Psychodynamic Therapy Psychodynamic theory views
Self psychological therapy involves helping people the human personality as developing from interactions with eating disorders give up their pathologic between conscious and unconscious mental processes. preference for food as a self-object and begin to rely The purpose of all forms of psychodynamic treatment on human beings as self-objects, beginning with their is to bring unconscious thoughts, emotions and memories into full consciousness so that the patient can gain more control over his/her life. Supportive Therapy Psychotherapy that focuses on the
management and resolution of current difficulties and Psychodynamic Group Therapy Psychodynamic groups
life decisions using the patient's strengths and are based on the same principles as individual available resources. psychodynamic therapy and aim to help people with past difficulties, relationships, and trauma, as well as Telephone Therapy A type of psychotherapy provided
current problems. The groups are typically composed over the telephone by a trained professional. of eight members plus one or two therapists.
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The Evidence on What Treatment Works:
Clinical Guidelines and Evidence Reports
If you want access to the same documents that clinicians use to guide their treatment decisions, and if you want to
know what the available evidence says on what works for treatment of eating disorders, you want to look at
published clinical practice guidelines and medical journal articles called systematic reviews. The information in this document provides links to that information so you can look it over and take it with you to discuss the care plan with the physicians and others who will treat your family member. This document discusses two types of evidence-based treatments for bulimia eating disorders in general; the information used by clinicians in determining other systematic review did not pool data for analysis appropriate care for eating disorders: clinical practice from groups of studies, but rather looked at individual guidelines and systematic reviews. We define below studies on their own. Both systematic reviews were what an evidence-based clinical guideline and a performed by very reputable research organizations: systematic review are and provide links to the two U.S. Evidence-based Practice Centers of the U.S. documents. If you review this information before Agency for Healthcare Research and Quality (AHRQ). meeting with the care team, it can help you have Links to the Executive Summary and full Evidence informed discussions about care plans with your loved Reports are provided. one's care team. Bulimia Nervosa: Efficacy of Available
Systematic Reviews of Clinical Studies
A systematic review is a comprehensive review and A Systematic Review conducted by ECRI Institute analysis of data from the available published clinical Evidence-based Practice Center ECRI Institute's studies on existing methods of diagnosing and treating approach was unique in producing this evidence report a disorder. Researchers start out with key clinical and the bulimia nervosa resource guide. The focus of questions that they seek to answer, and then they the work was driven by an external advisory committee perform a comprehensive search for published data to of patients and family members affected by bulimia analyze to address the questions. Thus, the data for nervosa, clinicians and specialists from leading eating analysis are collected from as many published clinical disorder treatment centers that treat eating disorders, studies as there are to address the question. The data scientists who conduct research on eating disorders, are then pooled together statistically where possible health insurance representatives, and others who and analyzed to figure out how well each treatment affect patient care. ECRI Institute gratefully works and for whom it works best. Sometimes sufficient acknowledges the support of The Hilda & Preston Davis data are not available to conclusively answer a Foundation, which provided major funding for this question. Knowing where the holes in the research are evidence report and the family resource guide and is important, because that knowledge will help in Web site that emerged from the research. The planning new research that hopefully will answer the approach was unique because of the intensive questions about "what works?" Also, it's important to involvement of families and recovering patients in understand that some treatments may not have formulating the key questions and reviewing the family evidence available about how well they work. and patient information before publication. Therefore, your decisions about treatment may have to be based on considerations other than conclusive Link to the Summary: clinical evidence. A lot more research is needed about what works best in the field of eating disorders. That said, some information is available about how well some types of treatment work. Keep in mind that a lack Link to the Full Report: of evidence doesn't mean that a treatment does not work—it just means no evidence is available to be able to conclude whether or not it works. Following this section are links to two systematic reviews: one pertains to bulimia nervosa and pooled data together where possible on all the different
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Management of Eating Disorders
A systematic review conducted by RTI
Clinical Practice Guidelines
International, University of North Carolina at
Chapel Hill Evidence-based Practice Center
A practice guideline is defined as a "systematically developed statement to assist practitioner and patient This systematic review of the literature focused on key decisions about appropriate healthcare for specific questions concerning anorexia nervosa, bulimia clinical conditions." The following four clinical practice nervosa, and eating disorders not otherwise specified guidelines have been published by reputable medical (i.e., especially binge eating disorder) to address organizations and are available to the medical questions posed by the American Psychiatric treatment team that is providing care to your child. We Association and Laureate Psychiatric Clinic and also provide summaries of these guidelines below. Hospital through AHRQ. Funding was provided by These guidelines were identified from the National AHRQ, the Office of Research on Women's Health at Guideline Clearinghouse (www.guideline.gov) the National Institutes of Health, and the Health Resources and Services Administration. We received Identifying and treating eating disorders. American guidance and input from a Technical Expert Panel. This Academy of Pediatrics. report was also published as four separate articles in the International Journal of Eating Disorders in 2007. Practice guideline for the treatment of patients Link to the Executive Summary: with eating disorders. American Psychiatric Link to the Full Report: Finnish Medical Society Duodecim. Eating disorders among children and adolescents. Berkman, N.D., C.M. Bulik, and K.N. Lohr. (2007). U.K. National Collaborating Centre for Mental Outcomes of Eating Disorders: A Systematic Review of Health (National Institute for Health and Clinical the Literature. International Journal of Eating Excellence [NICE]). Eating disorders. Core Disorders, 40(4): 293-309 interventions in the treatment and management of Brownley, K.A., N.D. Berkman, J.A. Sedway, K.N. Lohr, anorexia nervosa, bulimia nervosa and related and C.M. Bulik. (2007). Binge Eating Disorder Treatment: eating disorders. A Systematic Review of Randomized Controlled Trials. International Journal of Eating Disorders, 40(4):337-348 Bulik, C.M., N.D. Berkman, K.A. Brownley, J.A. Sedway, and K.N. Lohr (2007). Anorexia Nervosa Treatment: A Systematic Review of Randomized Controlled Trials. International Journal of Eating Disorders, 40(4): 310- Shapiro, J.R., N.D. Berkman, K.A. Brownley, J.A. Sedway, K.N. Lohr, and C.M. Bulik (2007). Bulimia Nervosa Treatment: A Systematic Review of Randomized Controlled Trials. International Journal of Eating Disorders, 40(4): 321-336
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Eating disorders among children and adolescents
From the Finnish Medical Society Duodecim
Currently, eating disorders are considered to be Bibliographic Source
multifarious. Genetic and sociocultural factors and also individual dynamics all affect eating Finnish Medical Society Duodecim. Eating disorders among children and adolescents. In: The typical age of onset is adolescence, when the EBM Guidelines. Evidence- Based Medicine body changes and grows. [Internet]. Helsinki, Finland: Wiley Interscience. Anorexia nervosa typically emerges between 14 John Wiley & Sons; 2007 Mar 28 [Various]. and 16 years of age or around the age of 18 years. Bulimia appears typically at the age of 19 to 20 years. Major Recommendations
Eating disorders are 10 to 15 times more common among girls than boys. The levels of evidence [A-D] supporting the Every 150th girl between the ages of 14 and 16 recommendations are defined at the end of the "Major years suffers from anorexia nervosa. Recommendations" field. There is no epidemiologic data on the occurrence of bulimia, but it is considered to be more Objectives
common than anorexia nervosa. Remember that eating disorders are very common Diagnostic Criteria for Anorexia Nervosa
among adolescent girls, and especially bulimic disorders are encountered in boys as well. The patient does not want to maintain his/her One must remember to look for signs of an eating normal body weight. disorder; patients seldom report it themselves. The patient's weight is at least 15% below that The diagnosis and planning of treatment are the expected for age and height. responsibility of special personnel. The patient's body image is distorted. The patient is afraid of gaining weight. Basic Rules
There is no other sickness that would explain the An eating disorder refers to states in which food and nourishment have an instrumental and Diagnostic Criteria of Bulimia Nervosa
manipulative role: food has become a way to regulate the appearance of the body. Desire to be thin, phobic fear of gaining weight. The spectrum of eating disorders is vast. The most Persistent preoccupation with eating and an common disorders are anorexia nervosa and irresistible urge or compulsive need to eat. bulimia nervosa. In addition, incomplete clinical Episodes of binge eating (at least twice a week); pictures and simple binge eating have become control over eating is lost. After the episode of binge eating, the person Recently the international trend has been to put attempts to eliminate the ingested food (e.g., by more emphasis on early reaction to the symptoms. self-induced vomiting and by abuse of purgatives Even small children can have different kinds of eating disorders that relate to difficulties in the relationships between the child and his/her
NEDA TOOLKIT for Parents
Anorexia nervosa generally starts gradually. In anorexia nervosa: Losing weight can either be very rapid or very slow. Generally the patients continue to go to Blood glucose levels on the lower border school; they go on with their hobbies and feel great about themselves. Therefore, the families are usually surprised to find that their child suffers from malnutrition. Increased serum amylase A screening questionnaire is helpful in the assessment of patients with suspected eating Differential Diagnosis
disorders (each positive answer gives one point; two or more points suggest an eating disorder). Severe somatic diseases, for example, brain Do you try to vomit if you feel Psychiatric diseases — severe depression, unpleasantly satiated? psychosis, and drug use Are you anxious with the thought that you cannot control the amount of food Treatment
If the symptoms correspond to the diagnostic Have you lost more than 6 kg of weight criteria of anorexia nervosa, the situation should during the last 3 months? be discussed with the family before treatment is Do you consider yourself obese although others say you are underweight? The adolescent and his/her family should be made Does food/thinking of food dominate aware of the seriousness of the disorder. Sometimes it takes time to motivate the patient to participate in the treatment. Anorexic adolescents deny their symptoms, and it The treatment is divided into: takes time and patience to motivate them to Restoring the state of nutrition accept treatment. Psychotherapeutic treatment Somatic symptoms include the following: Disappearance of menstruation If the state of malnutrition is life threatening, the The slowing of metabolism, constipation patient is first treated in a somatic ward, and Slow pulse, low blood pressure thereafter the adolescent is guided into therapy if Flushed and cold limbs Reduction of subcutaneous fat The forms of psychotherapy vary: both individual Bulimic adolescents are aware that their eating and family therapy have brought results; in cases habits are not normal, but the habit causes so of bulimia cognitive therapy and medication much guilt and shame that seeking treatment is (Lewandowski et al., 1997; Whittal, Agras, & Gould, 1999) [C] have been successful. Bulimia also causes physical symptoms, including With adolescents between the ages of 14 and 16 years, positive results have been obtained by treating the entire family. This is because the Disturbances of menstruation adolescent's symptoms are often connected with Disturbances in electrolyte and acid-alkali balances created by frequent difficulties to "cut loose" from the family. With older patients, individual, supportive, and long lasting treatment has been the best way to Damage to tooth enamel promote recovery. A prolonged state of malnutrition and insufficient outpatient care are reasons to direct a patient into forced treatment.
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A specialist should start all drug treatment. Different psychopharmaceuticals, for example, neuroleptics and antidepressants, have been tried in the treatment of anorexia nervosa. Controlled studies have proved them indisputably useful only if the disorder is linked to clear depression. Most research on the medical treatment of bulimia has concentrated on antidepressants (Bacaltchuk & Hay, 2003) [A], particularly fluoxetine, which has been found to decrease binge eating and vomiting for about two-thirds of bulimic patients. Prognosis
Early intervention improves prognosis. Eating disorders comprise a severe group of diseases that are difficult to treat. The prognosis for the near future of anorexic patients is good, but for the long term the prognosis is worse. The percentage of mortality is still 5% to 16%. Not enough follow-up research has been carried out on the prognosis of bulimia, but the disease is thought to last years. Bulimia can be associated with depression, self- destructiveness, alcohol or drug abuse, and other psychological problems. Link to Full Summary:
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Eating disorders: Core interventions in the treatment and
management of anorexia nervosa, bulimia nervosa, and
related eating disorders.
U.K. National Collaborating Centre for
shared with the patient and, where appropriate, Mental Health: Brief Summary
his/her family and caregivers. Bibliographic Source
Providing Good Information and Support
National Collaborating Centre for Mental Health. Eating disorders. Core interventions in the treatment C — Patients and, where appropriate, caregivers and management of anorexia nervosa, bulimia should be provided with education and information on nervosa and related eating disorders. Leicester (UK): the nature, course, and treatment of eating disorders. British Psychological Society; 2004. 260 p. [408 C — In addition to the provision of information, family and caregivers may be informed of self-help groups Major Recommendations
and support groups, and offered the opportunity to participate in such groups where they exist. Evidence categories (I-IV) and recommendation grades (A-C) are defined at the end of the Major C — Healthcare professionals should acknowledge Recommendations field. that many people with eating disorders are ambivalent about treatment. Healthcare professionals Care Across All Conditions
should also recognize the consequent demands and challenges this presents. Assessment and Coordination of Care
Getting Help Early
C — Assessment of people with eating disorders There can be serious long-term consequences to a should be comprehensive and include physical, delay in obtaining treatment. psychological, and social needs and a comprehensive assessment of risk to self. C — People with eating disorders seeking help should be assessed and receive treatment at the earliest C — The level of risk to the patient's mental and physical health should be monitored as treatment progresses because it may change--for example, C — Whenever possible patients should be engaged following weight gain or at times of transition and treated before reaching severe emaciation. This between services in cases of anorexia nervosa. requires both early identification and intervention. Effective monitoring and engagement of patients at C — For people with eating disorders presenting in severely low weight or with falling weight should be a primary care, general practitioners (GPs) should take responsibility for the initial assessment and the initial coordination of care. This includes the determination Management of Physical Aspects
of the need for emergency medical or psychiatric C — Where laxative abuse is present, patients should be advised to gradually reduce laxative use and C — Where management is shared between primary informed that laxative use does not significantly and secondary care, there should be clear agreement reduce calorie absorption. among individual healthcare professionals on the responsibility for monitoring patients with eating C — Treatment of both subthreshold and clinical disorders. This agreement should be in writing (where cases of an eating disorder in people with diabetes is appropriate using the Care Program Approach) and essential because of the greatly increased physical risk in this group.
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C — People with type 1 diabetes and an eating Identification and Screening of Eating Disorders in
disorder should have intensive regular physical Primary Care and Non-Mental Health Settings
monitoring, because they are at high risk of retinopathy and other complications. C — Target groups for screening should include young women with low body mass index (BMI) compared C — Pregnant women with eating disorders require with age norms, patients consulting with weight careful monitoring throughout the pregnancy and in concerns who are not overweight, women with the postpartum period. menstrual disturbances or amenorrhea, patients with gastrointestinal symptoms, patients with physical signs C — Patients with an eating disorder who are vomiting of starvation or repeated vomiting, and children with should have regular dental reviews. C — Patients who are vomiting should be given C — When screening for eating disorders one or two appropriate advice on dental hygiene, which should simple questions should be considered for use with include avoiding brushing after vomiting; rinsing with specific target groups (for example, "Do you think you a nonacid mouthwash after vomiting; and reducing an have an eating problem?" and "Do you worry acid oral environment (for example, limiting acidic excessively about your weight?"). C — Young people with type 1 diabetes and poor C — Healthcare professionals should advise people treatment adherence should be screened and with eating disorders and osteoporosis or related bone assessed for the presence of an eating disorder. disorders to refrain from physical activities that significantly increase the likelihood of falls. Management of Anorexia Nervosa in Primary
Additional Considerations for Children and
C —In anorexia nervosa, although weight and BMI are C — Family members, including siblings, should important indicators of physical risk they should not normally be included in the treatment of children and be considered the sole indicators (as they are adolescents with eating disorders. Interventions may unreliable in adults and especially in children). include sharing of information, advice on behavioral management, and facilitating communication. C — In assessing whether a person has anorexia nervosa, attention should be paid to the overall C — In children and adolescents with eating disorders, clinical assessment (repeated over time), including growth and development should be closely monitored. rate of weight loss, growth rates in children, objective Where development is delayed or growth is stunted physical signs, and appropriate laboratory tests. despite adequate nutrition, pediatric advice should be C — Patients with enduring anorexia nervosa not under the care of a secondary care service should be C — Healthcare professionals assessing children and offered an annual physical and mental health review adolescents with eating disorders should be alert to indicators of abuse (emotional, physical and sexual) and should remain so throughout treatment. Psychological Interventions for Anorexia
C — The right to confidentiality of children and adolescents with eating disorders should be respected. The delivery of psychological interventions should be accompanied by regular monitoring of a patient's C — Health care professionals working with children physical state including weight and specific indicators and adolescents with eating disorders should of increased physical risk. familiarize themselves with national guidelines and their employers' policies in the area of confidentiality.
NEDA TOOLKIT for Parents
Common Elements of the Psychological Treatment of
Psychological Aspects of Inpatient Care
C — For inpatients with anorexia nervosa, a structured C — Therapies to be considered for the psychological symptom-focused treatment regimen with the treatment of anorexia nervosa include cognitive expectation of weight gain should be provided in analytic therapy (CAT), cognitive behavior therapy order to achieve weight restoration. It is important to (CBT), interpersonal psychotherapy (IPT), focal carefully monitor the patient's physical status during psychodynamic therapy, and family interventions focused explicitly on eating disorders. C — Psychological treatment should be provided C — Patient and, where appropriate, carer preference which has a focus both on eating behavior and should be taken into account in deciding which attitudes to weight and shape and on wider psychological treatment is to be offered. psychosocial issues with the expectation of weight C — The aims of psychological treatment should be to reduce risk, to encourage weight gain and healthy C — Rigid inpatient behavior modification programs eating, to reduce other symptoms related to an eating should not be used in the management of anorexia disorder, and to facilitate psychological and physical Post-Hospitalization Psychological Treatment
Outpatient Psychological Treatments in First Episode
C — Following inpatient weight restoration, people and Later Episodes
with anorexia nervosa should be offered outpatient psychological treatment that focuses both on eating C — Most people with anorexia nervosa should be behavior and attitudes to weight and shape and on managed on an outpatient basis, with psychological wider psychosocial issues, with regular monitoring of treatment (with physical monitoring) provided by a both physical and psychological risk. health care professional competent to give it and to assess the physical risk of people with eating C — The length of outpatient psychological treatment and physical monitoring following inpatient weight restoration should typically be at least 12 months. C — Outpatient psychological treatment and physical monitoring for anorexia nervosa should normally be of Additional Considerations for Children and
at least 6 months' duration. Adolescents with Anorexia Nervosa
C — For patients with anorexia nervosa, if during B — Family interventions that directly address the outpatient psychological treatment there is significant eating disorder should be offered to children and deterioration, or the completion of an adequate adolescents with anorexia nervosa. course of outpatient psychological treatment does not lead to any significant improvement, more intensive C — Children and adolescents with anorexia nervosa forms of treatment (for example, a move from should be offered individual appointments with a individual therapy to combined individual and family health care professional separate from those with work or day care or inpatient care) should be their family members or carers. C — The therapeutic involvement of siblings and other C — Dietary counseling should not be provided as the family members should be considered in all cases sole treatment for anorexia nervosa. because of the effects of anorexia nervosa on other C — In children and adolescents with anorexia nervosa, the need for inpatient treatment and the need for urgent weight restoration should be balanced alongside the educational and social needs of the young person.
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Pharmacological Interventions for Anorexia
Managing Weight Gain
C — In most patients with anorexia nervosa, an average weekly weight gain of 0.5-1 kg in inpatient C — There is a very limited evidence base for the settings and 0.5 kg in outpatient settings should be an pharmacological treatment of anorexia nervosa. A aim of treatment. This requires about 3,500 to 7,000 range of drugs may be used in the treatment of extra calories a week. comorbid conditions but caution should be exercised in their use given the physical vulnerability of many C — Regular physical monitoring, and in some cases people with anorexia nervosa. treatment with a multi-vitamin/multi-mineral supplement in oral form, is recommended for people C — Medication should not be used as the sole or with anorexia nervosa during both inpatient and primary treatment for anorexia nervosa. outpatient weight restoration. Caution should be exercised in the use of medication for comorbid conditions such as depressive or C — Total parenteral nutrition should not be used for obsessive-compulsive features, as they may resolve people with anorexia nervosa, unless there is with weight gain alone. significant gastrointestinal dysfunction. C — When medication is used to treat people with Managing Risk
anorexia nervosa, the side effects of drug treatment (in particular, cardiac side effects) should be carefully C — Health care professionals should monitor considered because of the compromised physical risk in patients with anorexia nervosa. If this cardiovascular function of many people with anorexia leads to the identification of increased physical risk, the frequency of the monitoring and nature of the investigations should be adjusted accordingly. C — Health care professionals should be aware of the risk of drugs that prolong the QTc interval on the C — People with anorexia nervosa and their carers electrocardiogram (ECG) (for example, antipsychotics, should be informed if the risk to their physical health tricyclic antidepressants, macrolide antibiotics, and some antihistamines). In patients with anorexia nervosa at risk of cardiac complications, the C — The involvement of a physician or pediatrician prescription of drugs with side effects that may with expertise in the treatment of physically at-risk compromise cardiac functioning should be avoided. patients with anorexia nervosa should be considered for all individuals who are physically at risk. C — If the prescription of medication that may compromise cardiac functioning is essential, ECG C — Pregnant women with either current or remitted monitoring should be undertaken. anorexia nervosa may need more intensive prenatal care to ensure adequate prenatal nutrition and fetal C — All patients with a diagnosis of anorexia nervosa should have an alert placed in their prescribing record concerning the risk of side effects. C — Oestrogen administration should not be used to treat bone density problems in children and Physical Management of Anorexia Nervosa
adolescents as this may lead to premature fusion of Anorexia nervosa carries considerable risk of serious physical morbidity. Awareness of the risk, careful monitoring, and, where appropriate, close liaison with an experienced physician are important in the management of the physical complications of anorexia nervosa.
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Feeding Against the Will of the Patient
C — Health care professionals without specialist experience of eating disorders, or in situations of C — Feeding against the will of the patient should be uncertainty, should consider seeking advice from an an intervention of last resort in the care and appropriate specialist when contemplating a management of anorexia nervosa. compulsory admission for a patient with anorexia nervosa, regardless of the age of the patient. C — Feeding against the will of the patient is a highly specialized procedure requiring expertise in the care C — Health care professionals managing patients with and management of those with severe eating anorexia nervosa, especially that of the binge purging disorders and the physical complications associated sub-type, should be aware of the increased risk of self- with it. This should only be done in the context of the harm and suicide, particularly at times of transition Mental Health Act 1983 or Children Act 1989. between services or service settings. C — When making the decision to feed against the will Additional Considerations for Children and
of the patient, the legal basis for any such action must Adolescents
Service Interventions for Anorexia Nervosa
C — Health care professionals should ensure that children and adolescents with anorexia nervosa who have reached a healthy weight have the increased This section considers those aspects of the service energy and necessary nutrients available in their diet system relevant to the treatment and management of to support further growth and development. anorexia nervosa. C — In the nutritional management of children and C — Most people with anorexia nervosa should be adolescents with anorexia nervosa, carers should be treated on an outpatient basis. included in any dietary education or meal planning. C — Where inpatient management is required, this C — Admission of children and adolescents with should be provided within reasonable travelling anorexia nervosa should be to age-appropriate distance to enable the involvement of relatives and facilities (with the potential for separate children and carers in treatment, to maintain social and adolescent services), which have the capacity to occupational links, and to avoid difficulty in transition provide appropriate educational and related activities. between primary and secondary care services. This is particularly important in the treatment of children and C — When a young person with anorexia nervosa refuses treatment that is deemed essential, consideration should be given to the use of the Mental C — Inpatient treatment should be considered for Health Act 1983 or the right of those with parental people with anorexia nervosa whose disorder is responsibility to override the young person's refusal. associated with high or moderate physical risk. C — Relying indefinitely on parental consent to C — People with anorexia nervosa requiring inpatient treatment should be avoided. It is recommended that treatment should be admitted to a setting that can the legal basis under which treatment is being carried provide the skilled implementation of refeeding with out should be recorded in the patient's case notes, and careful physical monitoring (particularly in the first this is particularly important in the case of children few days of refeeding), in combination with and adolescents. psychosocial interventions. C — For children and adolescents with anorexia C — Inpatient treatment or day patient treatment nervosa, where issues of consent to treatment are should be considered for people with anorexia highlighted, health care professionals should consider nervosa whose disorder has not improved with seeking a second opinion from an eating disorders appropriate outpatient treatment, or for whom there is a significant risk of suicide or severe self-harm.
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C — If the patient with anorexia nervosa and those C — Selective serotonin reuptake inhibitors (SSRIs) with parental responsibility refuse treatment, and (specifically fluoxetine) are the drugs of first choice for treatment is deemed to be essential, legal advice the treatment of bulimia nervosa in terms of should be sought in order to consider proceedings acceptability, tolerability, and reduction under the Children Act 1989. Psychological Interventions for Bulimia
C — For people with bulimia nervosa, the effective dose of fluoxetine is higher than for depression (60 mg B — As a possible first step, patients with bulimia B — No drugs, other than antidepressants, are nervosa should be encouraged to follow an evidence- recommended for the treatment of bulimia nervosa. based self-help program. Management of Physical Aspects of Bulimia
B — Health care professionals should consider providing direct encouragement and support to patients undertaking an evidence based self-help program, as this may improve outcomes. This may be Patients with bulimia nervosa can experience sufficient treatment for a limited subset of patients. considerable physical problems as a result of a range of behaviors associated with the condition. Awareness A — Cognitive behavior therapy for bulimia nervosa of the risks and careful monitoring should be a (CBT-BN), a specifically adapted form of CBT, should concern of all health care professionals working with be offered to adults with bulimia nervosa. The course people with this disorder. of treatment should be for 16 to 20 sessions over 4 to 5 C — Patients with bulimia nervosa who are vomiting frequently or taking large quantities of laxatives C — Adolescents with bulimia nervosa may be treated (especially if they are also underweight) should have with CBT-BN adapted as needed to suit their age, their fluid and electrolyte balance assessed. circumstances, and level of development, and including the family as appropriate. C — When electrolyte disturbance is detected, it is usually sufficient to focus on eliminating the behavior B — When people with bulimia nervosa have not responsible. In the small proportion of cases where responded to or do not want CBT, other psychological supplementation is required to restore electrolyte treatments should be considered. balance, oral rather than intravenous administration is recommended, unless there are problems with B — Interpersonal psychotherapy should be gastrointestinal absorption. considered as an alternative to CBT, but patients should be informed it takes 8-12 months to achieve Service Interventions for Bulimia Nervosa
results comparable with CBT. The great majority of patients with bulimia nervosa Pharmacological Interventions for Bulimia
can be treated as outpatients. There is a very limited role for the inpatient treatment of bulimia nervosa. This is primarily concerned with the management of B — As an alternative or additional first step to using suicide risk or severe self-harm. an evidence-based self-help program, adults with bulimia nervosa may be offered a trial of an C — The great majority of patients with bulimia antidepressant drug. nervosa should be treated in an outpatient setting. B — Patients should be informed that antidepressant C — For patients with bulimia nervosa who are at risk drugs can reduce the frequency of binge eating and of suicide or severe self-harm, admission as an purging, but the longterm effects are unknown. Any inpatient or day patient, or the provision of more beneficial effects will be rapidly apparent. intensive outpatient care, should be considered.
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C — Psychiatric admission for people with bulimia B — Other psychological treatments (interpersonal nervosa should normally be undertaken in a setting psychotherapy for binge eating disorder and modified with experience of managing this disorder. dialectical behavior therapy) may be offered to adults with persistent binge eating disorder. C — Health care professionals should be aware that patients with bulimia nervosa who have poor impulse A — Patients should be informed that all control, notably substance misuse, may be less likely psychological treatments for binge eating disorder to respond to a standard program of treatment. As a have a limited effect on body weight. consequence treatment should be adapted to the problems presented. C — When providing psychological treatments for patients with binge eating disorder, consideration Additional Considerations for Children and
should be given to the provision of concurrent or Adolescents
consecutive interventions focusing on the management of comorbid obesity. C — Adolescents with bulimia nervosa may be treated C — Suitably adapted psychological treatments with CBT-BN adapted as needed to suit their age, should be offered to adolescents with persistent binge circumstances, and level of development, and eating disorder. including the family as appropriate.
General Treatment of Atypical Eating
Pharmacological Interventions for Binge
B — As an alternative or additional first step to using C — In the absence of evidence to guide the an evidence based self-help program, consideration management of atypical eating disorders (eating should be given to offering a trial of an SSRI disorders not otherwise specified) other than binge antidepressant drug to patients with binge eating eating disorder, it is recommended that the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the B — Patients with binge eating disorders should be individual patient's eating disorder. informed that SSRIs can reduce binge eating, but the long-term effects are unknown. Antidepressant drug Psychological Treatments for Binge Eating
treatment may be sufficient treatment for a limited Disorder
subset of patients. B — As a possible first step, patients with binge eating disorder should be encouraged to follow an evidence Evidence Categories
based self-help program. B — Health care professionals should consider I: Evidence obtained from a single randomized providing direct encouragement and support to controlled trial or a meta-analysis of randomized patients undertaking an evidence-based self-help controlled trials program as this may improve outcomes. This may be IIA: Evidence obtained from at least one well-designed sufficient treatment for a limited subset of patients. controlled study without randomization IIB: Evidence obtained from at least one well-designed A — Cognitive behavior therapy for binge eating quasiexperimental study disorder (CBTBED), a specifically adapted form of CBT, III: Evidence obtained from well-designed non- should be offered to adults with binge eating disorder. experimental descriptive studies, such as comparative studies, correlation studies, and case-control studies IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected
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Grade A — At least one randomized controlled trial as
part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence level I) without extrapolation Grade B — Well-conducted clinical studies but no
randomized clinical trials on the topic of recommendation (evidence levels II or III); or extrapolated from level I evidence Grade C — Expert committee reports or opinions
and/or clinical experiences of respected authorities (evidence level IV) or extrapolated from level I or II evidence. This grading indicates that directly applicable clinical studies of good quality are absent
or not readily available. Patient Resources
The following is available: Eating disorders: anorexia nervosa, bulimia nervosa and related eating disorders. Understanding NICE guidance: a guide for people with eating disorders, their advocates and carers, and the public. London: National Institute for Clinical Excellence. 2004 Jan. 44. Electronic copies: Available in English and Welsh in Portable Document Format (PDF) from the National Institute for Clinical Excellence (NICE) Web site Print copies: Available from the National Health Service (NHS) Response Line 0870 1555 455. ref: N0407. 11 Strand, London, WC2N 5HR.
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Identifying and treating eating disorders
American Academy of Pediatrics
Pediatricians need to be aware of the resources in Brief Summary
their communities so they can coordinate care of various treating professionals, helping to create a Bibliographic Source
seamless system between inpatient and outpatient management in their communities. Identifying and treating eating disorders. Pediatrics 2003 Jan;111(1):204-11. [78 references] PubMed Pediatricians should help advocate for parity of mental health benefits to ensure continuity of Major Recommendations
care for the patients with eating disorders. Pediatricians need to be knowledgeable about the Pediatricians need to advocate for legislation and early signs and symptoms of disordered eating regulations that secure appropriate coverage for and other related behaviors. medical, nutritional, and mental health treatment in settings appropriate to the severity of the illness (inpatient, day hospital, intensive Pediatricians should be aware of the careful balance that needs to be in place to decrease the outpatient, and outpatient). growing prevalence of eating disorders in children and adolescents. When counseling children on risk Pediatricians are encouraged to participate in the of obesity and healthy eating, care needs to be development of objective criteria for the optimal taken not to foster overaggressive dieting and to treatment of eating disorders, including the use of help children and adolescents build self-esteem specific treatment modalities and the transition while still addressing weight concerns. from one level of care to another. Pediatricians should be familiar with the screening and counseling guidelines for disordered eating and other related behaviors. Link to Full Summary: Pediatricians should know when and how to monitor and/ or refer patients with eating disorders to best address their medical and Link to Complete Guideline: nutritional needs, serving as an integral part of the multidisciplinary team. Pediatricians should be encouraged to calculate and plot weight, height, and body mass index (BMI) using age and gender-appropriate graphs at routine annual pediatric visits. Pediatricians can play a role in primary prevention through office visits and community- or school- based interventions with a focus on screening, education, and advocacy. Pediatricians can work locally, nationally, and internationally to help change cultural norms conducive to eating disorders and proactively to change media messages.
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Practice guideline for the treatment of patients with
and dental complications, it is important that psychiatrists consult other physician specialists and Bibliographic Sources
American Psychiatric Association (APA). Practice guideline for the treatment of patients with eating When a patient is managed by an interdisciplinary disorders. 3rd ed. Washington (DC): American team in an outpatient setting, communication among the professionals is essential to monitoring the Psychiatric Association (APA); 2006 Jun. 128 p. [765 patient's progress, making necessary adjustments to references] American Psychiatric Association. the treatment plan, and delineating the specific roles Treatment of patients with eating disorders, third and tasks of each team member [I]. edition. Am J Psychiatry 2006 Jul;163(7 Suppl):4-54. b. Assessing and Monitoring Eating Disorder
Symptoms and Behaviors
Each recommendation is identified as meriting one of A careful assessment of the patient's history, three categories of endorsement, based on the level of symptoms, behaviors, and mental status is the first clinical confidence regarding the recommendation, as step in making a diagnosis of an eating disorder [I]. indicated by a bracketed Roman numeral after the The complete assessment usually requires at least statement. Definitions of the categories of several hours and includes a thorough review of the endorsement are presented at the end of the "Major patient's height and weight history; restrictive and Recommendations" field. binge eating and exercise patterns and their changes; purging and other compensatory behaviors; core attitudes regarding weight, shape, and eating; and Psychiatric Management
associated psychiatric conditions [I]. A family history of Psychiatric management begins with the eating disorders or other psychiatric disorders, establishment of a therapeutic alliance, which is including alcohol and other substance use disorders; a enhanced by empathic comments and behaviors, family history of obesity; family interactions in relation positive regard, reassurance, and support [I]. Basic to the patient's disorder; and family attitudes toward psychiatric management includes support through the eating, exercise, and appearance are all relevant to provision of educational materials, including self-help the assessment [I]. A clinician's articulation of theories workbooks; information on community-based and that imply blame or permit family members to blame Internet resources; and direct advice to patients and one another or themselves can alienate family their families (if they are involved) [I]. A team members from involvement in the treatment and approach is the recommended model of care [I]. therefore be detrimental to the patient's care and recovery [I]. It is important to identify family stressors whose amelioration may facilitate recovery [I]. In the Coordinating Care and Collaborating with Other
assessment of children and adolescents, it is essential to involve parents and, whenever appropriate, school In treating adults with eating disorders, the personnel and health professionals who routinely psychiatrist may assume the leadership role within a work with the patient [I]. program or team that includes other physicians, psychologists, registered dietitians, and social workers or may work collaboratively on a team led by others. For the management of acute and ongoing medical
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c. Assessing and Monitoring the Patient's General
d. Assessing and Monitoring the Patient's Safety and
A full physical examination of the patient is strongly The patient's safety will be enhanced when particular recommended and may be performed by a physician attention is given to suicidal ideation, plans, familiar with common findings in patients with eating intentions, and attempts as well as to impulsive and disorders. The examination should give particular compulsive self-harm behaviors [I]. Other aspects of attention to vital signs, physical status (including the patient's psychiatric status that greatly influence height and weight), cardiovascular and peripheral clinical course and outcome and that are important to vascular function, dermatological manifestations, and assess include mood, anxiety, and substance use evidence of self-injurious behaviors [I]. Calculation of disorders, as well as motivational status, personality the patient's body mass index (BMI) is also useful (see traits, and personality disorders [I]. Assessment for suicidality is of particular importance in patients with i-tables.pdf [for ages 2-20] and
co-occurring alcohol and other substance use i-adults.pdf [for adults]) [I]. Early recognition of eating
disorder symptoms and early intervention may e. Providing Family Assessment and Treatment
prevent an eating disorder from becoming chronic [I]. During treatment, it is important to monitor the For children and adolescents with anorexia nervosa, patient for shifts in weight, blood pressure, pulse, family involvement and treatment are essential [I]. For other cardiovascular parameters, and behaviors likely older patients, family assessment and involvement to provoke physiological decline and collapse [I]. may be useful and should be considered on a case-by- Patients with a history of purging behaviors should case basis [II]. Involving spouses and partners in also be referred for a dental examination [I]. Bone treatment may be highly desirable [II]. density examinations should be obtained for patients who have been amenorrheic for 6 months or more [I]. 2. Choosing a Site of Treatment
In younger patients, examination should include Services available for treating eating disorders can growth pattern, sexual development (including sexual range from intensive inpatient programs (in which maturity rating), and general physical development [I]. general medical care is readily available) to The need for laboratory analyses should be residential and partial hospitalization programs to determined on an individual basis depending on the varying levels of outpatient care (in which the patient patient's condition or the laboratory tests' relevance receives general medical treatment, nutritional to making treatment decisions [I]. counseling, and/or individual, group, and family psychotherapy). Because specialized programs are not available in all geographic areas and their financial requirements are often significant, access to these programs may be limited; petition, explanation, and follow-up by the psychiatrist on behalf of patients and families may help procure access to these programs. Pretreatment evaluation of the patient is essential in choosing the appropriate treatment setting [I].
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In determining a patient's initial level of care or Hospitalization should occur before the onset of whether a change to a different level of care is medical instability as manifested by abnormalities in appropriate, it is important to consider the patient's vital signs (e.g., marked orthostatic hypotension with overall physical condition, psychology, behaviors, and an increase in pulse of 20 beats per minute (bpm) or a social circumstances rather than simply rely on one or drop in standing blood pressure of 20 millimeters of more physical parameters, such as weight [I]. Weight mercury (mmHg), bradycardia <40 bpm, tachycardia in relation to estimated individually healthy weight, >110 bpm, or an inability to sustain core body the rate of weight loss, cardiac function, and temperature), physical findings, or laboratory tests [I]. metabolic status are the most important physical To avert potentially irreversible effects on physical parameters to be considered when choosing a growth and development, many children and treatment setting; other psychosocial parameters are adolescents require inpatient medical treatment, even also important [I]. Healthy weight estimates for a when weight loss, although rapid, has not been as given individual must be determined by that person's severe as that suggesting a need for hospitalization in physicians [I]. Such estimates may be based on adult patients [I]. historical considerations (often including that person's growth charts) and, for women, the weight at which Patients who are physiologically stabilized on acute healthy menstruation and ovulation resume, which medical units will still require specific inpatient may be higher than the weight at which menstruation treatment for eating disorders if they do not meet and ovulation became impaired. Admission to or biopsychosocial criteria for less intensive levels of continuation of an intensive level of care (e.g., care and/or if no suitable less intensive levels of care hospitalization) may be necessary when access to a are accessible because of geographic or other reasons less intensive level of care (e.g., partial hospitalization) [I]. Weight level per se should never be used as the is absent because of geography or a lack of resources sole criterion for discharge from inpatient care [I]. Assisting patients in determining and practicing appropriate food intake at a healthy body weight is Generally, adult patients who weigh less than likely to decrease the chances of their relapsing after approximately 85% of their individually estimated healthy weights have considerable difficulty gaining weight outside of a highly structured program [II]. Most patients with uncomplicated bulimia nervosa do Such programs, including inpatient care, may be not require hospitalization; indications for the medically and psychiatrically necessary even for some hospitalization of such patients include severe patients who are above 85% of their individually disabling symptoms that have not responded to estimated healthy weight [I]. Factors suggesting that adequate trials of outpatient treatment, serious hospitalization may be appropriate include rapid or concurrent general medical problems (e.g., metabolic persistent decline in oral intake, a decline in weight abnormalities, hematemesis, vital sign changes, despite maximally intensive outpatient or partial uncontrolled vomiting), suicidality, psychiatric hospitalization interventions, the presence of disturbances that would warrant the patient's additional stressors that may interfere with the hospitalization independent of the eating disorder patient's ability to eat, knowledge of the weight at diagnosis, or severe concurrent alcohol or drug which instability previously occurred in the patient, dependence or abuse [I]. co-occurring psychiatric problems that merit hospitalization, and the degree of the patient's denial Legal interventions, including involuntary and resistance to participate in his or her own care in hospitalization and legal guardianship, may be less intensively supervised settings [I]. necessary to address the safety of treatment-reluctant patients whose general medical conditions are life threatening [I].
NEDA TOOLKIT for Parents
The decision about whether a patient should be In an outpatient setting, patients can remain with their hospitalized on a psychiatric versus a general medical families and continue to attend school or work. or adolescent/ pediatric unit should be made based on Inpatient care may interfere with family, school, and the patient's general medical and psychiatric status, work obligations; however, it is important to give the skills and abilities of local psychiatric and general priority to the safe and adequate treatment of a medical staff, and the availability of suitable programs rapidly progressing or otherwise unresponsive to care for the patient's general medical and disorder for which hospital care might be necessary [I]. psychiatric problems [I]. There is evidence to suggest that patients with eating disorders have better 3. Choice of Specific Treatments for Anorexia
outcomes when treated on inpatient units specializing in the treatment of these disorders than when treated in general inpatient settings where staff lack expertise The aims of treating anorexia nervosa are to 1) restore and experience in treating eating disorders [II]. patients to a healthy weight (associated with the return of menses and normal ovulation in female Outcomes from partial hospitalization programs that patients, normal sexual drive and hormone levels in specialize in eating disorders are highly correlated male patients, and normal physical and sexual growth with treatment intensity. The more successful and development in children and adolescents); 2) treat programs involve patients in treatment at least 5 physical complications; 3) enhance patients' days/week for 8 hours/day; thus, it is recommended motivation to cooperate in the restoration of healthy that partial hospitalization programs be structured to eating patterns and participate in treatment; 4) provide at least this level of care [I]. provide education regarding healthy nutrition and eating patterns; 5) help patients reassess and change Patients who are considerably below their healthy core dysfunctional cognitions, attitudes, motives, body weight and are highly motivated to adhere to conflicts, and feelings related to the eating disorder; 6) treatment, have cooperative families, and have a brief treat associated psychiatric conditions, including symptom duration may benefit from treatment in deficits in mood and impulse regulation and self- outpatient settings, but only if they are carefully esteem and behavioral problems; 7) enlist family monitored and if they and their families understand support and provide family counseling and therapy that a more restrictive setting may be necessary if where appropriate; and 8) prevent relapse. persistent progress is not evident in a few weeks [II]. Careful monitoring includes at least weekly (and often a. Nutritional Rehabilitation
two to three times a week) weight determinations The goals of nutritional rehabilitation for seriously done directly after the patient voids and while the underweight patients are to restore weight, normalize patient is wearing the same class of garment (e.g., eating patterns, achieve normal perceptions of hunger hospital gown, standard exercise clothing) [I]. In and satiety, and correct biological and psychological patients who purge, it is important to routinely sequelae of malnutrition [I]. For patients age 20 years monitor serum electrolytes [I]. Urine specific gravity, and younger, an individually appropriate range for orthostatic vital signs, and oral temperatures may expected weight and goals for weight and height may need to be measured on a regular basis [II]. be determined by considering measurements and clinical factors, including current weight, bone age estimated from wrist x-rays and nomograms, menstrual history (in adolescents with secondary amenorrhea), mid-parental heights, assessments of skeletal frame, and benchmarks from Centers for Disease Control and Prevention (CDC) growth charts (available at http://www.cdc.gov/growthcharts/) [I].
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For individuals who are markedly underweight and for Patients who require much lower caloric intakes or children and adolescents whose weight has deviated are suspected of artificially increasing their weight by below their growth curves, hospital-based programs fluid loading should be weighed in the morning after for nutritional rehabilitation should be considered [I]. they have voided and are wearing only a gown; their For patients in inpatient or residential settings, the fluid intake should also be carefully monitored [I]. discrepancy between healthy target weight and Urine specimens obtained at the time of a patient's weight at discharge may vary depending on patients' weigh-in may need to be assessed for specific gravity ability to feed themselves, their motivation and ability to help ascertain the extent to which the measured to participate in aftercare programs, and the weight reflects excessive water intake [I]. Regular adequacy of aftercare, including partial monitoring of serum potassium levels is hospitalization [I]. It is important to implement recommended in patients who are persistent vomiters refeeding programs in nurturing emotional contexts [I]. Hypokalemia should be treated with oral or [I]. For example, it is useful for staff to convey to intravenous potassium supplementation and patients their intention to take care of them and not rehydration [I]. let them die even when the illness prevents the patients from taking care of themselves [II]. It is also Physical activity should be adapted to the food intake useful for staff to communicate clearly that they are and energy expenditure of the patient, taking into not seeking to engage in control battles and have no account the patient's bone mineral density and punitive intentions when using interventions that the cardiac function [I]. Once a safe weight is achieved, patient may experience as aversive [I]. the focus of an exercise program should be on the patient's gaining physical fitness as opposed to In working to achieve target weights, the treatment expending calories [I]. plan should also establish expected rates of controlled weight gain. Clinical consensus suggests Weight gain results in improvements in most of the that realistic targets are 2-3 pounds (lb)/week for physiological and psychological complications of hospitalized patients and 0.5-1 lb/week for individuals semistarvation [I]. It is important to warn patients in outpatient programs [II]. Registered dietitians can about the following aspects of early recovery [I]: As help patients choose their own meals and can provide they start to recover and feel their bodies getting a structured meal plan that ensures nutritional larger, especially as they approach frightening, adequacy and that none of the major food groups are magical numbers on the scale that represent phobic avoided [I]. Formula feeding may have to be added to weights, they may experience a resurgence of anxious the patient's diet to achieve large caloric intake[II]. It and depressive symptoms, irritability, and sometimes is important to encourage patients with anorexia suicidal thoughts. These mood symptoms, non-food- nervosa to expand their food choices to minimize the related obsessional thoughts, and compulsive severely restricted range of foods initially acceptable behaviors, although often not eradicated, usually to them [II]. Caloric intake levels should usually start decrease with sustained weight gain and weight at 30-40 kilocalories/kilogram (kcal/kg) per day maintenance. Initial refeeding may be associated with (approximately 1,000-1,600 kcal/day). During the mild transient fluid retention, but patients who weight gain phase, intake may have to be advanced abruptly stop taking laxatives or diuretics may progressively to as high as 70-100 kcal/kg per day for experience marked rebound fluid retention for several some patients; many male patients require a very weeks. As weight gain progresses, many patients also large number of calories to gain weight [II]. develop acne and breast tenderness and become unhappy and demoralized about resulting changes in
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Patients may experience abdominal pain and bloating Patients' serum levels of phosphorus, magnesium, with meals from the delayed gastric emptying that potassium, and calcium should be determined daily accompanies malnutrition. These symptoms may for the first 5 days of refeeding and every other day for respond to pro-motility agents [III]. Constipation may several weeks thereafter, and electrocardiograms be ameliorated with stool softeners; if unaddressed, it should be performed as indicated [II]. For children and can progress to obstipation and, rarely, to acute bowel adolescents who are severely malnourished (weight <70% of healthy body weight), cardiac monitoring, especially at night, may be desirable [II]. Phosphorus, When life-preserving nutrition must be provided to a magnesium, and/or potassium supplementation patient who refuses to eat, nasogastric feeding is should be given when indicated [I]. preferable to intravenous feeding [I]. When nasogastric feeding is necessary, continuous feeding b. Psychosocial Interventions
(i.e., over 24 hours) may be better tolerated by patients and less likely to result in metabolic abnormalities The goals of psychosocial interventions are to help than three to four bolus feedings a day [II]. In very patients with anorexia nervosa 1) understand and difficult situations, where patients physically resist and cooperate with their nutritional and physical constantly remove their nasogastric tubes, feeding rehabilitation, 2) understand and change the through surgically placed gastrostomy or jejunostomy behaviors and dysfunctional attitudes related to their tubes may be an alternative to nasogastric feeding [II]. eating disorder, 3) improve their interpersonal and In determining whether to begin involuntary forced social functioning, and 4) address comorbid feeding, the clinician should carefully think through psychopathology and psychological conflicts that the clinical circumstances, family opinion, and reinforce or maintain eating disorder behaviors. relevant legal and ethical dimensions of the patient's treatment [I]. The general principles to be followed in Acute Anorexia Nervosa
making the decision are those directing good, humane care; respecting the wishes of competent patients; and During acute refeeding and while weight gain is intervening respectfully with patients whose judgment occurring, it is beneficial to provide anorexia nervosa is severely impaired by their psychiatric disorders patients with individual psychotherapeutic when such interventions are likely to have beneficial management that is psychodynamically informed and results [I]. For cooperative patients, supplemental provides empathic understanding, explanations, praise overnight pediatric nasogastric tube feeding has been for positive efforts, coaching, support, encouragement, used in some programs to facilitate weight gain [III]. and other positive behavioral reinforcement [I]. Attempts to conduct formal psychotherapy with With severely malnourished patients (particularly starving patients who are often negativistic, those whose weight is <70% of their healthy body obsessional, or mildly cognitively impaired may be weight) who undergo aggressive oral, nasogastric, or ineffective [II]. parenteral refeeding, a serious refeeding syndrome can occur. Initial assessments should include vital For children and adolescents, the evidence indicates signs and food and fluid intake and output, if that family treatment is the most effective indicated, as well as monitoring for edema, rapid intervention [I]. In methods modeled after the weight gain (associated primarily with fluid overload), Maudsley approach, families become actively congestive heart failure, and gastrointestinal involved, in a blame-free atmosphere, in helping patients eat more and resist compulsive exercising
NEDA TOOLKIT for Parents
For some outpatients, a short-term course of family For adolescents who have been ill <3 years, after therapy using these methods may be as effective as a weight has been restored, family therapy is a long-term course; however, a shorter course of necessary component of treatment [I]. Although therapy may not be adequate for patients with severe studies of different psychotherapies focus on these obsessive-compulsive features or non-intact families interventions as distinctly separate treatments, in practice there is frequent overlap of interventions [II]. Most inpatient-based nutritional rehabilitation It is important for clinicians to pay attention to programs create a milieu that incorporates emotional cultural attitudes, patient issues involving the gender nurturance and a combination of reinforcers that link of the therapist, and specific concerns about possible exercise, bed rest, and privileges to target weights, abuse, neglect, or other developmental traumas [II]. desired behaviors, feedback concerning changes in Clinicians need to attend to their countertransference weight, and other observable parameters [II]. For reactions to patients with a chronic eating disorder, adolescents treated in inpatient settings, participation which often include beleaguerment, demoralization, in family group psychoeducation may be helpful to and excessive need to change the patient [I]. their efforts to regain weight and may be equally as effective as more intensive forms of family therapy At the same time, when treating patients with chronic illnesses, clinicians need to understand the longitudinal course of the disorder and that patients Anorexia Nervosa after Weight Restoration
can recover even after many years of illness [I]. Because of anorexia nervosa's enduring nature, Once malnutrition has been corrected and weight gain psychotherapeutic treatment is frequently required for has begun, psychotherapy can help patients with at least 1 year and may take many years [I]. anorexia nervosa understand 1) their experience of their illness; 2) cognitive distortions and how these Anorexics and Bulimics Anonymous and Overeaters have led to their symptomatic behavior; 3) Anonymous are not substitutes for professional developmental, familial, and cultural antecedents of treatment [I]. Programs that focus exclusively on their illness; 4) how their illness may have been a abstaining from binge eating, purging, restrictive maladaptive attempt to regulate their emotions and eating, or excessive exercising (e.g., 12-step programs) cope; 5) how to avoid or minimize the risk of relapse; without attending to nutritional considerations or and 6) how to better cope with salient developmental cognitive and behavioral deficits have not been and other important life issues in the future. Clinical studied and therefore cannot be recommended as the experience shows that patients may often display sole treatment for anorexia nervosa [I]. improved mood, enhanced cognitive functioning, and clearer thought processes after there is significant It is important for programs using 12-step models to improvement in nutritional intake, even before there is be equipped to care for patients with the substantial substantial weight gain [II]. psychiatric and general medical problems often associated with eating disorders [I]. Although families To help prevent patients from relapsing, emerging and patients are increasingly accessing worthwhile, data support the use of cognitive-behavioral helpful information through online web sites, psychotherapy for adults [II]. Many clinicians also use newsgroups, and chat rooms, the lack of professional interpersonal and/or psychodynamically oriented supervision within these resources may sometimes individual or group psychotherapy for adults after lead to users' receiving misinformation or create their weight has been restored [II]. unhealthy dynamics among users.
NEDA TOOLKIT for Parents
It is recommended that clinicians inquire about a patient's or family's use of Internet-based support and For example, these medications may be considered for other alternative and complementary approaches and those with persistent depressive, anxiety, or obsessive- be prepared to openly and sympathetically discuss the compulsive symptoms and for bulimic symptoms in information and ideas gathered from these sources [I]. weight-restored patients [II]. A U.S. Food and Drug Administration (FDA) black box warning concerning Chronic Anorexia Nervosa
the use of bupropion in patients with eating disorders has been issued because of the increased seizure risk Patients with chronic anorexia nervosa generally show in these patients. Adverse reactions to tricyclic a lack of substantial clinical response to formal antidepressants and monoamine oxidase inhibitors psychotherapy. Nevertheless, many clinicians report (MAOIs) are more pronounced in malnourished seeing patients with chronic anorexia nervosa who, individuals, and these medications should generally be after many years of struggling with their disorder, avoided in this patient population [I]. Second- experience substantial remission, so clinicians are generation antipsychotics, particularly olanzapine, justified in maintaining and extending some degree risperidone, and quetiapine, have been used in small of hope to patients and families [II]. More extensive series and individual cases for patients, but controlled psychotherapeutic measures may be undertaken to studies of these medications are lacking. Clinical engage and help motivate patients whose illness is impressions suggest that they may be useful in resistant to treatment [II] or, failing that, as patients with severe, unremitting resistance to gaining compassionate care [I]. For patients who have weight; severe obsessional thinking; and denial that difficulty talking about their problems, clinicians have assumes delusional proportions [III]. Small doses of reported that a variety of nonverbal therapeutic older antipsychotics such as chlorpromazine may be methods, such as the creative arts, movement therapy helpful prior to meals in very disturbed patients [III]. programs, and occupational therapy, can be useful Although the risks of extrapyramidal side effects are [III]. Psychosocial programs designed for patients with less with second-generation antipsychotics than with chronic eating disorders are being implemented at first-generation antipsychotics, debilitated anorexia several treatment sites and may prove useful [II]. nervosa patients may be at a higher risk for these than c. Medications and Other Somatic Treatments
Therefore, if these medications are used, it is i. Weight Restoration
recommended that patients be carefully monitored for extrapyramidal symptoms and akathisia [I]. It is also The decision about whether to use psychotropic important to routinely monitor patients for potential medications and, if so, which medications to choose side effects of these medications, which can result in will be based on the patient's clinical presentation [I]. insulin resistance, abnormal lipid metabolism, and The limited empirical data on malnourished patients prolongation of the QTc interval [I]. Because indicate that selective serotonin reuptake inhibitors ziprasidone has not been studied in individuals with (SSRIs) do not appear to confer advantage regarding anorexia nervosa and can prolong QTc intervals, weight gain in patients who are concurrently receiving careful monitoring of serial electrocardiograms and inpatient treatment in an organized eating disorder serum potassium measurements is needed if anorexic program [I]. However, SSRIs in combination with patients are treated with ziprasidone [I]. psychotherapy are widely used in treating patients with anorexia nervosa.
NEDA TOOLKIT for Parents
Antianxiety agents used selectively before meals may Hormone therapy usually induces monthly menstrual be useful to reduce patients' anticipatory anxiety bleeding, which may contribute to the patient's denial before eating [III], but because eating disorder of the need to gain further weight [II]. Before estrogen patients may have a high propensity to become is offered, it is recommended that efforts be made to dependent on benzodiazepines, these medications increase weight and achieve resumption of normal should be used routinely only with considerable menses [I]. There is no indication for the use of caution [I]. Pro-motility agents such as bisphosphonates such as alendronate in patients with metoclopramide may be useful for bloating and anorexia nervosa [II]. Although there is no evidence abdominal pains that occur during refeeding in some that calcium or vitamin patients [II]. Electroconvulsive therapy (ECT) has D supplementation reverses decreased bone mineral generally not been useful except in treating severe co- density, when calcium dietary intake is inadequate for occurring disorders for which ECT is otherwise growth and maintenance, calcium supplementation should be considered [I], and when the individual is not exposed to daily sunlight, vitamin D Although no specific hormone treatments or vitamin supplementation may be used [I]. However, large supplements have been shown to be helpful [I], supplemental doses of vitamin D may be hazardous [I]. supplemental calcium and vitamin D are often recommended [III]. Zinc supplements have been 4. Choice of Specific Treatments for Bulimia Nervosa
reported to foster weight gain in some patients, and patients may benefit from daily zinc-containing The aims of treatment for patients with bulimia multivitamin tablets [II]. nervosa are to 1) reduce and, where possible, eliminate binge eating and purging; 2) treat physical ii.
complications of bulimia nervosa; 3) enhance patients' motivation to cooperate in the restoration of healthy Some data suggest that fluoxetine in dosages of up to eating patterns and participate in treatment; 4) 60 mg/day may help prevent relapse [II]. For patients provide education regarding healthy nutrition and receiving cognitive-behavioral therapy (CBT) after eating patterns; 5) help patients reassess and change weight restoration, adding fluoxetine does not appear core dysfunctional thoughts, attitudes, motives, to confer additional benefits with respect to conflicts, and feelings related to the eating disorder; 6) preventing relapse [II]. Antidepressants and other treat associated psychiatric conditions, including psychiatric medications may be used to treat specific, deficits in mood and impulse regulation, self-esteem, ongoing psychiatric symptoms of depressive, anxiety, and behavior; 7) enlist family support and provide obsessive-compulsive, and other comorbid disorders family counseling and therapy where appropriate; and [I]. Clinicians should attend to the black box warnings 8) prevent relapse. in the package inserts relating to antidepressants and discuss the potential benefits and risks of a. Nutritional Rehabilitation Counseling
antidepressant treatment with patients and families if such medications are to be prescribed [I]. A primary focus for nutritional rehabilitation is to help the patient develop a structured meal plan as a means iii.
Chronic Anorexia Nervosa
of reducing the episodes of dietary restriction and the urges to binge and purge [I]. Adequate nutritional Although hormone replacement therapy (HRT) is intake can prevent craving and promote satiety [I]. It is frequently prescribed to improve bone mineral density important to assess nutritional intake for all patients, in female patients, no good supporting evidence exists even those with a normal body weight (or normal either in adults or in adolescents to demonstrate its BMI), as normal weight does not ensure appropriate nutritional intake or normal body composition [I].
NEDA TOOLKIT for Parents
Among patients of normal weight, nutritional A variety of self-help and professionally guided self- counseling is a useful part of treatment and helps help programs have been effective for some patients reduce food restriction, increase the variety of foods with bulimia nervosa [I]. Several innovative online eaten, and promote healthy but not compulsive programs are currently under investigation and may exercise patterns [I]. be recommended in the absence of alternative treatments [III]. Support groups and 12-step programs b. Psychosocial Interventions
such as Overeaters Anonymous may be helpful as adjuncts in the initial treatment of bulimia nervosa It is recommended that psychosocial interventions be and for subsequent relapse prevention, but they are chosen on the basis of a comprehensive evaluation of not recommended as the sole initial treatment the individual patient that takes into consideration approach for bulimia nervosa [I]. the patient's cognitive and psychological Issues of countertransference, discussed above with development, psychodynamic issues, cognitive style, respect to the treatment of patients with anorexia comorbid psychopathology, and preferences as well nervosa, also apply to the treatment of patients with as patient age and family situation [I]. For treating bulimia nervosa [I]. acute episodes of bulimia nervosa in adults, the evidence strongly supports the value of CBT as the c. Medications
most effective single intervention [I]. Some patients who do not respond initially to CBT may respond when i.
switched to either interpersonal therapy (IPT) or Antidepressants are effective as one component of an fluoxetine [II] or other modes of treatment such as initial treatment program for most bulimia nervosa family and group psychotherapies [III]. Controlled patients [I], with SSRI treatment having the most trials have also shown the utility of IPT in some cases evidence for efficacy and the fewest difficulties with adverse effects [I]. To date, fluoxetine is the best studied of these and is the only FDA-approved In clinical practice, many practitioners combine medication for bulimia nervosa. Sertraline is the only elements of CBT, IPT, and other psychotherapeutic other SSRI that has been shown to be effective, as techniques. Compared with psychodynamic or demonstrated in a small, randomized controlled trial. interpersonal therapy, CBT is associated with more In the absence of therapists qualified to treat bulimia rapid remission of eating symptoms [I], but using nervosa with CBT, fluoxetine is recommended as an psychodynamic interventions in conjunction with CBT initial treatment [I]. Dosages of SSRIs higher than and other psychotherapies may yield better global those used for depression (e.g., fluoxetine 60 mg/day) outcomes [II]. Some patients, particularly those with are more effective in treating bulimic symptoms [I]. concurrent personality pathology or other co- Evidence from a small open trial suggests fluoxetine occurring disorders, require lengthy treatment [II]. may be useful for adolescents with bulimia [II]. Clinical reports suggest that psychodynamic and psychoanalytic approaches in individual or group Antidepressants may be helpful for patients with format are useful once bingeing and purging improve substantial concurrent symptoms of depression, anxiety, obsessions, or certain impulse disorder symptoms or for patients who have not benefited from Family therapy should be considered whenever or had only a suboptimal response to appropriate possible, especially for adolescent patients still living psychosocial therapy [I]. Tricyclic antidepressants and with their parents [II] or older patients with ongoing MAOIs have been rarely used with bulimic patients conflicted interactions with parents [III]. Patients with and are not recommended as initial treatments [I]. marital discord may benefit from couples therapy [II].
NEDA TOOLKIT for Parents
Several different antidepressants may have to be tried iii.
Combining Psychosocial Interventions and
sequentially to identify the specific medication with the optimum effect [I]. In some research, the combination of antidepressant Clinicians should attend to the black box warnings therapy and CBT results in the highest remission rates; relating to antidepressants and discuss the potential therefore, this combination is recommended initially benefits and risks of antidepressant treatment with when qualified CBT therapists are available patients and families if such medications are to be [II]. In addition, when CBT alone does not result in a substantial reduction in symptoms after 10 sessions, it is recommended that fluoxetine be added [II]. Small controlled trials have demonstrated the efficacy of the anticonvulsant medication topiramate, but iv.
because adverse reactions to this medication are common, it should be used only when other Bright light therapy has been shown to reduce binge medications have proven ineffective [III]. Also, because frequency in several controlled trials and may be used patients tend to lose weight on topiramate, its use is as an adjunct when CBT and antidepressant therapy problematic for normal or underweight individuals have not been effective in reducing bingeing Two drugs that are used for mood stabilization, 5. Eating Disorder Not Otherwise Specified
lithium and valproic acid, are both prone to induce weight gain in patients [I] and may be less acceptable Patients with subsyndromal anorexia nervosa or to patients who are weight preoccupied. However, bulimia nervosa who meet most but not all of the lithium is not recommended for patients with bulimia DSM-IV-TR criteria (e.g., weight >85% of expected nervosa because it is ineffective [I]. In patients with co- weight, binge and purge frequency less than twice per occurring bulimia nervosa and bipolar disorder, week) merit treatment similar to that of patients who treatment with lithium is more likely to be associated fulfill all criteria for these diagnoses [II]. with toxicity [I]. a. Binge Eating Disorder
i. Nutritional Rehabilitation and Counseling
Limited evidence supports the use of fluoxetine for relapse prevention [II], but substantial rates of relapse Behavioral weight control programs incorporating occur even with treatment. In the absence of adequate low- or very-low-calorie diets may help with weight data, most clinicians recommend continuing loss and usually with reduction of symptoms of binge antidepressant therapy for a minimum of 9 months eating [I]. It is important to advise patients that weight and probably for a year in most patients with bulimia loss is often not maintained and that binge eating may nervosa [II]. Case reports indicate that recur when weight is gained [I]. It is also important to methylphenidate may be helpful for bulimia nervosa advise them that weight gain after weight loss may be patients with concurrent attention- accompanied by a return of binge eating patterns [I]. deficit/hyperactivity disorder (ADHD) [III], but it should Various combinations of diets, behavior therapies, be used only for patients who have a very clear interpersonal therapies, psychodynamic diagnosis of ADHD [I]. psychotherapies, non-weight-directed psychosocial treatments, and even some "non-diet/health at every size" psychotherapy approaches may be of benefit for binge eating and weight loss or stabilization [III].
NEDA TOOLKIT for Parents
Patients with a history of repeated weight loss The anticonvulsant medication topiramate is effective followed by weight gain ("yo-yo" dieting) or patients for binge reduction and weight loss, although adverse with an early onset of binge eating may benefit from effects may limit its clinical utility for some individuals following programs that focus on decreasing binge [II]. Zonisamide may produce similar effects regarding eating rather than on weight loss [II]. weight loss and can also cause side effects [III]. There is little empirical evidence to suggest that obese iv.
Combining Psychosocial and Medication
binge eaters who are primarily seeking weight loss should receive different treatment than obese individuals who do not binge eat [I]. For most eating disorder patients, adding antidepressant medication to their behavioral weight ii. Other Psychosocial Treatments
control and/or CBT regimen does not have a significant effect on binge suppression when Substantial evidence supports the efficacy of compared with medication alone. However, individual or group CBT for the behavioral and medications may induce additional weight reduction psychological symptoms of binge eating disorder [I]. and have associated psychological benefits [II]. Adding IPT and dialectical behavior therapy have also been the weight loss medication orlistat to a guided self- shown to be effective for behavioral and help CBT program may yield additional weight psychological symptoms and can be considered as reduction [II]. Fluoxetine in conjunction with group alternatives [II]. Patients may be advised that some behavioral treatment may not aid in binge cessation studies suggest that most patients continue to show or weight loss but may reduce depressive symptoms behavioral and psychological improvement at their 1- year follow-up [II]. Substantial evidence supports the efficacy of self-help and guided self-help CBT b. Night Eating Syndrome
programs and their use as an initial step in a sequenced treatment program [I]. Other therapies that Progressive muscle relaxation has been shown to use a "non-diet" approach and focus on self- reduce symptoms associated with night eating acceptance, improved body image, better nutrition syndrome [III]. Sertraline has also been shown to and health, and increased physical movement have reduce these symptoms [II]. been tried, as have addiction-based 12-step approaches, self-help organizations, and treatment Definitions
programs based on the Alcoholics Anonymous model, but no systematic outcome studies of these programs The three categories of endorsement are as follows: are available [III]. [I] Recommended with substantial clinical confidence [II] Recommended with moderate clinical confidence iii. Medications
[III] May be recommended on the basis of individual Substantial evidence suggests that treatment with antidepressant medications, particularly SSRI antidepressants, is associated with at least a short-term reduction in binge eating behavior but, in most cases, not with substantial weight loss [I]. The Link to Full Summary: medication dosage is typically at the high end of the recommended range [I]. The appetite-suppressant medication sibutramine is effective for binge Link to Information for the Public: suppression, at least in the short term, and is also associated with significant weight loss [II].
NEDA TOOLKIT for Parents
How to find a suitable treatment setting
Several considerations enter into finding a suitable
Determining Quality of Care
treatment setting for the patient. The patient's options may be limited by his/her available insurance Determining the quality of care offered by a center is coverage, by whether or not a particular center or difficult at this time. No organization yet exists to therapist accepts insurance, and the ability of the specifically accredit treatment centers for the quality patient to pay in the absence of insurance. Primary and standard of eating disorder-specific care. Leaders care physicians (i.e., family doctor, gynecologist, within the national eating disorders community pediatrician, internal medicine doctor) may be able to organized in mid-2006 to develop care standards and play a valuable advisory role in referring patients for a process for accrediting eating disorder centers. That treatment if they have had previous experience with effort is ongoing. One national organization, the Joint referring to eating disorder facilities, participating as a Commission on Accreditation of Healthcare member of a care team for a patient with an eating Organizations (JCAHO), provides generic accreditation disorder, or outpatient therapists. Some primary care for healthcare facilities, and some eating disorder physicians, however, don't have much or any centers advertise "JCAHO accreditation." JCAHO experience in this area. Therefore, it's important to ask accreditation does not link directly to quality of care about their experience before asking for a referral. for treatment of eating disorders. Another issue regarding quality of care is that much care is delivered In 2005 and again in 2007, ECRI Institute (a nonprofit on an outpatient basis. For individual psychotherapists health services research organization) sought to in private practice, no special credentialing or identify all healthcare facilities that stated that they specialty certification exists regarding treatment of offered treatment for eating disorders. This included eating disorders. Thus, any mental healthcare hospitals, psychiatric hospitals, residential centers, professional can offer to treat an eating disorder and outpatient-care facilities. We surveyed treatment whether or not he/ she has experience or training in facilities nationwide to obtain information about their this specific area. Therefore, it is important to ask a treatment philosophies, treatment approach, years of prospective therapist about his/her knowledge about experience, and the clinical and support services they eating disorders and years of experience treating offer. The information is available in a searchable database, www.bulimiaguide.org. This database focuses on facilities offering any or all levels of care Factors Affecting Choice of Treatment Center
(see the tool explaining Treatment setting and levels of care). It does not include a listing of individual For insured patients, the choice of a treatment center therapist outpatient practices. For information on may be dictated by the beneficiary's health insurance outpatient-only therapists, go to the "treatment plan. Health insurers should provide a list of in- referral" source at www.nationaleatingdisorders.org; network (covered) treatment centers. If the treatment www.something-fishy.org/treatmentfinder; or center is outside of the health insurer's system (out-of- www.edreferral.com. network), the insurer might pay a percentage of the treatment costs leaving the patient responsible for the remainder. It is best to negotiate this percentage with the insurer before starting treatment. A small number of treatment centers offer financial assistance; but most do not. However, inquiring about treatment scholarships, as they are termed, may be worth investigating if the patient does not have financial resources or insurance.
NEDA TOOLKIT for Parents
Costs aside, other factors may be important to the Professionals in a Multi-disciplinary Care
patient in selecting a treatment center: the treatment center's philosophy (or religious affiliation, if any), multidisciplinary approach to care, distance from Primary care physician (i.e., family doctor, internal home, staff/patient ratio, professional qualifications of medicine doctor, pediatrician, gynecologist) staff, their experience in treating eating disorders, and Psychiatrist adjunct therapies offered. Some treatment centers Nutritionist provide therapies in addition to psychiatric counseling Clinical psychologist and pharmacotherapy, like equine therapy, massage, Psychopharmacologist (psychiatrist, clinical dance, or art therapy. These therapies may be psychologist, or pharmacologist with special appealing, although you may want to consider knowledge about medications used for mental whether they're covered by your health insurance. Social worker Some important questions to ask treatment centers Claims advocate for reimbursement are provided at the end of this document. If you are Other professionals who administer supplemental considering traveling some distance to a center, you services such as massage, yoga, exercise may want to ask these questions by phone before you programs, and art therapy invest the time and expense in traveling. Also, if the patient is going to enter some type of facility, knowing how the facility plans for discharge is important. Discharge plans can be complicated and require much coordination of care among different healthcare providers. That takes time. Effective discharge planning needs to start much earlier than a day or two before the patient is expected to be discharged from a Also important in your considerations are the type of care team a facility typically uses. Below is a list of the types of professionals that are generally recommended to be on the care team to ensure well- rounded care. Once a treatment facility decision has been made, there is another checklist of questions in a separate document in this toolkit—Questions to ask the care team—that you may want to ask the care Lastly, there are some questions a family may want to ask the treatment facility and care team separately (i.e., not in the presence of the patient). We have created a separate checklist in another document in the Parent Toolkit: Questions parents may want to ask treatment providers privately. Depending on the patient's age, you may need written permission to speak about the patient with a treatment facility or member of the care team.
NEDA TOOLKIT for Parents
Questions to Ask When Seeking a Treatment Center
Does the center accept the patient's insurance? If Who will the patient have the most contact with so, how much will it cover? on a daily basis? Does the center offer help in obtaining What is the mealtime support philosophy? reimbursement from the insurer? Who will update key family or friends? How often? Does the center offer financial assistance? How is care coordinated for the patient inside the How long has the center been in business? center and outside if needed? What is its treatment philosophy? How does the center communicate with the Does the center have any religious affiliations and patient's family doctors and other doctors who what role do they play in treatment philosophy? may routinely provide care? Does the center provide multidisciplinary care? What are your criteria for determining whether a Is the location convenient for the patient and patient needs to be partially or fully hospitalized? his/her support people who will be involved What happens in counseling sessions? Will there through recovery? be individual and group sessions? If the location is far away for in-person family Will there be family sessions? participation, what alternatives are there? How does the care team measure success for the What security does the facility have in place to protect patients? How do you decide when a patient is ready to How quickly will you complete a full assessment How is that transition managed with the patient Prior to traveling to the treatment center: what are your specific medical criteria for admission What after-care plans do you have in place and at and will you talk with my insurance company what point do you begin planning for discharge? before we arrive to determine eligibility for What follow-up care after discharge is needed and who should deliver it? What is expected of the family during the person's Does the patient have a follow-up appointment in hand before being discharged? Is the follow-up Anorexic specific: Please describe your strategy for appointment within 7 days of the discharge date? accomplishing refeeding and weight gain, and When is payment due? please include anticipated time frame. What are the visiting guidelines for family or Key Sources
ECRI Institute Bulimia Resource Guide What levels of care does the center provide? Please define criteria for each level mentioned. ECRI Institute interviews with families and treatment What types of professionals participate on the care team and what is each person's role? What are the credentials and experience of the How many hours of treatment are provided to a patient each day and week? Which professional serves as team leader? What types of therapy does the center consider essential? Optional? What is the patient-staff ratio? What is the rate of turnover (staff resigning) for How is that handled with patients?
NEDA TOOLKIT for Parents
Treatment settings and levels of care
Several types of treatment centers and levels of care are available for treating eating disorders. Knowing the
terms used to describe these is important because insurance benefits (and the duration of benefits) are tied not
only to a patient's diagnosis, but also to the type of treatment setting and level of care.
Treatment is delivered in hospitals, residential
Psychotherapy and drug therapy are available in all treatment facilities, and private office settings. Levels the care settings. Many settings provide additional of care consist of acute short-term inpatient care, care options that can be included as part of a tailored partial inpatient care, intensive outpatient care (by treatment plan. Support groups may help a patient to day or evening), and outpatient care. Acute inpatient maintain good mental health and may prevent relapse hospitalization is necessary when a patient is after discharge from a more intensive program. medically or psychiatrically unstable. Once a patient is medically stable, he/she is discharged from a hospital, The intensity and duration of treatment depends on: and ongoing care is typically delivered at a subacute insurance coverage limits and ability to pay for care residential treatment facility. The level of care in such a facility can be full-time inpatient, partial severity and duration of the disorder; inpatient, intensive outpatient by day or evening, and mental health status; and outpatient. There are also facilities that operate only coexisting medical or psychological disorders. as outpatient facilities. Outpatient psychotherapy and medical follow-up may also be delivered in a private A health professional on the treatment team will make treatment recommendations after examining and consulting with the patient. The treatment setting and level of care should complement the general goals of treatment. Typically, Criteria for treatment setting and levels of
to medically stabilize the patient; help the patient to stop destructive behaviors (i.e., restricting foods, binge eating, Inpatient
purging/nonpurging); and Patient is medically unstable as determined by: Unstable or depressed vital signs address and resolve any coexisting mental health problems that may be triggering the behavior. Laboratory findings presenting acute health risk Complications due to coexisting medical problems Patients with severe symptoms often begin treatment such as diabetes as inpatients and move to less intensive programs as Patient is psychiatrically unstable as determined by: symptoms subside. Hospitalization may be required Rapidly worsening symptoms for complications of the disorder, such as electrolyte Suicidal and unable to contract for safety imbalances, irregular heart rhythm, dehydration, severe underweight, or acute life-threatening mental Residential
breakdown. Partial hospitalization may be required Patient is medically stable and requires no intensive when the patient is medically stable, and not a threat medical intervention. to him/ herself or others, but still needs structure to continue the healing process. Partial hospitalization Patient is psychiatrically impaired and unable to programs last between 3 and 12 hours per day, respond to partial hospital or outpatient treatment. depending on the patient's needs.
NEDA TOOLKIT for Parents
Patient is medically stable but: Eating disorder impairs functioning, though without immediate risk Needs daily assessment of physiologic and mental Patient is psychiatrically stable but: Unable to function in normal social, educational, or vocational situations Engages in daily binge eating, purging, fasting or very limited food intake, or other pathogenic weight control techniques Intensive Outpatient/Outpatient
Patient is medically stable and: No longer needs daily medical monitoring Patient is psychiatrically stable and has: Symptoms under sufficient control to be able to function in normal social, educational, or vocational situations and continue to make progress in recovery These criteria summarize typical medical necessity criteria for treatment of eating disorders used by many healthcare facilities, eating disorder specialists, and health plans for determining level of care needed. Please see Questions to Ask a Treatment Center for additional help in determining a suitable treatment
NEDA TOOLKIT for Parents
Questions to ask the care team at a facility
Some of these questions pertain to particular eating disorders; some pertain to particular treatment settings; and some pertain to any eating disorder and all settings. What are the names, roles, titles, and contact When do you begin discharge planning? Do you information of those who will treat my family schedule and give the patient a specific follow-up appointment date/time at discharge? What other professionals will be involved in the How do you follow up if the patient does not show up for a scheduled appointment? What treatment plan do you recommend? Do you What are your criteria for determining whether and use current published clinical guidelines to guide when a patient needs to be hospitalized? treatment? If so, which guidelines? What happens in counseling sessions? Will there be What's your prognosis for the patient's chance of a individual and group sessions? Will there be family full recovery? How long might it take? How do you measure success? If I become very concerned about the patient, who What specific goals will be set for the treatment How long does each counseling session last? How Is there any psychiatric diagnosis in addition to the many will there be? How often will they happen? eating disorder? How will it be treated? What contact can the patient have with family and What physical/medical complications need friends through the course of treatment? ongoing treatment? What are we permitted to bring when visiting? What will the sequence of treatments be? What are we not permitted to bring? Are there alternative or adjunct treatments you How will you help us prepare for the patient's What benefits and risks are associated with the What should we do and who should we contact in recommended treatments and alternatives? the event of a partial or complete relapse? How can I best help my family member during What books, websites, or other sources of treatment? What is my role within the treatment? information would you recommend? How often will you talk to me about my family member's progress? What if my family member doesn't want to participate in therapy? What are your admissions criteria for residential, inpatient, partial hospital, intensive, and outpatient/inpatient care? How much weight gain should be expected in what time period for anorexia? What can I do to support my family member during a time of weight gain? Who should monitor refeeding and/or weight status? What procedures should we follow for How do family members determine whether purge behavior is occurring at home? What should we do if we notice this behavior? If my family member is being treated as an outpatient, how do you decide if more intensive intervention is needed? How often do team members communicate with each other? (Even if the team doesn't talk to each other, you can serve as a liaison to relay
NEDA TOOLKIT for Parents
Questions to ask when interviewing a therapist
What is your experience and how long have you What happens in counseling sessions? If a been treating eating disorders? particular session is upsetting for my child, will How are you licensed? What are your training you advise me on how best to support my child? credentials? Do you belong to the Academy for How long does each counseling session last? How Eating Disorders (AED)? AED is a professional many will there be and how often? group that offers its members educational How often will you meet with me/us as parents? trainings every year. This doesn't prove that How do you involve key family members or individuals are up-to-date, but it does increase the What specific goals will be set for treatment and How would you describe your treatment style? how will they be communicated? Many different treatment styles exist. Different How and when will progress be assessed? approaches may be more or less appropriate for How long will the treatment process take? How your child and family depending on your child's do you know when recovery is happening and situation and needs. therapy can stop? What kind of evaluation process do you use to Do you charge for phone calls or emails from recommend a treatment plan? Who all is involved patients or family between sessions? If so, what do in that planning? you charge and how and to whom (insurance What are the measurable criteria you use to assess company or patient) is that billed? how well treatment is working? Can you give me a Will you send me written information, a treatment plan, treatment price, etc.? The more information Do you use published clinical practice guidelines the therapist or facility is able to send in writing, to guide your treatment planning for eating the better informed you will be. Do you deal directly with the insurer or do I need What psychotherapeutic approaches and tools do When is payment due? How do you treat coexisting mental health Are you reimbursable by my insurance? What if I conditions such as depression or anxiety? don't have insurance or mental health benefits How do you decide which approach is best for the under my health care plan? patient? Do you ever use more than one It is important for you to research your insurance What kind of medical information do you need? coverage policy and what treatment alternatives are Will a medical evaluation be needed before my available in order for you and your treatment provider child begins treatment? to design a treatment plan that suits your coverage. How will you work with my child's other doctors, such as medical doctors, who may need to provide With a careful search, the provider you select will be helpful. If the first time you meet is awkward, don't be How often will you communicate with them? Will you work with my child's school and discouraged. The first few appointments with any teachers? How often do you communicate with treatment provider can be challenging. It takes time to build trust when you are sharing highly personal Will medication play a role in my child's information. If you continue feeling that a different therapeutic environment is needed, consider other Do you work with a psychopharmacologist if medication seems indicated or do I find one on my What is your availability in an emergency? If you are not available, what are my alternatives? What are your criteria for determining whether a patient needs to be hospitalized? What is your appointment availability? Do you offer after work or early morning appointments?
NEDA TOOLKIT for Parents
Questions parents may want to ask treatment providers
Appropriate support from parents and family is crucial to the treatment process and recovery. Below are some questions you can ask the treatment provider (at an eating disorder facility or private practice) to assist you in providing the best support possible for your loved one. Remember you may need to be proactive to help Is it wise for a recovering patient to have a job ensure the communication process flows smoothly. related to food or exercise? And don't forget to find support for yourself! As a How should I involve my family member in meal parent, family member, or friend it's easy to overlook planning, preparation, and food shopping? the self-care you need as you focus on your loved How much weight gain should be expected in one's recovery. National Eating Disorders Association's what time period with anorexia nervosa? (NEDA's) treatment referral resource on the website What support can I offer during a time of weight lists family support groups, though you can ask the treatment provider helping your loved one to make a Is it my responsibility to monitor refeeding and/or weight? What procedures should I follow for How can I best support my child/family member How do family members determine if purge during treatment? behavior is occurring in the home setting? What is my role? What action should I take if we notice this How often can I discuss progress with you? What should be done if my child/family member If I become anxious or notice problems, who does not want to participate in treatment? Can my child/family member be admitted to a My family member doesn't want anyone to know facility against her/his will? If so, under what about the illness. I do because it would help me to share about the illness with select, carefully How should I prepare for our family member's chosen, discrete people in our lives. They could be supportive, but I'm afraid that my family member What books, websites, or other resources do you might see them as spies. What should I do? How can I tell if a relapse is occurring? What If the patient is age 18, and often even younger, parents will need written permission from the patient If my family member receives outpatient to discuss his/her situation with a healthcare provider treatment, how will you decide if more intensive (professional or facility). treatment is needed? If I have concerns about how it's going, who What limits should be placed on exercise? What distinguishes compulsive from healthy exercise? Are there any special first-aid items such as Gatorade® or Pedialyte® that I should keep on hand to help with bulimia-related emergencies? How can I encourage "safe" food choices? What if my family member shuts me out of talking Will my family member be in group treatment with people of similar age/sex? What kind of food- related supervision should I provide? If my family member is fascinated by cooking, nutrition, or fitness, should those interests be
NEDA TOOLKIT for Parents
Find eating disorder treatment
Online databases and telephone referral lines are available to help families find a suitable treatment setting.
Excellent resources are listed below
Treatment Center Databases to Search
The database contains listings from individual therapists, dieticians, treatment centers, and other Treatment center listings can be accessed from the professionals worldwide who treat eating disorders. NEDA homepage. This database contains listings from Open the "treatment finder" tab on the left, and search professionals who treat eating disorders. Simply open by category (type of treatment), country, state, area the treatment referral tab and agree to the disclaimer. code, name, services, description, or zip code. Find an eating disorders treatment provider who will serve your state, a nationwide list of What to Consider When Searching for a
inpatient/residential treatment facilities, search for Treatment Center
free support groups in your area or locate a national Eating Disorders Research Study. Several considerations enter into finding a suitable treatment setting. Options may be limited by factors Bulimia Guide
such as insurance coverage, location, or ability to pay for treatment in the absence of insurance. When contacting treatment centers, be sure to talk with This database focuses on U.S. centers that treat all them to find out their complete admission criteria and types of eating disorders (not just bulimia) and offer whether your loved one meets their criteria for various levels of care and many types of treatment treatment. That way, you can better ensure that your from standard to alternative. On this website, you can loved one will meet their criteria before traveling. browse center listings by state, type of treatment Arriving at a center only to find out, after they take offered, whether or not they accept insurance, or other sufficiently detailed patient intake information, that characteristics by selecting from the drop-down lists. they won't admit your loved one is a situation you'll Some states have no eating disorder treatment want to prevent. Primary care physicians (i.e., family centers, and that's why no listings come up for some doctor, gynecologist, pediatrician, internal medicine states. This information was compiled from detailed doctor) may be able to assist in referring patients to questionnaires sent to every center to gather appropriate treatment facilities, because they may information about its treatment philosophies, have experience with various centers or outpatient approaches, staffing, and the clinical and support services it offers. The amount of information centers provided varies widely among centers. This database Telephone Referral and Information
does not contain listings for individual outpatient Helplines
therapists who claim to treat eating disorders. NEDA Helpline 800.931.2237
Something Fishy 866.690.7239
Hope Line Network 800.273.TALK
National Suicide Hotline 800.784.2433
National Call Center for At-Risk Youth 800.USA.KIDS
NEDA TOOLKIT for Parents
How to take care of yourself while caring for a loved one
with an eating disorder
Take time for yourself. Keep in mind that what you Remind yourself daily that you are doing the best do is a much more powerful message than what for your child or family member. Keeping a journal you say. Being a good role model for your child or can help— making a self-commitment to jot down family member during the healing process means one positive thought each day can help. taking care of your own physical, emotional, and spiritual needs. Find support in what others are saying – join a local or online support group. If you are married or in a significant relationship, spend time on that relationship. Talk daily to your Say "No" when you can. Give yourself a break. partner about your feelings and frustrations. Take Don't take on any added responsibilities at this time for a hug. If time allows, make a date for something you both enjoy to have fun. Explore your options if you think you may need to Seek support from family, friends, and/or leave work temporarily to provide full-time care. professionals whom you find to be helpful. Allow Learn about the Family and Medical Leave Act yourself to be cared for. (FMLA). FMLA provides job protection for employees who must leave their job for family Ask for help with the mundane. It makes your medical concerns. friends feel useful and keeps you from becoming isolated. Make a list of things you can use help with: laundry, errands, lawn care, housecleaning, meals for the rest of the family. If someone says, "Let me know if there is anything I can help with," show them your list of unassigned tasks. Ask what
NEDA TOOLKIT for Parents
Parents of children of legal age or friends of a person
Other documents worth knowing about include a with an eating disorder may want to help navigate medical POA, which lets someone make medical insurance issues and finding treatment facilities, or decisions about the patient's healthcare if the patient participate in treatment, but cannot talk with health is incapable of making these decisions. professionals or facilities on a patient's behalf without The rules about medical POAs vary by state and it's the patient's permission because of certain regulations best to consult a lawyer to write one. Advanced protecting medical privacy. The Health Insurance directives are another set of documents that the Portability and Accountability Act of 1996, or HIPAA, patient authorizes for future treatment in case the protects individuals' medical records from becoming patient cannot make decisions at that time. Most public knowledge. HIPAA states that under normal hospitals have forms for patients to fill out to specify circumstances, medical records are private and that anyone with access to them, like healthcare professionals, healthcare facilities, or insurers, cannot In most states parents have medical POA over their share that medical information with anyone but the children as long as the children are younger than age patient. HIPAA protection also extends to human 18 although the exact regulations depend on the state. resources (HR) departments at employers. If a person Parents do not have medical or durable POA over discloses his/her medical condition to HR personnel children who are older than age 18, even if the when talking about health insurance benefits, HR is children are covered under the parents' health required to maintain confidentiality. If HR divulges insurance policy. If a child is in college, is over age 18, information without permission, the harmed party can but is still covered by the parents' insurance, then the file a civil rights complaint. HIPAA requires companies parents and child must go through the usual legal to have policies that provide for sanctions against any process to set up POA. This can be a problem if the HR person who releases confidential medical child does not want treatment or is at odds with the information. The Americans with Disabilities Act may parents, which is sometimes the case. Parents have no provide recourse for anyone fired from a job because legal authority to force a legally adult child into of a medical condition. If a friend or family member is helping a patient through the treatment process, the patient can give oral permission for that person to see the patient's records and participate when talking with healthcare providers or insurers. That person may also make doctors' appointments for the patient. A friend or family member cannot see a patient's medical files or transport the files or lab samples if the patient is absent, even if permission has been given orally. To grant a friend or family member access to medical records, the patient must provide a durable power of attorney (POA) document. This document varies by state so it's best to have a lawyer create it. Anyone with a POA can sign legal documents for the patient and read or transport medical records in the patient's
NEDA TOOLKIT for Parents
NEDA TOOLKIT for Parents
Navigating and Understanding Health Insurance Issues
This guidance is intended to assist people looking for help when accessing care and when insurance denies coverage for treatment of eating disorders. The information here was compiled from research by ECRI Institute and the experience of parents and treatment providers who have had experience obtaining coverage for eating disorders care. In a separate document are sample letters to adapt to Another issue is the level of benefits for mental various insurance situations related to obtaining healthcare. For years, many health plans provided few appropriate care. This information has not been or no mental health benefits. When they did, most prepared by attorneys and is not intended as a legal subcontracted those benefits through "mental health document. This information does not guarantee carve-out" plans. Such plans are administered by success. If you have suggestions, feedback, or personal behavioral health service companies that are separate additions to share (e.g., submit a sample letter you've from health plans. This approach made well-rounded used with your insurance company with all identifying care by a multidisciplinary team very difficult to information removed), please email National Eating achieve. Even when a psychotherapist and medical Disorders Association at doctor want to integrate services and case firstname.lastname@example.org with "Insurance management to treat the patient as a whole person, Issues" in the subject line. the healthcare delivery system in the United States poses barriers that prevent that from happening. The National Eating Disorders Association fields many questions every day that focus on how to gain access For example, when a service is provided by a doctor or to care and navigate insurance issues. While there is facility, a billing code is needed to obtain little argument that early intervention offers the best reimbursement for services. Certain rules and chance for recovery, insurance and the healthcare regulations govern how services must be coded and system can pose barriers to accessing prompt, who can perform those services. Different types of comprehensive treatment. facilities and different healthcare professionals must use codes that apply to that type of facility and health Accessing the full benefits a patient is entitled to professional. Also, if codes don't exist for certain under his/her health plan contract requires services delivered in a particular setting, then facilities understanding a few things about all the factors that and health professionals have no way to bill for their affect access to care, coverage, and reimbursement. services. Codes used for billing purposes are set up by Navigating the system to find out what the patient is various entities, such as the American Medical entitled to receive also takes a lot of energy. While Association, U.S. Medicare program, and the World parents can legally act on behalf of children younger Health Organization's International Classification of than age 18, they need permission from a child older Diseases. Thus, even a patient with good health than age 18 to act on his/her behalf. insurance may face barriers to care simply because of the way our healthcare system is set up. Because treatment usually involves both mental healthcare and medical care aspects, a well-rounded The system is slowly changing. Sporadic improvements care plan must address both types of care. The overall have come about as a result of lawsuits and state healthcare system has long treated medical care and legislation prompted by individuals, legislators, mental healthcare separately. The result of that care clinicians, support groups, and mental health model is that health insurer benefits plans have often advocacy groups. The U.S. federal government and followed suit by separating mental health benefits most U.S. states have passed some form of mental (also called behavioral health benefits) from medical health parity law. Generally these laws require benefits. This split has created great difficulty for insurers to provide benefits for mental healthcare that people with an eating disorder because they need an are equivalent to benefits for medical care. These laws integrated care plan. Ways to steer through these do, however, vary widely in their provisions. difficulties are offered here in an 8-step plan.
NEDA TOOLKIT for Parents
Landmark lawsuits brought by families of patients with bulimia nervosa and/or anorexia in two states— Wisconsin in 1991, and Minnesota in 2001—were watershed events that set legal precedents about what insurers should cover for eating disorders. These lawsuits also raised public awareness of the problems faced by people seeking coverage for treatment of eating disorders. Nonetheless, the system today has a long way to go to improve access to care and adequate reimbursement for care for a sufficient period for a patient with an eating disorder. Given that appropriate well-integrated treatment for eating disorders can easily cost more than $30,000 dollars per month, even with insurance, an insured individual is usually responsible for some portion of The first-line of decision making about health plan benefits is typically made by a utilization review manager or case manager. These managers review the requests for benefits submitted by a healthcare provider and determine whether the patient is entitled to benefits under the patient's contract. These decision makers may have no particular expertise in the complex, inter-related medical/mental healthcare needs for an eating disorder. Claims can be rejected outright or approved for only part of the recommended treatment plan. Advance, adequate preparation on the part of the patient or the patients' support people is the best way to maximize benefits. Prepare to be persistent, assertive, and rational in explaining the situation and care needs. Early preparation can avert future coverage problems and situations that leave the patient holding the lion's
NEDA TOOLKIT for Parents
Steps to maximize insurance benefits
A spouse, partner, friend, or other person who wants to act on behalf of the patient will need to have the Read the other information in the Parent Toolkit to patient sign appropriate authorizations. Medical learn about eating disorders, treatment, current confidentiality is discussed later in this section. clinical practice guidelines, and how you can best advocate for and support the family member who has Read the patient's entire insurance benefits
an eating disorder. Refer to the latest evidence-based manual carefully to understand the available
clinical practice guidelines in this toolkit and have benefits
them in hand when speaking to your health plan about benefits. Be prepared to ask your health plan Obtain a copy of the full plan description from the for the evidence-based information they use to create health plan's member's website (i.e., the specific plan their coverage policy for eating disorders. that pertains to the insured), the insurer or, if the insurance plan is through work, the employer's human Find out if your state has a mental health parity law or resources department. This document may be longer mandate and what the terms of that law or mandate than 100 pages. Do not rely on general pamphlets or are. Mental health parity simply means that your policy highlights. Read the detailed description of the insurance company must not limit mental health and benefits contract to find out what is covered and for substance abuse healthcare by imposing lower day how long. If you can't understand the information, try and visit limits, higher copayments and deductibles, talking with the human resources staff at the company and lower annual and lifetime spending caps than that the insurance policy comes through, with an they do for medical care. The website insurance plan representative (the number is on the www.bulimiaguide.org has detailed information about back of your insurance identification card), or with a which states have mental health parity laws or billing/claims staff person at facilities where you are mandates and what those laws and mandates cover. considering obtaining treatment. If hospital See the Eating Disorders Coalition for Research, Policy emergency care is not needed, make an appointment & Action web site for how to get involved in the effort with a physician you trust to get a referral or directly to influence federal policy at: contact eating disorder treatment centers to find out how to get a full assessment and diagnosis. The assessment should consider all related physical and Get organized
psychological problems (other documents in this toolkit explain the diagnostic or assessment process If a patient's first encounter with the healthcare and testing). The four main reasons for doing this are: system is admission to an emergency room for a life- threatening situation with an eating disorder, whoever To obtain as complete a picture as possible about is going to deal with insurance issues on the patient's everything that is wrong behalf will need to get organized very quickly to To develop the best plan for treatment figure out how to best access benefits. Patients who To obtain cost estimates before starting treatment are seriously medically compromised will likely be in To obtain the benefits the patient is entitled to the hospital for a few days before discharge to under his/ her contract for the type of care outpatient care or a residential eating disorder center. needed—for example, many insurers provide Those few days are critical to negotiating more coverage benefits for severe mental disorder reimbursement for the longer-term care. diagnoses. Some insurers categorize anorexia and If the situation is not an acute emergency and you bulimia nervosa as severe disorders that qualify want to find a treatment center, consider whether you for extensive inpatient and outpatient benefits, have authority to act on the patient's behalf or while others may not. whether the patient must give you written authority to act on his/her behalf. If a child is 18 years of age or older, parents will need the child's written permission to act on the child's behalf. Healthcare providers have forms that require signatures to allow free flow of communication and decision making.
NEDA TOOLKIT for Parents
Medical benefits coverage also often comes into play This will improve your chance of getting one contact to treat eating disorder-associated medical conditions, person to talk with over the longer term of treatment so diagnosing all physical illnesses present is who better understands the complexities of treatment. important. Other mental conditions often coexist with Confirm with the insurer that the patient has benefits an eating disorder and should be considered during for treatment. Also ask about "in-network" and "out-of- the assessment, including depression, trauma, network" benefits and the eating disorder facilities obsessive compulsive disorder, anxiety, social phobias, that have contracts with the patient's insurance and chemical dependence. These coexisting company, because this affects how much of the costs conditions can affect eligibility for various benefits the patient is responsible for. If the insurer has no (and often can mean more benefits can be accessed) contract with certain treatment facilities, benefits may and eligibility for treatment centers. still be available, but may be considered out-of- network. In this case, the claims will be paid at a lower Keep careful and complete records of
rate and the patient will have a larger share of the bill. communications with the insurance company
and healthcare providers for future reference
You may also want to consider having an attorney in mind at this point in case you need to consult as needed
someone if roadblocks appear; however, avoid an adversarial attitude at the beginning. Remember to From the first call you make, keep a complete record keep complete written records of all communications of your conversation. Treatment often occurs over a with every person you speak with at your insurance long period of time. Maintaining a log book—whether company. Other things to remember: computerized or in hard copy—can be important for future reference if there are questions about claims. Thank and compliment anyone who has assisted Decide where all notes and documentation will be kept for easy access. Create a back-up copy of You're more likely to receive friendly service when everything, and keep it in a safe and separate place. you are polite while being persistent. The record log of conversations should contain the Send important letters via certified mail to ensure they can be tracked and signed for at the recipient Notes taken of each conversation with an insurer Set a timeframe and communicate when you or healthcare provider would like an answer. Make follow-up phone calls Date, time, name, and title of person with whom if you have not received a response in that Person's contact information Don't assume one department knows what the other department is doing. Copy communications As a courtesy, you may wish to let the people you talk to all the departments, including health, mental with know that you are keeping careful records of health, enrollment, and other related your conversations to help you and the patient remember what was discussed. If you decide to tape Don't panic when and if you receive the first record any conversation, you must first inform and ask denial. Typically, a denial is an automatic the permission of the person with whom you are computer-generated response that requires a "human override." Often you need to go up at least one level, and perhaps two levels, to reach the Call the insurer to discuss benefits options
decision maker with authority to override the automated denial. With documentation of the patient's diagnosis and Your insurance company only knows what you and proposed care plan in hand, it's a good idea to call the the treating professionals tell them. Make sure insurance company before the patient formally enters they have all information necessary to make a treatment program. Quite often, preauthorization for decisions that will be of most benefit to you or a treatment facility or healthcare provider is needed. Ask for a case manager who has credentials in eating Make no assumptions. Your insurance company is not the enemy – but may be uninformed about your case. Treat each person as though he/she has a tough job to do.
NEDA TOOLKIT for Parents
Be aware that if the patient is a college student who Not all health plans will do this, but some do, so it's had to drop out of school to seek treatment and was worth asking. Going this route can save the behavioral covered by school insurance or a parent's insurance health benefits for the time when the patient is better policy, the student may no longer be covered if not a able to take part in the psychotherapy. full-time student. While many people will continue working or attending school, some cannot. If this is the Another way to get the most out of benefits is to find case, it's important to understand what happens with out whether chemical dependency or substance abuse insurance. Most insurance policies cover students as benefits are included in the mental health day long as they are enrolled in 12 credit hours per allotment or if it is a separate benefit. If it is separate semester and attend classes. Experts in handling and the patient does not really need this benefit, find insurance issues for patients with eating disorders out whether the insurer will "flex" the benefit to apply caution that patients who have dropped out of school it for treating an eating disorder. should avoid trying to cover up that fact to maintain benefits, because insurance companies will usually Find out the authorizations for care that the
find out and then expect the patient to repay any insurer requires for the patient to access
benefits that were paid out. If coverage has been lost, the student may be eligible to enroll in a Consolidated Omnibus Budget Once insurance benefits are confirmed, be sure to Reconciliation Act (COBRA) insurance program. obtain the health plan authorizations required for COBRA is an Act of Congress that allows people who reimbursement for the care the patient will receive. have lost insurance benefits to continue those benefits Sometimes authorizations and referrals are sent as long as they pay the full premium and qualify for electronically to the concerned parties. Always the program. See www.cobrainsurance.com for more confirm that they have been sent and received by the information. A person eligible for COBRA has only 30 appropriate parties. Ask for the level-of-care criteria days from the time of loss of benefits to enroll in a the patient must meet to be eligible for the various COBRA plan. It is critical that the sign up for COBRA be levels of benefits. Again, keep a record of the done or that option is lost. Be sure to get written authorizations received. confirmation of COBRA enrollment from the plan. If the student is not eligible for COBRA, an insurance Communicate with key caregivers to give any
company may offer a "conversion" plan for individual needed input and devise a treatment plan.
Obtain the names of the people who will be providing If the patient is in the hospital and will be discharged care and having daily interactions with the patient to a residential treatment center, discuss how the (including lower-level staff such as aides). Try to meet medical and behavioral health components of with, or talk by phone, to each caregiver on the team. benefits will work. Although a patient may be Discuss the diagnosis (and whether there is more than "medically stable" at discharge, he/she may not be one primary diagnosis) and treatments options, and nearly well enough to participate fully in ask whether there is clinical evidence to support the psychotherapy at the residential center. The patient's recommended treatment and what that evidence is. medical condition, though not life-threatening at this point, affects mental health and ability to participate in treatment. Restoring physical health may take days or weeks. Therefore, before the patient is admitted to a residential eating disorder center or placed in outpatient treatment, contact the patient's health plan or employer (if applicable and the health plan is self- funded by the employer) and ask for the early claims for psychotherapy to be paid under the medical benefits instead of the behavioral health benefits. The language to use is: "Will you intercept psychotherapy claims and pay them under medical benefits until the patient is stable enough to participate fully and assist in her treatment?"
NEDA TOOLKIT for Parents
This information can be useful when talking to the Enlist support from family members and
insurance company about benefits, because insurance companies value evidence-based care. Also, ask how friends you can count on.
the treatment plan will be coordinated and managed, and who will coordinate the plan. In the case of Make a list of people you can count on for moral bulimia nervosa, the patient often has close to normal support throughout the course of treatment. Keep body weight. However, serious, but less obvious their names, phone numbers, and email addresses medical conditions may also be present (e.g., handy. For this list, identify people who can help the osteoporosis, heart problems, kidney problems, brain patient remain focused and provide helpful emotional abnormalities, diarrhea, reflux, nausea, malnutrition, support and encouragement while navigating the heartburn). Tests that are used to diagnose medical system to obtain care and while receiving care. Find symptoms and criteria for levels of care are listed in out from each of them their availability (i.e., times, First steps to getting help in this toolkit. Ask for "letters dates) for support and the kind of support they can of support" from the healthcare team. See Sample offer. Also consider distributing that list among key letter #6 in Sample letters to use with insurers in this people on the list so they know who is in your support toolkit. Using language that is used by insurance network. Also, list key healthcare provider (facilities companies is helpful to have common ground. For and healthcare providers) contact numbers on that list example, it's important to point out care that is in the event of an emergency. considered by the doctors to be "medically necessary" for the patient's recovery. Documentation like this is useful to provide to the insurer when discussing reimbursement, because it gives both you and the insurer a framework for discussion. With regard to the healthcare providers, ask them how to and who can obtain copies of the patient's medical records, who will provide progress reports, how often they will provide them, and to whom. Ask the healthcare provider (whether a facility or individual therapist) for an itemization of the estimated costs of care, which costs will likely be paid by the insurer, and which costs will be paid by the patient. Also ask how billing for reimbursement will be handled—ask whether you have to submit claims or whether the healthcare service provider submits the claims on the patient's behalf.
NEDA TOOLKIT for Parents
COBRA rights checklist
This is a list of requirements that employers must follow to inform their group health plan beneficiaries
(employees, spouses, dependents) of their rights under the Consolidated Omnibus
Budget Reconciliation Act (COBRA).
Payment of COBRA premiums
Model general and election notices available at Premiums are due the first of the coverage month. An administrative charge may be added to the General Rights Notice (must be sent within 90 monthly premium. There is a 30-day grace period days of enrollment into a group health plan - to make payments. This begins on the second day health, dental, vision, flexible spending account) of the coverage month. For example, September's Specific Rights Notice (Election notice - the plan grace period expires on October 1, not September administrator must provide the notice within 14 days after receiving notice of a qualifying event) Conversion Rights Notice (must be sent 180 days Reasons for terminating COBRA coverage
prior to the end of the maximum continuation The maximum continuation period has been Notice of Unavailability (must be sent when the plan administrator denies coverage after receiving The Qualified Beneficiary fails to make a timely notice and explain why continuation coverage is COBRA premium payment. The Qualified Beneficiary is covered under Notice of Termination of COBRA Rights (must be another group health plan AFTER the election of sent when COBRA coverage terminates before the end of the maximum COBRA period) The Qualified Beneficiary is no longer disabled after the start of the 11-month extension has Enrollment into group health plan
The Employer ceases to provide any group health Send General COBRA notice addressed to covered coverage to any covered employee. employee and spouse, if applicable, to home The Qualified Beneficiary has become entitled to address within 90 days of enrollment into group Medicare, part A or B (For purposes of Medicare, ELIGIBLE means the person has attained the age Send General COBRA notice to covered spouse if of 65. ENTITLEMENT means the person has added during open enrollment or qualified event actually become enrolled under Medicare). Types of qualifying events for COBRA
During open enrollment, the same information Employee Termination and enrollment options must be communicated to Employee Reduction in Hours COBRA Qualified Beneficiaries as to active Employee Death employees. This includes allowing Qualified Entitlement to Medicare Beneficiaries the ability to enroll under a new Employee Divorce or Legal Separation Loss of Dependent Child Status Length of coverage available 18 months (Employee Events) 36 months (Dependent Events) 29 months (Disability Extension periods)
NEDA TOOLKIT for Parents
Sample letters to use with insurance companies
This section provides seven sample letters to use for various circumstances you may encounter that require you to
communicate with insurance companies. These letters were developed and used by families who encountered
Keep in mind that a cordial, business communication tone is essential as discussed in Navigating and
understanding health insurance issues. Remember: Follow up letters with phone calls and document whom you speak to. Don't assume one insurance department knows what the other is doing. Don't panic! Your current issue or rejection can be a computer generated "glitch." Copy letters to others relevant to the request. Also, if you are complimenting someone for the assistance they've provided, tell them you'd love to send a copy to their boss to let him/ her know about the great service you've received. Supply supporting documents. Get a signed delivery receipt – especially when time is of the essence. Sample letters begin on the following page.
NEDA TOOLKIT for Parents
Sample Letter #1
Request that the copay for the psychiatrist from the patient be changed to a medical copay rate instead of the higher mental health copay, because the psychiatrist was providing medication management, not psychotherapy. Adjustments can be made so that the family is billed for the medical copay. Remember, the psychiatrist must use the proper billing code. To: Name of Clinical Appeals Staff Person INS. CO. NAME & ADDRESS From: YOUR NAME & ADDRESS Re: PATIENT'S NAME DOB (Date of Birth) Insurance ID# Dear [obtain and insert the name of a person to address your letter to—avoid sending to a generic title or "To Whom It May Concern"]; Thank you for assisting me with my [son's/daughter's] medical care. As you can imagine, this process is very emotionally draining on the entire family. However, the cooperation of the fine staff at [INSURANCE COMPANY NAME] makes it a little easier. At this time, I would like to request that [INS. CO.] review the category that [Dr. NAME's] services have been placed into. It appears that I am being charged a copay for [his/her] treatment as a mental health service when in reality [he/she] provides [PATIENT NAME] with pharmacologic management for [his/her] neuro-bio-chemical disorder. Obviously, this is purely a medical consultation. Please review this issue and kindly make adjustments to past and future consultations. Thank you in advance for your cooperation and assistance. [YOUR NAME] Cc: [list the people in the company you are sending copies to]
NEDA TOOLKIT for Parents
Sample Letter #2
The need to flex hospital days for counseling sessions. Remember, just because you are using outpatient services does not mean that you cannot take advantage of benefits for a more acute level of care if your child is eligible for that level of care. The insurance company only knows the information you supply, so be specific and provide support from the treatment team! 10 Hospital days were converted to 40 counseling sessions. Date: To: Name of an individual in the Ins. Co. Management Dept INS. CO. NAME & ADDRESS From: YOUR NAME & ADDRESS Re: PATIENT'S NAME DOB (Date of Birth) Insurance ID# Case # Dear [insert name]: This letter is in response to [insurance company name's] denial of continued counseling sessions for my [daughter/son]. I would like this decision to be reconsidered because [insert PATIENT NAME] continues to meet the American Psychiatric Association's clinical practice guidelines criteria for Residential treatment/Partial hospitalization. [His/Her] primary care provider, [NAME], supports [his/her] need for this level of care (see attached – Sample Letter #3 below provides an example of a physician letter). Therefore, although [he/she] chooses to receive services from an outpatient team, [he/she] requires an intensive level of support from that team, including ongoing counseling, to minimally meet [his/her] needs. I request that you correct the records re: [PATIENT NAME's] level of care to reflect [his/her] needs and support these needs with continued counseling services, since partial hospitalization/residential treatment is a benefit [he/she] is eligible for and requires. I am enclosing a copy of the APA guidelines and have noted [PATIENT NAME'S] current status. If you have further questions you may contact me at: [PHONE#] or [Dr. NAME] at: [PHONE#]. Thank you in advance for your cooperation and prompt attention to this matter. [YOUR NAME] Cc: [Case manager] [Ins. Co. Medical manager]
NEDA TOOLKIT for Parents
Sample Letter #3
Letter to a managed care plan to seek reimbursement for services that the patient received when time was
insufficient to obtain pre-authorization because of the serious nature of the illness and the need to deal with it
urgently. Remember: you need to research the professionals available through your plan and local support systems. In this case, after contacting their local association for eating disorders experts, the family that created this letter realized that no qualified medical experts were in their area to diagnose and make recommendations for their child. Keep in mind that you need to seek a qualified expert and not a world-famous expert. Make sure you provide very specific information from your research.
Reimbursement was provided for the evaluating/treating psychiatrist visits and medications. Further research and
documentation was required to seek reimbursement for the treatment facility portion. DATE To: Get the name of a person to direct a letter to INS. CO. NAME & ADDRESS From: YOUR NAME & ADDRESS Re: PATIENT'S NAME DOB (Date of Birth) Insurance ID# Case # Dear [insert name]: My [son/daughter] has been under treatment for [name the eating disorder and any applicable co-existing condition] since [month/year]. [He/she] was first seen at the college health clinic at [UNIVERSITY NAME] and then referred for counseling that was arranged through [INS. CO.]. At the end of the semester I met with my [son/daughter] and [his/her] therapist to make plans for treatment over the summer. At that time, residential treatment was advised, which became a serious concern for us. We then sought the opinion of a qualified expert about this advice. I first spoke to [PATIENT NAME'S] primary physician and then contacted the local eating disorders support group. No qualified expert emerged quickly from the community of our [INS. CO.] network providers. In my research to identify someone experienced in eating disorder evaluation and treatment, I discovered that [insert Dr.NAME at HOSPITAL in LOCATION] was the appropriate person to contact to expedite plans for our child. Dr. [NAME] was willing to see [him/her] immediately, so we made those arrangements. As you can imagine, this was all very stressful for the entire family. Since continuity of care was imperative, we went ahead with the process and lost sight of the preapproval needed from [INS. CO.]. I am enclosing the bills we paid for those initial visits for reimbursement. [PATIENT NAME] was consequently placed in a residential setting in the [LOCATION] area and continues to see Dr. [NAME] through arrangements made by [INS. CO.]. Also, at the beginning of [his/her] placement, some confusion existed about medications necessary for [PATIENT NAME] during this difficult/ acute care period. At one point payment for one of [his/her] medications was denied even though the treatment team recommended it, and it was prescribed by [his/her] primary care physician, Dr. [NAME]. I spoke to a [INS. CO.] employee [insert name] at [PHONE #] to rectify the situation; however, I felt it was a little too late to meet my timeframe for visiting [PATIENT NAME], so I paid for the Rx myself and want reimbursement at this time. If you have any questions, please speak to [employee name]. Thank you in advance for your cooperation. I'd be happy to answer any further questions and can be reached at: [PHONE] Sincerely, [YOUR NAME]
NEDA TOOLKIT for Parents
Sample Letters #4
To continue insurance while attending college less than full-time so that student can remain at home for a
semester due the eating disorder. Note: When a student does not register on time at the primary university at
which he/she has been enrolled, insurance is automatically terminated at that time. Automatic termination can cause an enormous amount of paperwork if not rectified IMMMEDIATELY. The first letter informs the insurance company of the student's current enrollment status in a timely fashion, and the second letter responds to the abrupt and retroactive termination. Students affected by an eating disorder may be eligible for a medical leave of absence from college for up to one year—so you may want to inquire about that at the student's college.
The student was immediately reinstated as a less than full-time student.
DATE To: NAME OF CONTACT PERSON INS. CO. NAME & ADDRESS From: YOUR NAME & ADDRESS Re: PATIENT'S NAME DOB (Date of Birth) Insurance ID# Case # Dear [NAME]: We spoke the other day regarding my [son's/daughter's] enrollment status. I am currently following up on your instructions and appreciate your assistance in explaining what to do. [Dr. NAME] is sending you a letter that should arrive very soon about [PATIENT NAME's] medical status that required [him/her] to reduce the number of classes [he/she] will be able to take this fall. When [he/she] completes re-enrollment at [UNIVERSITY NAME] (which is not possible to do until the first day of classes, [DATE]), [he/she] will have the registrar's office notify you of her status. At this time, [NAME] plans to be a part-time student at [UNIVERSITY] for the [DATE] semester and plans to return to [UNIVERSITY] in [DATE], provided [his/her] disorder stabilizes. If all goes well; [he/she] may be able to graduate with [his/her] class and complete [his/ her] coursework by the [DATE] in spite of the medical issues. Please feel free to get answers to any questions regarding these plans from [PATIENT NAME'S academic advisor Mr./Ms. NAME], whom [PATIENT NAME] has given written permission in a signed release to speak to you. This advisor has been assisting my [son/daughter] with [his/her] academic plans and is aware of [his/her] current medical status. The advisor's phone number and email are: [PHONE #/ email]. Please feel free to contact me at [PHONE #] if you have any questions or need any further information. Thank you for your assistance. Sincerely, [YOUR NAME]
NEDA TOOLKIT for Parents
Sample Letter #5
Follow-up letter to enrollment department after coverage was terminated retroactively to June 1st by the
insurance company's computer.
(HEADING SAME AS PREVIOUS LETTER) Dear [NAME]: I am sure you can imagine my shock at receiving the attached letter [copy of the letter you received] that my [son/daughter] received about termination of coverage. [NAME] has been receiving coverage from [INSURANCE COMPANY] for treatment of serious medical issues since [DATE]. We have received wonderful assistance from [NAME], Case Manager [PHONE#]; [NAME], Mental Health Clinical Director [PHONE#]; and Dr. [NAME], [INS. CO.] Medical Director [PHONE #]. I am writing to describe the timeline of events with copies to the people who have assisted us as noted above. In [DATE], [ PATIENT NAME] requested a temporary leave of absence from [UNIVERSITY 1 NAME] to study at [UNIVERSITY 2 NAME] for one year. [He/she] was accepted at [UNIVERSITY 2 NAME] and attended the [DATE] semester. At the end of the spring semester [PATIENT NAME'S] medical issues intensified and [PATIENT NAME] returned home for the summer. The summer of [YEAR] has been very complicated and a drain on our entire family. The supportive people noted earlier in this letter made our plight bearable but we were constantly dealing with one medical issue after another. At the beginning of August [PATIENT NAME] and the treatment team members began to discuss [PATIENT NAME's] needs for the fall semester of [YEAR]. As far as our family was concerned, all options [UNIV. 1, UNIV. 2, & several local options full and part-time] needed to be up for discussion to meet [patient name's] medical needs. We hoped that with the help of [his/her] medical team we could make appropriate plans in a timely fashion. During [PATIENT NAME's] appointments the first two weeks of August, the treatment team agreed that [PATIENT NAME] should continue to live at home and attend a local university on a part-time basis for the fall semester. This decision was VERY difficult for [PATIENT NAME] and our family. [PATIENT NAME ]still hopes/plans to return to [UNIV. 1] in [date] as a full-time student. [He/ she] has worked with [his/her] [UNIV. 1] advisor since [date] to work out a plan that might still allow [him/her] to graduate with [his/her] class even if [he/she] needed to complete a class or two in the summer of [YEAR]. This decision by [NAME] was difficult but also a major breakthrough/necessity for [his/her] treatment. After a workable plan was made, I called the enrollment department at [INS. CO. NAME] to gain information about the process of notification regarding this change in academic status due to [his/her] current medical needs. [INS. EMPLOYEE NAME] communicated to me that I needed to have my child's primary care physician write a letter supporting these plans. This letter is forthcoming as we speak. As soon as [PATIENT NAME's] fall classes are finalized on [date]' that information will also be sent to you. In summary, [PATIENT NAME] intended to be a full-time student this fall until [his/her] treatment team suggested otherwise in the early August. At that time I began notifying the insurance company. Please assist us in expediting this process. I ask that you immediately reinstate [him/her] as a policy member. If [his/her] status is not resolved immediately it will generate a GREAT DEAL of unnecessary extra work for all parties involved and, quite frankly, I'm not sure that our family can tolerate the useless labor when our energy is so depleted and needed for the medical/life issues at hand. I am attaching 1) my previous enrollment notification note; 2) [PATIENT NAME's] acceptance from [UNIV. 2]; 3) a copy of [PATIENT NAME'S] apartment lease for the year; and 4) [his/her] recent letter to [UNIV. 2] notifying them that [he/she] will be unable to complete the year as a visiting student for medical reasons. Please call me TODAY at [PHONE #] to update me on this issue. This is very draining on our family. Thank you for your assistance. Sincerely, [YOUR NAME] Cc: [CASE MANAGER, MENTAL HEALTH CLINICAL DIRECTOR, MEDICAL DIRECTOR]
NEDA TOOLKIT for Parents
SAMPLE LETTER #6
Letter from doctor describing any medical complications your child has had, the doctor's recommendations for
treatment, and the doctor's prediction of outcome if this treatment is not received. This is a sample physician letter that parents can bring to their child's doctor as a template to work from. To: [Get the name of a medical director at the insurance company]: INS. CO. NAME & ADDRESS Re: PATIENT'S NAME DOB (Date of Birth) Insurance ID# We are writing this letter to summarize our treatment recommendations for [patient name]. We have been following [patient name] in our program since [DATE]. During these past [NUMBER years], [patient name] has had [NUMBER] hospitalizations for medical complications of [insert conditions, e.g., malnutrition, profound bradycardia, hypothermia, orthostasis]. Each of the patient's hospital admissions are listed below [list each and every one separately]: Admission Date – Discharge Date [condition] In all, [patient] has spent [NUMBER] days of the past [NUMBER years] in the hospital due to complications of [his/her] malnutrition.[Patient name's] malnutrition is damaging more than [his/her] heart. [His/Her] course has been complicated by the following medical issues: List each issue and its medical consequence [e.g., secondary amenorrhea since DATE, which has the potential to cause irreversible bone damage leading to osteoporosis in his/her early adult life.] Despite receiving intensive outpatient medical, nutritional and psychiatric treatment, [patient name's] medical condition has continued to deteriorate with [describe symptoms/signs, e.g., consistent weight loss since DATE] and is currently 83% of [his/her] estimated minimal ideal body weight (the weight where the nutritionist estimates[ he/she] will regain regular menses). White blood cell count and serum protein and albumin levels have been steadily decreasing as well, because of extraordinarily poor nutritional intake. Given this history, prior levels of outpatient care that have failed, and [his/her] current grave medical condition, we recommend that [patient name] urgently receive more intensive psychiatric and nutritional treatment that can be delivered only in a residential treatment program specializing in eating disorders. We recommend a minimum 60- to 90-day stay in a tiered program that offers: intensive residential and transitional components focusing on adolescents and young adults with eating disorders (not older patients). [Patient] requires intensive daily psychiatric, psychologic, and nutritional treatment by therapists well trained in the treatment of this disease. Such a tiered program could provide the intensive residential treatment that [he/she] so desperately needs so [he/she] can show that [he/she] can maintain any progress in a transitional setting. We do not recommend treatment in a non-eating disorder-specific behavioral treatment center. [Patient]'s severe anorexia requires subspecialty-level care. Examples of such programs would include [name facilities]. Anorexia nervosa is a deadly disease with a 10% to 15% mortality rate; 15% to 25% of patients develop a severe lifelong course. We believe that without intensive treatment in a residential program, [patient name's and condition], and the medical complications that it causes, will continue to worsen causing [him/her] to be at significant risk of developing lifelong anorexia nervosa or dying of the disease. We understand that in the past, your case reviewers have denied [patient] this level of care. This is the only appropriate and medically responsible care plan that we can recommend. We truly believe that to offer a lesser level of care is medically negligent. We trust that you will share our grave concern for [patient's] medical needs and approve the recommended level of care to assist in [his/her] recovery. Thank you for your thorough consideration of this matter. Please feel free to contact us with any concerns regarding [patient's] care. Sincerely, [PHYSICIAN NAME]
NEDA TOOLKIT for Parents
SAMPLE LETTER #7
"Discussion" with the insurance company about residential placement when the insurance company suggests that
the patient needs to fail at lower levels of care before being eligible for residential treatment. In a telephone
conversation, the parents asked the insurance company to place a note in the patient file indicating the insurance company was willing to disregard the American Psychiatric Association guidelines and recommendations of the patient's treatment team and take responsibility for the patient's life. (SEND BY CERTIFIED MAIL!)
Shortly thereafter, the parents received a letter authorizing the residential placement.
To: CEO (by name) INS. CO. NAME & ADDRESS (use the headquarters) From: YOUR NAME & ADDRESS Re: PATIENT'S NAME DOB (Date of Birth) Insurance ID# Case # Dear (Pres. of INS. CO.): Residential placement services for eating disorder treatment have been denied for our [son/daughter] against the recommendations of a qualified team of experts consistent with the American Psychiatric Association's evidence- based clinical practice guidelines. Full documentation of our child's grave medical condition and history and our attempts to obtain coverage for that care is available from our case manager [name]. At this time, I would like you to put in writing to me and to my child's case file that [INS. CO.] is taking complete responsibility for my [son's/daughter's] life. [YOUR NAME] Cc: [CASE MANAGER NATIONAL MEDICAL DIRECTOR (get the names for both the medical and behavioral health divisions) NATIONAL MEDICAL DIRECTOR—Behavioral Health]
NEDA TOOLKIT for Parents
How to manage an appeals process
Continue treatment during the appeals
Ask the insurer what evidence-based
outcome measures it uses to assess patient
health and eligibility for benefits.
Appeals can take weeks or months to complete, and health professionals and facilities that treat eating Some insurance companies may use body mass index disorders advise that it's very important for the (BMI) as a criterion for inpatient admission or patient's well-being to stay in treatment if at all discharge from treatment for bulimia nervosa, for possible to maintain progress in recovery. example, which may not be a valid outcome measure. This is because patients with bulimia nervosa can have Clarify with the insurer the reasons for the
close-to-ideal BMIs, when in fact, they may be very denial of coverage.
sick. Thus, BMI does not correlate well with good health in a patient with bulimia nervosa. For example, Most insurers send the denial in writing. Claims if a patient with bulimia nervosa was previously advocates at treatment centers advise patients and overweight or obese and lost significant weight in a families to make sure they understand the reasons for short timeframe, the patient's weight might approach the denial and ask the insurance company for the the norm for BMI. Yet, a sudden and large weight loss reason in writing if a written response has not been in such a person could adversely affect his or her blood chemistry and indicate a need for intensive treatment or even hospitalization. Send copies of the letter of denial to all
concerned parties with documentation of the
Ask that medical benefits, rather than mental
health benefits, be used to cover
hospitalization costs for bulimia nervosa-
Claims advocates at treatment centers state that related medical problems.
sending documentation of an appeals request to the medical director, the human resources director of the Claims advocates advise that sometimes claims for company where the patient works (or has insurance physical problems such as those arising from excessive under), if applicable can help bring attention to the fasting or purging, for example, are filed under the situation. Presenting a professional-looking and wrong arm of the insurance benefit plan—they are organized appeal with appropriate documentation, filed under mental health instead of medical benefits. including an evidence-based care plan makes the They say it's worth checking with the insurance strongest case possible. Initial denials are often company to ensure this hasn't happened. That way, overturned at higher appeal levels, because higher- mental health benefits can be reserved for the level appeals are often reviewed by a doctor who may patient's nonmedical treatment needs like have a better understanding than the initial claims psychotherapy. Various diagnostic laboratory tests can reviewer of the clinical information provided, identify the medical conditions that need to be treated especially well-organized, evidence-based in a patient with eating disorders. Also, if a patient has a diagnosis of two mental disorders (also called a dual diagnosis), and if that diagnosis is considered by the insurance company to be more "severe" than an eating disorder, the patient may be eligible for more days of treatment.
NEDA TOOLKIT for Parents
Ask the insurer whether they will "flex the
Negotiate with the treatment center about
the cost of treatment.
Flexing benefits means that the insurer applies one Our survey of treatment centers indicates that some type of benefit for a different use. For example, treatment centers have a sliding fee scale and may medical benefits might be "flexed" to cover some adjust the treatment charges or set up a payment aspect of mental health treatment— usually plan for the patient's out-of pocket costs. inpatient treatment. Also, inpatient benefits might be flexed (traded) to substitute intensive outpatient Discuss with the insurer how existing laws
care for inpatient care—for example, 30 inpatient and clinical practice standards affect your
days for 60 intensive outpatient benefit days. Substance abuse (also called chemical dependency) situation.
benefits might be traded for additional benefits to treat the eating disorder if the beneficiary thinks Educate yourself about how the state's mental he/she will never need the substance abuse benefits health parity laws and mandates apply to the available under his/ her coverage. There is a clinical patient's insurance coverage. Also ask the insurer if it rationale for doing this: if the eating disorder is not is aware of evidence reports on treatment for eating treated appropriately from the outset, the insurer disorders and guidelines like the American risks incurring additional and higher costs for patient Psychiatric Association's clinical guidelines for care in the future because further hospitalization treating eating disorders: www.psych.org. Ask what and treatment may be needed. By flexing inpatient role the evidence plays in the decision about medical benefits or trading inpatient days for benefits. As a last resort, some patients or their outpatient days to obtain more days of mental advocates may also contact the state insurance health treatment, future and possibly higher commissioner, state consumer's rights commission, healthcare expenses might be avoided. While an attorney, the media, or legislators to bring insurers are not obligated to do flex benefits, they attention to the issue of access to care for patients may respond to a sound, logical argument to do so if with eating disorders. it makes good sense from both a business and patient care perspective in the longer term. If you can support this argument with your doctors' recommended treatment plan and clinical evidence from practice guidelines and an evidence report, the insurer may agree. If the patient is employed or in a union, consider asking the employer (or its human resources manager) or union representative to negotiate with the insurer about aspects of the coverage policy that seem open to interpretation. As a client of the insurance company, the employer is likely paying a lot of money to provide benefits to employees (even when employees pay part of the insurance premiums). Because insurance companies want to maintain good business relationships with their clients, the employer may have more influence than the patient alone when negotiating for reimbursement. Many patients or families of patients are afraid or embarrassed to discuss bulimia or anorexia with an employer. Remember that legally, a person cannot be fired and insurance cannot be dropped solely because of having an eating disorder (or any other health condition).
NEDA TOOLKIT for Parents
NEDA TOOLKIT for Parents
This eating disorders glossary defines terms you may encounter when seeking information and talking with care
providers about diagnosis and treatment of all types of eating disorders. It also contains some slang terms that may be used by individuals with an eating disorder.
Alternative Therapy In the context of treatment for
Art Therapy A form of expressive therapy that uses
eating disorders, a treatment that does not use drugs visual art to encourage the patient's growth of self- or bring unconscious mental material into full awareness and self-esteem to make attitudinal and consciousness. For example yoga, guided imagery, behavioral changes. expressive therapy, and massage therapy are considered alternative therapies. Atypical Antipsychotics A new group of medications
used to treat psychiatric conditions. These drugs may Amenorrhea The absence of at least three
have fewer side effects than older classes of drugs consecutive menstrual cycles. used to treat the same psychiatric conditions. Ana Slang for anorexia or anorexic.
B&P An abbreviation used for binge eating and
purging in the context of bulimic behavior. ANAD (National Association of Anorexia Nervosa and
Associated Disorders) A nonprofit corporation that
Behavior Therapy (BT) A type of psychotherapy that
seeks to alleviate the problems of eating disorders, uses principles of learning to increase the frequency especially anorexia nervosa and bulimia nervosa. of desired behaviors and/or decrease the frequency of problem behaviors. When used to treat an eating Anorexia Nervosa A disorder in which an individual
disorder, the focus is on modifying the behavioral refuses to maintain minimally normal body weight, abnormalities of the disorder by teaching relaxation intensely fears gaining weight, and exhibits a techniques and coping strategies that affected significant disturbance in his/her perception of the individuals can use instead of not eating, or binge shape or size of his/her body. eating and purging. Subtypes of BT include dialectical behavior therapy (DBT), exposure and Anorexia Athletica The use of excessive exercise to
response prevention (ERP), and hypnobehavioral Anticonvulsants Drugs used to prevent or treat
Binge Eating Disorder (also Bingeing) Consuming an
amount of food that is considered much larger than the amount that most individuals would eat under Antiemetics Drugs used to prevent or treat nausea
similar circumstances within a discrete period of time. Also referred to as "binge eating." Anxiety A persistent feeling of dread, apprehension,
Beneficiary The recipient of benefits from an
and impending disaster. There are several types of insurance policy anxiety disorders, including: panic disorder, agoraphobia, obsessive-compulsive disorder, social Biofeedback A technique that measures bodily
and specific phobias, and posttraumatic stress functions, like breathing, heart rate, blood pressure, disorder. Anxiety is a type of mood disorder. (See skin temperature, and muscle tension. Biofeedback is Mood Disorders.) used to teach people how to alter bodily functions through relaxation or imagery. Typically, a Arrhythmia An alteration in the normal rhythm of the
practitioner describes stressful situations and guides a person through using relaxation techniques. The person can see how their heart rate and blood pressure change in response to being stressed or relaxed. This is a type of non-drug, non-
NEDA TOOLKIT for Parents
Body Dysmorphic Disorder or Dysmorphophobia A
COBRA A federal act in 1985 that included provisions
mental condition defined in the DSM-IV in which the to protect health insurance benefits coverage for patient is preoccupied with a real or workers and their families who lose their jobs. The perceived defect in his/her appearance. (See DSM- landmark Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) health benefit provisions became law in 1986. The law amends the Body Image The subjective opinion about one's
Employee Retirement Income Security Act (ERISA), physical appearance based on self-perception of the Internal Revenue Code, and the Public Health body size and shape and the reactions of others. Service Act to provide continuation of employer- sponsored group health coverage that otherwise Body Mass Index (BMI) A formula used to calculate
might be terminated. The U.S. Centers for Medicare & the ratio of a person's weight to height. BMI is Medicaid Services has advisory jurisdiction for the expressed as a number that is used to determine COBRA law as it applies to state and local whether an individual's weight is within normal government (public sector) employers and their ranges for age and sex on a standardized BMI chart. group health plans. The U.S. Centers for Disease Control and Prevention Web site offers BMI calculators and standardized Cognitive Therapy (CT) A type of psychotherapeutic
treatment that attempts to change a patient's feelings and behaviors by changing the way the Bulimia Nervosa A disorder defined in the DSM-IV-R
patient thinks about or perceives his/her significant in which a patient binges on food an average of life experiences. Subtypes include cognitive analytic twice weekly in a three-month time period, followed therapy and cognitive orientation therapy. by compensatory behavior aimed at preventing weight gain. This behavior may include excessive Cognitive Analytic Therapy (CAT) A type of cognitive
exercise, vomiting, or the misuse of laxatives, therapy that focuses its attention on discovering how diuretics, other medications, and enemas. a patient's problems have evolved and how the procedures the patient has devised to cope with Bulimarexia A term used to describe individuals who
them may be ineffective or even harmful. CAT is engage alternately in bulimic behavior and anorexic designed to enable people to gain an understanding of how the difficulties they experience may be made worse by their habitual coping mechanisms. Case Management An approach to patient care in
Problems are understood in the light of a person's which a case manager mobilizes people to organize personal history and life experiences. The focus is on appropriate services and supports for a patient's recognizing how these coping procedures originated treatment. A case manager coordinates mental and how they can be adapted. health, social work, educational, health, vocational, transportation, advocacy, respite care, and Cognitive Behavior Therapy (CBT) A treatment that
recreational services, as needed. The case manager involves three overlapping phases when used to ensures that the changing needs of the patient and treat an eating disorder. For example, with bulimia, family members supporting that patient and family the first phase focuses on helping people to resist members supporting that patient are met. the urge to binge eat and purge by educating them about the dangers of their behavior. The second phase introduces procedures to reduce dietary restraint and increase the regularity of eating. The last phase involves teaching people relapse- prevention strategies to help them prepare for possible setbacks. A course of individual CBT for bulimia nervosa usually involves 16- to 20-hour-long sessions over a period of 4 to 5 months. It is offered on an individual, group, or self-managed basis. The goals of CBT are designed to interrupt the proposed bulimic cycle that is perpetuated by low self-esteem, extreme concerns about shape and weight, and extreme means of weight control.
NEDA TOOLKIT for Parents
Cognitive Orientation Therapy (COT) A type of
Disordered Eating Term used to describe any
cognitive therapy that uses a systematic procedure atypical eating behavior. to understand the meaning of a patient's behavior by exploring certain themes such as aggression and Drunkorexia Behaviors that include any or all of the
avoidance. The procedure for modifying behavior following: replacing food consumption with then focuses on systematically changing the excessive alcohol consumption; consuming food patient's beliefs related to the themes and not along with sufficient amounts of alcohol to induce directly to eating behavior vomiting as a method of purging and numbing Comorbid Conditions Multiple physical and/or
mental conditions existing in a person at the same DSM-IV The fourth (and most current as of 2006)
time. (See Dual Diagnosis.) edition of the Diagnostic and Statistical Manual for Mental Disorders IV published by the American Crisis Residential Treatment Services Short-term,
Psychiatric Association (APA). This manual lists round-the-clock help provided in a nonhospital mental diseases, conditions, and disorders, and also setting during a crisis. The purposes of this care are lists the criteria established by APA to diagnose to avoid inpatient hospitalization, help stabilize the them. Several different eating disorders are listed in individual in crisis, and determine the next the manual, including bulimia nervosa. appropriate step. DSM-IV Diagnostic Criteria A list of symptoms in the
Cure The treated condition or disorder is
Diagnostic and Statistical Manual for Mental permanently gone, never to return in the individual Disorders IV published by APA. The criteria describe who received treatment. Not to be confused with the features of the mental diseases and disorders "remission." (See Remission.) listed in the manual. For a particular mental disorder to be diagnosed in an individual, the individual must Dental Caries Tooth cavities. The teeth of people
exhibit the symptoms listed in the criteria for that with bulimia who using vomiting as a purging disorder. Many health plans require that a DSM-IV method may be especially vulnerable to developing diagnosis be made by a qualified clinician before cavities because of the exposure of teeth to the high approving benefits for a patient seeking treatment acid content of vomit. for a mental disorder such as anorexia or bulimia. Depression (also called Major Depressive Disorder) A
DSM-IV-R Diagnostic Criteria Criteria in the revised
condition that is characterized by one or more major edition of the DSM-IV used to diagnose mental depressive episodes consisting of two or more weeks during which a person experiences a depressed mood or loss of interest or pleasure in nearly all Dual Diagnosis Two mental health disorders in a
activities. It is one of the mood disorders listed in the patient at the same time, as diagnosed by a clinician. DSM-IV-R. (See Mood Disorders.) For example, a patient may be given a diagnosis of both bulimia nervosa and obsessive-compulsive Diabetic Omission of Insulin A nonpurging method of
disorder or anorexia and major depressive disorder. compensating for excess calorie intake that may be used by a person with diabetes and bulimia. Eating Disorders Anonymous (EDA) A fellowship of
individuals who share their experiences with each Dialectical Behavior Therapy (DBT) A type of
other to try to solve common problems and help behavioral therapy that views emotional each other recover from their eating disorders. deregulation as the core problem in bulimia nervosa. It involves teaching people with bulimia nervosa Eating Disorders Not Otherwise Specified (ED-NOS)
new skills to regulate negative emotions and replace Any disorder of eating that does not meet the criteria dysfunctional behavior. A typical course of treatment for anorexia nervosa or bulimic nervosa. is 20 group sessions lasting 2 hours once a week. (See Behavioral Therapy.) Eating Disorder Inventory (EDI) A self-report test that
clinicians use with patients to diagnose specific eating disorders and determine the severity of a patient's condition.
NEDA TOOLKIT for Parents
Eating Disorder Inventory-2 (EDI-2) Second edition of
Expressive Therapy A nondrug, nonpsychotherapy
form of treatment that uses the performing and/or visual arts to help people express their thoughts and Ed Slang Eating disorder.
emotions. Whether through dance, movement, art, drama, drawing, painting, etc., expressive therapy ED Acronym for eating disorder.
provides an opportunity for communication that might otherwise remain repressed. Electrolyte Imbalance A physical condition that
occurs when ionized salt concentrations (commonly Eye Movement Desensitization and Reprocessing
sodium and potassium) are at abnormal levels in the (EMDR) A nondrug and nonpsychotherapy form of
body. This condition can occur as a side effect of treatment in which a therapist waves his/her fingers some bulimic compensatory behaviors, such as back and forth in front of the patient's eyes, and the patient tracks the movements while also focusing on a traumatic event. It is thought that the act of Emetic A class of drugs that induces vomiting.
tracking while concentrating allows a different level Emetics may be used as part of a bulimic of processing to occur in the brain so that the patient compensatory behavior to induce vomiting after a can review the event more calmly or more binge eating episode. completely than before. Enema The injection of fluid into the rectum for the
Family Therapy A form of psychotherapy that
purpose of cleansing the bowel. Enemas may be involves members of a nuclear or extended family. used as a bulimic compensatory behavior to purge Some forms of family therapy are based on after a binge eating episode. behavioral or psychodynamic principles; the most common form is based on family systems theory. Equine/Animal-assisted Therapy A treatment
This approach regards the family as the unit of program in which people interact with horses and treatment and emphasizes factors such as become aware of their own emotional states relationships and communication patterns. With through the reactions of the horse to their behavior. eating disorders, the focus is on the eating disorder and how the disorder affects family relationships. Exercise Therapy An individualized exercise plan
Family therapy tends to be short-term, usually that is written by a doctor or rehabilitation specialist, lasting only a few months, although it can last longer such as a clinical exercise physiologist, physical depending on the family circumstances. therapist, or nurse. The plan takes into account an individual's current medical condition and provides Guided Imagery A technique in which the patient is
advice for what type of exercise to perform, how directed by a person (either in person or by using a hard to exercise, how long, and how many times per tape recording) to relax and imagine certain images and scenes to promote relaxation, promote changes in attitude or behavior, and encourage physical Exposure and Response Prevention (ERP) A type of
healing. Guided imagery is sometimes called behavior therapy strategy that is based on the theory visualization. Sometimes music is used as that purging serves to decrease the anxiety background noise during the imagery session. (See associated with eating. Purging is therefore Alternative Therapy.) negatively reinforced via anxiety reduction. The goal of ERP is to modify the association between anxiety and purging by preventing purging following eating until the anxiety associated with eating subsides. (See Behavioral Therapy.)
NEDA TOOLKIT for Parents
Health Insurance Portability and Accountability Act
Hypoglycemia An abnormally low concentration of
(HIPAA) A federal law enacted in 1996 with a number
glucose in the blood. of provisions intended to ensure certain consumer health insurance protections for working Americans In-network benefits Health insurance benefits that a
and their families and standards for electronic beneficiary is entitled to receive from a designated health information and protect privacy of group (network) of healthcare providers. The individuals' health information. HIPAA applies to "network" is established by the health insurer that three types of health insurance coverage: group contracts with certain providers to provide care for health plans, individual health insurance, and beneficiaries within that network. comparable coverage through a high-risk pool. HIPAA may lower a person's chance of losing Indemnity Insurance A health insurance plan that
existing coverage, ease the ability to switch health reimburses the member or healthcare provider on a plans, and/or help a person buy coverage on his/her fee-for-service basis, usually at a rate lower than the own if a person loses employer coverage and has no actual charges for services rendered, and often after other coverage available. a deductible has been satisfied by the insured. Health Insurance Reform for Consumers Federal law
Independent Living Services Services for a person
has provided to consumers some valuable–though with a medical or mental health-related problem limited–protections when obtaining, changing, or who is living on his/ her own. Services include continuing health insurance. Understanding these therapeutic group homes, supervised apartment protections, as well as laws in the state in which one living, monitoring the person's compliance with resides, can help with making more informed prescribed mental and medical treatment plans, and choices when work situations change or when changing health coverage or accessing care. Three important federal laws that can affect coverage and Intake Screening An interview conducted by health
access to care for people with eating disorders are service providers when a patient is admitted to a listed below. More information is available at: hospital or treatment program. International Classification of Diseases (ICD-10) The
World Health Organization lists international Consolidated Omnibus Budget Reconciliation standards used to diagnose and classify diseases. Act of 1985 (COBRA) The listing is used by the healthcare system so Health Insurance Portability and Accountability clinicians can assign an ICD code to submit claims to Act of 1996 (HIPAA); insurers for reimbursement for services for treating Mental Health Parity Act of 1996 (MHPA). various medical and mental health conditions in patients. The code is periodically updated to reflect Health Maintenance Organization (HMO) A health
changes in classifications of disease or to add new plan that employs or contracts with primary care physicians to write referrals for all care that covered patients obtain from specialists in a network of Interpersonal Therapy (IPT) IPT (also called
healthcare providers with whom the HMO contracts. interpersonal psychotherapy) is designed to help The patient's choice of treatment providers is usually people identify and address their interpersonal problems, specifically those involving grief, interpersonal role conflicts, role transitions, and Hematemesis The vomiting of blood.
interpersonal deficits. In this therapy, no emphasis is placed directly on modifying eating habits. Instead, Hypno-behavioral Therapy A type of behavioral
the expectation is that the therapy will enable therapy that uses a combination of behavioral people to change as their interpersonal functioning techniques such as self-monitoring to change improves. IPT usually involves 16 to 20 hour-long, maladaptive eating disorders and hypnotic one-on-one treatment sessions over a period of 4 to techniques intended to reinforce and encourage behavior change.
NEDA TOOLKIT for Parents
Ketosis A condition characterized by an abnormally
Maudsley Method A family-centered treatment
elevated concentration of ketones in the body program with three distinct phases. The first phase tissues and fluids, which can be caused by starvation. for a patient who is severely underweight is to regain It is a complication of diabetes, starvation, and control of eating habits and break the cycle of starvation or binge eating and purging. The second phase begins once the patient's eating is under Level of Care The care setting and intensity of care
control with a goal of returning independent eating that a patient is receiving (e.g., inpatient hospital, to the patient. The goal of the third and final phase is outpatient hospital, outpatient residential, intensive is to address the broader concerns of the outpatient, residential). Health plans and insurance patient's development. companies correlate their payment structures to the level of care being provided and also map a patient's Mealtime Support Therapy Treatment program
eligibility for a particular level of care to the developed to help patients with eating disorders eat patient's medical/ psychological status. healthfully and with less emotional upset. Major Depression See Major Depressive Disorder.
Mental Health Parity Laws Federal and State laws
that require health insurers to provide the same Major Depressive Disorder A condition that is
level of healthcare benefits for mental disorders and characterized by one or more major depressive conditions as they do for medical disorders and episodes that consist of periods of two or more conditions. For example, the federal Mental Health weeks during which a patient has either a depressed Parity Act of 1996 (MHPA) may prevent a group mood of loss of interest or pleasure in nearly all health plan from placing annual or lifetime dollar activities. (See Depression) limits on mental health benefits that are lower, or less favorable, than annual or lifetime dollar limits Mallory-Weiss Tear One or more slit-like tears in the
for medical and surgical benefits offered under the mucosa at the lower end of the esophagus as a result of severe vomiting. Mia Slang. For bulimia or bulimic.
Mandometer Therapy Treatment program for eating
disorders based on the idea that psychiatric Modified Cyclic Antidepressants A class of
symptoms of people with eating disorders emerge as medications used to treat depression. a result of poor nutrition and are not a cause of the eating disorder. A Mandometer is a computer that Monoamine Oxidase Inhibitors A class of
measures food intake and is used to determine a medications used to treat depression. course of therapy. Mood Disorders Mental disorders characterized by
Mandates See State Mandates.
periods of depression, sometimes alternating with periods of elevated mood. People with mood Massage Therapy A generic term for any of a number
disorders suffer from severe or prolonged mood of various types of therapeutic touch in which the states that disrupt daily functioning. Among the practitioner massages, applies pressure to, or general mood disorders classified in the Diagnostic manipulates muscles, certain points on the body, or and Statistical Manual of Mental Disorders (DSM-IV) other soft tissues to improve health and well-being. are major depressive disorder, bipolar disorder, and Massage therapy is thought to relieve anxiety and dysthymia. (See Anxiety and Major Depressive depression in patients with an eating disorder. Movement/Dance Therapy The psychotherapeutic
use of movement as a process that furthers the emotional, cognitive, social, and physical integration of the individual, according to the American Dance Therapy Association.
NEDA TOOLKIT for Parents
Motivational Enhancement Therapy (MET) A
Osteoporosis A condition characterized by a
treatment is based on a model of change, with focus decrease in bone mass with decreased density and on the stages of change. Stages of change represent enlargement of bone spaces, thus producing porosity constellations of intentions and behaviors through and brittleness. This can sometimes be a which individuals pass as they move from having a complication of an eating disorder, including bulimia problem to doing something to resolve it. The stages nervosa and anorexia nervosa. of change move from "pre-contemplation," in which individuals show no intention of changing, to the Out-of-network benefits Healthcare obtained by a
"action" stage, in which they are actively engaged in beneficiary from providers (hospitals, clinicians, etc.) overcoming their problem. Transition from one stage that are outside the network that the insurance to the next is sequential, but not linear. The aim of company has assigned to that beneficiary. Benefits MET is to help individuals move from earlier stages obtained outside the designated network are usually into the action stage using cognitive and emotional reimbursed at a lower rate. In other words, beneficiaries share more of the cost of care when obtaining that care "out of network" unless the Nonpurging Any of a number of behaviors engaged
insurance company has given the beneficiary special in by a person with bulimia nervosa to offset written authorization to go out of network. potential weight gain from excessive calorie intake from binge eating. Nonpurging can take the form of Parity Equality (see Mental Health Parity Laws).
excessive exercise, misuse of insulin by people with diabetes, or long periods of fasting. Partial Hospitalization (Intensive Outpatient) For a
patient with an eating disorder, partial Nutritional Therapy Therapy that provides patients
hospitalization is a time-limited, structured program with information on the effects of their eating of psychotherapy and other therapeutic services disorder. For example, therapy often includes, as provided through an outpatient hospital or appropriate, techniques to avoid binge eating and community mental health center. The goal is to refeed, and advice about making meals and eating. resolve or stabilize an acute episode of The goals of nutrition therapy for individuals with mental/behavioral illness. anorexia and bulimia nervosa differ according to the disorder. With bulimia, for example, goals are to Peptic Esophagitis Inflammation of the esophagus
stabilize blood sugar levels, help individuals caused by reflux of stomach contents and acid. maintain a diet that provides them with enough nutrients, and help restore gastrointestinal health. Pharmacotherapy Treatment of a disease or
condition using clinician-prescribed drugs. Obsessive-compulsive Disorder (OCD) Mental
disorder in which recurrent thoughts, impulses, or Phenethylamine Monoamine Reuptake Inhibitors A
images cause inappropriate anxiety and distress, class of drugs used to treat depression. followed by acts that the sufferer feels compelled to perform to alleviate this anxiety. Criteria for mood Pre-existing Condition A health problem that existed
disorder diagnoses can be found in the DSMIV. or was treated before the effective date of one's health insurance policy. Opioid Antagonists A type of drug therapy that
interferes with the brain's opioid receptors and is Provider A healthcare facility (e.g., hospital,
sometimes used to treat eating disorders. residential treatment center), doctor, nurse, therapist, social worker, or other professional who Orthorexia Nervosa An eating disorder in which a
provides care to a patient. person obsesses about eating only "pure" and healthy food to such an extent that it interferes with Psychoanalysis An intensive, nondirective form of
the person's life. This disorder is not a diagnosis psychodynamic therapy in which the focus of listed in the DSM-IV. treatment is exploration of a person's mind and habitual thought patterns. It is insight oriented, meaning that the goal of treatment is for the patient to increase understanding of the sources of his/her inner conflicts and emotional problems.
NEDA TOOLKIT for Parents
Psychodrama A method of psychotherapy in which
Recovery Retreat See Residential Treatment Center.
patients enact the relevant events in their lives instead of simply talking about them. Relaxation Training A technique involving tightly
contracting and releasing muscles with the intent to Psychodynamic Therapy Psychodynamic theory
release or reduce stress. views the human personality as developing from interactions between conscious and unconscious Remission A period in which the symptoms of a
mental processes. The purpose of all forms of disease are absent. Remission differs from the psychodynamic treatment is to bring unconscious concept of "cure" in that the disease can return. The mental material and processes into full term "cure" signifies that the treated condition or consciousness so that the patient can gain more disorder is permanently gone, never to return in the control over his/her life. individual who received treatment. Psychodynamic Group Therapy Psychodynamic
Residential Services Services delivered in a
groups are based on the same principles as structured residence other than the hospital or a individual psychodynamic therapy and aim to help people with past difficulties, relationships, and trauma, as well as current problems. The groups are Residential Treatment Center A 24-hour residential
typically composed of eight members plus one or environment outside the home that includes 24-hour provision or access to support personnel capable of meeting the client's needs. Psychoeducational Therapy A treatment intended to
teach people about their problem, how to treat it, Selective Serotonin Reuptake Inhibitors (SSRI) A class
and how to recognize signs of relapse so that they of antidepressants used to treat depression, anxiety can get necessary treatment before their difficulty disorders, and some personality disorders. These worsens or recurs. Family psychoeducation includes drugs are designed to elevate the level of the teaching coping strategies and problem-solving neurotransmitter serotonin. A low level of serotonin skills to families, friends, and/or caregivers to help is currently seen as one of several neurochemical them deal more effectively with the individual. symptoms of depression. Low levels of serotonin in turn can be caused by an anxiety disorder, because Psychopathological Rating Scale Self-Rating Scale
serotonin is needed to metabolize stress hormones. for Affective Syndromes (CPRS-SA) A test used to
estimate the severity of depression, anxiety, and Self-directedness A personality trait that comprises
obsession in an individual. self-confidence, reliability, responsibility, resourcefulness, and goal orientation. Psychopharmacotherapy Use of drugs for treatment
of a mental or emotional disorder. Self-guided Cognitive Behavior Therapy A modified
form of cognitive behavior therapy in which a Psychotherapy The treatment of mental and
treatment manual is provided for people to proceed emotional disorders through the use of psychologic with treatment on their own, or with support from a techniques (some of which are described below) nonprofessional. Guided self-help usually implies designed to encourage communication of conflicts that the support person may or may not have some and insight into problems, with the goal being relief professional training, but is usually not a specialist in of symptoms, changes in behavior leading to eating disorders. The important characteristics of the improved social and vocational functioning, and self-help approach are the use of a highly structured personality growth. and detailed manual-based CBT, with guidance as to the appropriateness of self-help, and advice on Purging To evacuate the contents of the stomach or
where to seek additional help. bowels by any of several means. In bulimia, purging is used to compensate for excessive food intake. Methods of purging include vomiting, enemas, and excessive exercise.
NEDA TOOLKIT for Parents
Self Psychology A type of psychoanalysis that views
Telephone Therapy A type of psychotherapy
anorexia and bulimia as specific cases of pathology provided over the telephone by a trained of the self. According to this viewpoint, for example, people with bulimia nervosa cannot rely on human beings to fulfill their self-object needs (e.g., Tetracyclics A class of drugs used to treat depression.
regulation of self-esteem, calming, soothing, vitalizing). Instead, they rely on food (its Therapeutic Foster Care A foster care program in
consumption or avoidance) to fulfill these needs. Self which youths who cannot live at home are placed in psychological therapy involves helping people with homes with foster parents who have been trained to bulimia give up their pathological preference for provide a structured environment that supports the food as a self-object and begin to rely on human child's learning, social, and emotional skills. beings as selfobjects, beginning with their therapist. Thinspiration Slang Photographs, poems, or any
Self-report Measures An itemized written test in
other stimulus that influences a person to strive to which a person rates his/her feeling towards each question; the test is designed to categorize the personality or behavior of the person. Third-party Payer An organization that provides
health insurance benefits and reimburses for care for State Mandate A proclamation, order, or law from a
state legislature that issues specific instructions or regulations. Many states have issued mandates Thyroid Medication Abuse Excessive use or misuse of
pertaining to coverage of mental health benefits and drugs used to treat thyroid conditions; a side effect specific disorders the state requires insurers to cover. of these drugs is weight loss. Substance Abuse Use of a mood or behavior-altering
Treatment Plan A multidisciplinary care plan for
substance in a maladaptive pattern resulting in each beneficiary in active case management. It significant impairment or distress of the user. includes specific services to be delivered, the frequency of services, expected duration, community Substance Use Disorders The fourth edition of the
resources, all funding options, treatment goals, and Diagnostic and Statistical Manual of Mental assessment of the beneficiary environment. The plan Disorders (DSM-IV) defines a substance use disorder is updated monthly and modified when appropriate. as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as Tricyclic Antidepressants A class of drugs used to
manifested by one (or more) of the following, treat depression. occurring within a 12-month period: (1) Recurrent substance use resulting in a failure to fulfill major Trigger A stimulus that causes an involuntary reflex
role obligations at work, school, or home; behavior. A trigger may cause a recovering person (2) Recurrent substance use in situations in which it with bulimia to engage in bulimic behavior again. is physically hazardous; and (3) Recurrent substance- related legal, social, and/ or interpersonal problems. Usual and Customary Fee An insurance term that
indicates the amount the insurance company will Subthreshold Eating Disorder Condition in which a
reimburse for a particular service or procedure. This person exhibits disordered eating but not to the amount is often less than the amount charged by the extent that it fulfills all the criteria for diagnosis of service provider. an eating disorder. Vocational Services Programs that teach skills
Supportive Residential Services See Residential
needed for self-sufficiency. Treatment Center. Yoga A system of physical postures, breathing
Supportive Therapy Psychotherapy that focuses on
techniques, and meditation practices to promote the management and resolution of current bodily or mental control and well-being. difficulties and life decisions using the patient's strengths and available resources.
NEDA TOOLKIT for Parents
Common Myths about eating disorders
Ways to start a discussion with a loved one
who might have an eating disorder
ECRI Institute Feasibility Study on Eating Disorders Awareness and Education Needs. March 2004; 24 p. Navigating the System: Consumer Tips for Getting Treatment for Eating Disorders, Margo Maine, PhD for An Eating Disorders Resource for Schools, The Victorian Centre of Excellence in Eating Disorders and the Eating Disorders Foundation of Victoria (2004); pgs Identifying and treating eating disorders. American Academy of Pediatrics. Practice Guideline Pediatrics 2003 Jan; 111 (1): 204-11 Eating Disorders: A Time for Change Practice guideline for the treatment of patients with Russell, Michael. 2006 Myths About Eating Disorders. eating disorders. American Psychiatric Association. EzineArticles (December 02), Why parent-school communications may be
U.S. Department of Health and Human Services; Office on Women's Health; Eating Disorders difficult: Regulatory constraints and
American School Counselor Association American Psychiatric Association Diagnostic and Statistical Manual for Mental disorders-IV ECRI Institute interviews with educators and parents of children with eating disorders Eating disorder signs, symptoms, and
Levine, M. (1994). "A Short List of Salient Warning Signs Treatment settings and levels of care
for Eating Disorders." Presented at the 13th National ECRI Institute Bulimia Resource Guide
American Psychiatric Association (1994). Diagnostic and Statistical Manual for Mental Disorders, 4th ed. APA: Washington D.C. Questions to ask the care team at a facility
Zerbe, K.J. (1995). The Body Betrayed. Carlsbad, CA: Gurze Books. ECRI Institute Bulimia Resource Guide
U.S. Office on Women's Health: Eating Disorders Gidwani, G.P. and Rome, E.S. (1997). Eating Disorders. Clinical Obstetrics and Gynecology, 40(3), 601-615. Questions parents may want to ask treatment
ECRI Institute Bulimia Resource Guide ECRI Institute Bulimia Resource Guide
ECRI Institute interviews with parents
NEDA TOOLKIT for Parents
How to take care of yourself while caring for
a loved one with an eating disorder
Canadian National Eating Disorder Information Centre University of Florida, Institute of Food and Agricultural Anorexia nervosa and related eating disorders, Inc. Confidentiality Issues
ECRI Institute Bulimia Resource Guide
COBRA rights checklist
U.S. Department of Labor www.dol.gov ECRI Institute Bulimia Resource Guide
Sample letters to use with insurance
National Eating Disorders Association member How to manage an appeals process
ECRI Institute Bulimia Resource Guide
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Lupus Get the facts about lupus, including symptoms, risk factors, and the different types.
- Menopause Facts about menopause, including the stages, symptoms, and types.
- Ulcerative Colitis Facts about ulcerative colitis, including causes, signs and symptoms.
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Dr. Madhu T Vishwanath has the following 1 specialty
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Madhu T Vishwanath has the following 6 expertise
- Weight Loss
Dr. Madhu T Vishwanath has 0 board certified specialties
Showing 5 of 31
Dr. Vishwanath is pleasantly different. Do not to have to deal with outer waiting and inner waiting rooms (remember the Sienfeld episode). She is pleasant, listens to you and tries to understand your symptoms before attempting to diagnose. I have been hurried in other Doctors offices and sometimes forget to mention symptoms. For the few times I have been there for myself and my daughters, she has done an excellent job diagnosing and prescribing the right medicine.
21 Years Experience
Jjm Medical College Davangere
Graduated in 1997
Dr. Madhu T Vishwanath accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Anthem Blue Open Access POS Alternate Network
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS GA Blue Choice HMO
- BCBS GA Blue Choice PPO
- BCBS GA Blue Open Access POS
- BCBS GA BlueChoice Option POS
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry CoventryOne - GA
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana National POS
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsSynergy Chiropractic Pc, 3969 S Cobb Dr SE Ste 205, Smyrna, GA
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Autism Spectrum Disorder
Get the facts about Autism Spectrum Disorder (ASD), including the different types and the most common symptoms.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
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Dr. Jeffeory H White has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Jeffeory H White has the following 6 expertise
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
- Pediatric Diabetes
Dr. Jeffeory H White is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 5 of 6
My daughter Emily was afraid and suspicious of EVERYONE, but she took to Dr. White like a duck to water. He has a great sense of humor, is caring, quick with a smile. Ready to give up his day off for a bead in the nose and unflappable. Which calms a mom's frayed nerves. He always found the problem quickly and correctly and Emily always felt better, after seeing Dr. White. I am sorry that she has become a young lady now and has out grown her old friend, but one thing I am positive of, she has never forgotten him.
NCQA Patient-Centered Medical Home
The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into what patients want it to be. Medical homes can lead to higher quality and lower costs, and can improve patients' and providers' experience of care.
On-Time Doctor Award (2014)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Bridges to Excellence: Physician Office Systems Recognition Program
This program is designed to recognize practices that use information systems to enhance the quality of patient care. To obtain Recognition, practices must demonstrate that they have implemented systematic office
Loma Linda University Medical Center
Dr. Jeffeory H White accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Anthem Blue Open Access POS Alternate Network
- BCBS GA Blue Choice HMO
- BCBS GA Blue Choice PPO
- BCBS GA Blue Open Access POS
- BCBS GA BlueChoice Option POS
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry CoventryOne - GA
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Options PPO
Locations & DirectionsWhites Pediatrics Urgent Care, 1575 Chattanooga Ave Ste 1, Dalton, GA
Take a minute to learn about Dr. Jeffeory H White in this video.
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Binge Eating Disorder
Get the facts about binge eating disorder, including symptoms, causes and related conditions.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
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About Dr. John S Brown III
Dr. John S Brown III, MD is a Doctor primarily located in Merrillville, IN. He has 43 years of experience. His specialties include Family Medicine and Emergency Medicine. Dr. Brown is affiliated with Methodist Hospital Southlake Campus. Dr. Brown has received 2 awards. He speaks English.
Dr. John S Brown III has the following 2 specialties
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
- Emergency Medicine
An emergency physician is a doctor who is an expert in handling conditions of an urgent and extremely dangerous nature. These specialists work in the emergency room (ER) departments of hospitals where they oversee cases involving cardiac distress, trauma, fractures, lacerations and other acute conditions.
Emergency physicians are specially trained to make urgent life-saving decisions to treat patients during an emergency medical crisis. These doctors diagnose and stabilize patients before they are either well enough to be discharged, or transferred to the appropriate department for long-term care.
Dr. John S Brown III has the following 8 expertise
- Family Planning
- Weight Loss
- Flu (Human Influenza)
- Weight Loss (non-surgical)
Dr. John S Brown III has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 17
I scheduled an appointment at Dr. Brown's office due to a sharp pain in my back. They gladly took my information but neglected to tell me they charge $202.00 just for showing up. Dr. Brown spent less than 15 minutes with me. A nurse took my blood pressure then I sat waiting for almost 20 minutes. Dr. Brown came in, listened to my heart, told another nurse to take a chest X-Ray and left. He looked at the X-Ray and said my pain was from work, it was not. I have been doing the same job for many years and it definitely was not from that. His advice was take some ibuprofen (I already had been). Maybe it is time for Dr. Brown to retire as he seems to old to care about his patients but does not mind padding the bill to get more money. I called and asked about the $202.00 charge and Sheila very rudely told me it was for being a new patient. She claimed it was standard. I talked to co-workers who said they paid less than $100.00 and the doctor correctly diagnosed what was wrong. This is not a place to go if you want sound medical care and do not want to be ripped off. Sheila needs to think of another line of work. She is rude, crude and lacks basic customer service skills.
He was OK...but not very personable..never would talk to you if u had a question on the phone..n very quick with his appointments with me...some of the staff was very nice but some were very rude esp.his office manager.....very..very rude n unprofessional.. I would never recommend anyone go to this office n I'm never going back.....
Patients' Choice Award (2015, 2016, 2017, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2014)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Dr. Brown is affiliated (can practice and admit patients) with the following hospital(s).
43 Years Experience
Indiana University School Of Medicine
Graduated in 1975
Bronson Methodist Hospital
Dr. John S Brown III accepts the following insurance providers.
- Anthem Blue Access PPO
- Anthem IN Pathway X Bronze Direct CACA HIX
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
Coventry Health Care
- Coventry IL PPO
- Coventry MO PPO
- First Health PPO
- Multiplan PPO
- PHCS PPO
- PriorityHealth Priority PPO
- Sagamore Plus
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsFamily Health Wellness Center, 8683 Connecticut St Ste B, Merrillville, IN
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Roy B Kellum has the following 2 specialties
- Orthopaedic Surgery
- Obstetrics & Gynecology
Dr. Roy B Kellum has the following 12 expertise
- Multiple Sclerosis (MS)
- Child Birth
- Pelvic Exam
- Menstrual Pain
- Hot Flashes
- Birth Control
- Women's Health
- Pap Smear
Dr. Roy B Kellum has 2 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Roy B Kellum is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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I have seen Dr. Kellum for two decades, and he delivered both of my children. His assistant, Leann, is very friendly and helpful. When I have needed it, I have always been able to get an appt on the same day. Dr. Kellum will always call me after a visit to discuss any issues -- he doesn't leave it to staff.
Dr Kellum has been my dr. for 15 years. He is one of the most caring and kind doctors I have ever been to.
Compassionate Doctor Recognition (2018)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Patients' Choice Award (2017, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
38 Years Experience
University Of Mississippi School Of Medicine
Graduated in 1980
Dr. Roy B Kellum accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsJackson Healthcare for Women, 291 E Layfair Dr, Flowood, MS
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Dr. Scott A Fleischer has the following 3 specialties
- Geriatric Psychiatry
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
Dr. Scott A Fleischer has the following 14 expertise
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
- Depressive Disorder
- Alzheimer's Disease
- Mood Disorders
- Sleep Disorders
- Bipolar Disorder
- Personality Disorder
- Mental Illness
- Manic Depressive Disorder
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Bipolar Disorder / Manic Depressive Disorder
Dr. Scott A Fleischer is Board Certified in 2 specialties
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My Mother's condition was very difficult to diagnose and Dr. Fleischer with his years of experience knew exactly what it was. My family is very fortunate to have my Mother's ongoing treatment by him because she is happier and healthier. The people in the office are caring and compassionate, and they went out of their way to assist us.
Patients' Choice Award (2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
41 Years Experience
Drexel University College Of Medicine
Graduated in 1977
Hahnemann University Hospital
Dr. Scott A Fleischer accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
Capital Blue Cross
- Capital BC PPO
- Highmark Community Blue PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- IBC Keystone HMO POS
- IBC Personal Choice PPO
Locations & DirectionsScott Fleischer & Associates, 455 Pennsylvania Ave Ste 105, Fort Washington, PA
Take a minute to learn about Dr. Scott A Fleischer in this video.
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Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon attachment disorder that can affect kids. REACTIVE ATTACHMENT DISORDER is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited" form—or can present itself as indiscriminate sociability, such as excessive familiarity with relative strangers—known as the "dis-inhibited form". The term is used in both the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10) and in the DSM-IV-IV-TR, the revised fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In ICD-10, the inhibited form is called REACTIVE ATTACHMENT DISORDER, and the dis-inhibited form is called "dis-inhibited attachment disorder", or "DAD". In the DSM-IV, both forms are called REACTIVE ATTACHMENT DISORDER; for ease of reference, this article will follow that convention and refer to both forms as reactive attachment disorder.
REACTIVE ATTACHMENT DISORDER arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a youngster's communicative efforts. Not all, or even a majority of such experiences, result in the disorder. It is differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as mental retardation, all of which can affect attachment behavior. The criteria for a diagnosis of a reactive attachment disorder are very different from the criteria used in assessment or categorization of attachment styles such as insecure or disorganized attachment.
Kids with REACTIVE ATTACHMENT DISORDER are presumed to have grossly disturbed internal working models of relationships which may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. However, the opening of orphanages in Eastern Europe following the end of the Cold War in the early-1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism and assessment of disorders of attachment and led to efforts from the late-1990s onwards to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications.
Mainstream treatment and prevention programs that target REACTIVE ATTACHMENT DISORDER and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the youngster with a different caregiver. Most such strategies are in the process of being evaluated. Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or attachment disorder within the complementary and alternative medicine field commonly known as attachment therapy. Attachment therapy has an unconventional theoretical base and uses diagnostic criteria or symptom lists unrelated to criteria under ICD-10 or DSM-IV-IV-TR, or to attachment behaviors. A range of treatment approaches are used in attachment therapy, some of which are physically coercive and considered to be antithetical to attachment theory.
Signs and symptoms—
Pediatricians are often the first health professionals to assess and raise suspicions of REACTIVE ATTACHMENT DISORDER in kids with the disorder. The initial presentation varies according to the developmental and chronological age of the youngster, though it always involves a disturbance in social interaction. Infants up to about 18–24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli. Laboratory investigations will be unremarkable barring possible findings consistent with malnutrition or dehydration, while serum growth hormone levels will be normal or elevated.
The core feature is that the style of social relating by affected kids involves either indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers—older kids and adolescents may also aim attempts at peers—or extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed. The disorder arises from a severe lack of developmentally appropriate attachment behaviors and, thus, appropriate social relatedness.
While REACTIVE ATTACHMENT DISORDER is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as kids can form stable attachments and social relationships despite marked abuse and neglect.
There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures is used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure (devised by developmental psychologist Mary Ainsworth), the separation and reunion procedure and the Preschool Assessment of Attachment, the Observational Record of the Care-giving Environment, the Attachment Q-sort and a variety of narrative techniques using stem stories, puppets or pictures. For older kids, actual interviews such as the Child Attachment Interview and the Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as the Working Model of the Youngster Interview.
More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah (1999). The DAI is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely "having a discriminated, preferred adult", "seeking comfort when distressed", "responding to comfort when offered", "social and emotional reciprocity", "emotional regulation", "checking back after venturing away from the care giver", "reticence with unfamiliar adults", "willingness to go off with relative strangers", "self-endangering behavior", "excessive clinging", "vigilance/hyper-compliance" and "role reversal". This method is designed to pick up not only REACTIVE ATTACHMENT DISORDER but also the proposed new alternative categories of disorders of attachment.
REACTIVE ATTACHMENT DISORDER is one of the least researched and most poorly understood disorders in the DSM-IV. There is little systematic epidemiologic information on REACTIVE ATTACHMENT DISORDER, its course is not well established and it appears difficult to diagnose accurately. There is a lack of clarity about the presentation of attachment disorders over the age of five years and difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the consequences of maltreatment.
According to the American Academy of Youngster and Adolescent Psychiatry (AACAP), kids who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan. The signs or symptoms of REACTIVE ATTACHMENT DISORDER may also be found in other psychiatric disorders and AACAP advises against giving a youngster this label or diagnosis without a comprehensive evaluation. Their practice parameter states that the assessment of reactive attachment disorder requires evidence directly obtained from serial observations of the youngster interacting with his or her primary caregivers and history (as available) of the youngster’s patterns of attachment behavior with these caregivers. In addition it requires observations of the youngster’s behavior with unfamiliar adults and a comprehensive history of the youngster’s early care-giving environment including, for example, pediatricians, teachers, or caseworkers. In the US, initial evaluations may be conducted by psychologists, psychiatrists, specialist Licensed Clinical Social Workers or psychiatric nurses.
In the UK, the British Association for Adoption and Fostering (BAAF), advise that only a psychiatrist can diagnose an attachment disorder and that any assessment must include a comprehensive evaluation of the youngster’s individual and family history.
According to the AACAP Practice Parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older kids and adults has not been resolved. Attachment behaviors used for the diagnosis of REACTIVE ATTACHMENT DISORDER change markedly with development and defining analogous behaviors in older kids is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence. Assessments of REACTIVE ATTACHMENT DISORDER past school age may not be possible at all as by this time kids have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior.
ICD-10 describes reactive attachment disorder of childhood, known as REACTIVE ATTACHMENT DISORDER, and dis-inhibited attachment disorder, less well known as DAD. DSM-IV-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and dis-inhibited type, both known as REACTIVE ATTACHMENT DISORDER. The two classifications are similar, and both include:
• a history of significant neglect
• an implicit lack of identifiable, preferred attachment figure
• markedly disturbed and developmentally inappropriate social relatedness in most contexts
• onset before five years of age
• the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder
ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM-IV states in relation to both forms there must be a history of "pathogenic care" defined as persistent disregard of the youngster's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the diagnosis is the youngster's history of care rather than observation of symptoms.
In DSM-IV-IV-TR the inhibited form is described as: Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper-vigilant, or highly ambivalent responses (e.g. the youngster may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit "frozen watchfulness", hyper-vigilance while keeping an impassive and still demeanor). Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior. The dis-inhibited form shows: Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures). There is therefore a lack of "specificity" of attachment figure, the second basic element of attachment behavior.
The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-IV-TR as follows:
• abuse, (psychological or physical), in addition to neglect
• associated emotional disturbance
• evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults, (dis-inhibited form only)
• poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases, (inhibited form only)
The first of these is somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to attachment disorder.
The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the dis-inhibited form is more enduring. ICD-10 states the dis-inhibited form "tends to persist despite marked changes in environmental circumstances". Dis-inhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same youngster. The question of whether there are in fact two subtypes has been raised. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision. One reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and various ways of categorizing more severe disorders of attachment.
The diagnostic complexities of REACTIVE ATTACHMENT DISORDER mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential. Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with REACTIVE ATTACHMENT DISORDER, leading to over and under diagnosis. REACTIVE ATTACHMENT DISORDER can also be confused with neuropsychiatric disorders such as autism spectrum disorders, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization. Kids with an autistic disorder are likely to be of normal size and weight and often exhibit a degree of mental retardation. They are unlikely to improve upon being removed from the home.
In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM-IV and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are un-validated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-IV-TR or ICD-10. Many kids are being diagnosed with REACTIVE ATTACHMENT DISORDER because of behavioral problems that are outside the criteria. There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of attachment relationships can contribute to the etiology, maintenance and treatment of externalizing disorders.
The Randolph Attachment Disorder Questionnaire or REACTIVE ATTACHMENT DISORDERQ is one of the better known of these checklists and is used by attachment therapists and others. The checklist includes 93 discrete behaviors, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. Critics assert that it is un-validated and lacks specificity.
History and theoretical framework—
Reactive attachment disorder first made its appearance in standard nosologies of psychological disorders in DSM-IV-III, 1980, following an accumulation of evidence on institutionalized kids. The criteria included a requirement of onset before the age of 8 months and was equated with failure to thrive. Both these features were dropped in DSM-IV-III-R, 1987. Instead, onset was changed to being within the first 5 years of life and the disorder itself was divided into two subcategories, inhibited and dis-inhibited. These changes resulted from further research on maltreated and institutionalized kids and remain in the current version, DSM-IV-IV, 1994, and its 2000 text revision, DSM-IV-IV-TR, as well as in ICD-10, 1992. Both nosologies focus on young kids who are not merely at increased risk for subsequent disorders but are already exhibiting clinical disturbance.
The broad theoretical framework for current versions of REACTIVE ATTACHMENT DISORDER is attachment theory, based on work conducted from the 1940s to the 1980s by John Bowlby, Mary Ainsworth and René Spitz. Attachment theory is a framework that employs psychological, ethological and evolutionary concepts to explain social behaviors typical of young kids. Attachment theory focuses on the tendency of infants or kids to seek proximity to a particular attachment figure (familiar caregiver), in situations of alarm or distress, behavior which appears to have survival value. This is known as a discriminatory or selective attachment. Subsequently, the youngster begins to use the caregiver as a base of security from which to explore the environment, returning periodically to the familiar person. Attachment is not the same as love and/or affection although they are often associated. Attachment and attachment behaviors tend to develop between the ages of six months and three years. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Caregiver responses lead to the development of patterns of attachment, that in turn lead to internal working models which will guide the individual's feelings, thoughts, and expectations in later relationships. For a diagnosis of reactive attachment disorder, the youngster's history and atypical social behavior must suggest the absence of formation of a discriminatory or selective attachment.
The pathological absence of a discriminatory or selective attachment needs to be differentiated from the existence of attachments with either typical or somewhat atypical behavior patterns, known as styles. There are four attachment styles ascertained and used within developmental attachment research. These are known as secure, anxious-ambivalent, anxious-avoidant, (all organized) and disorganized. The latter three are characterized as insecure. These are assessed using the Strange Situation Procedure, designed to assess the quality of attachments rather than whether an attachment exists at all.
A securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset when the caregiver departs, and happy to see the caregiver return. The anxious-ambivalent toddler is anxious of exploration, extremely distressed when the caregiver departs but ambivalent when the caregiver returns. The anxious-avoidant toddler will not explore much, avoid or ignore the parent – showing little emotion when the parent departs or returns – and treat strangers much the same as caregivers with little emotional range shown. The disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. Evidence suggests this occurs when the care-giving figure is also an object of fear, thus putting the youngster in an irresolvable situation regarding approach and avoidance. On reunion with the caregiver, these kids can look dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors implying fear of the person who is being sought. It is thought to represent a breakdown of an inchoate attachment strategy and it appears to affect the capacity to regulate emotions.
Although there are a wide range of attachment difficulties within the styles which may result in emotional disturbance and increase the risk of later psychopathologies, particularly the disorganized style, none of the styles constitute a disorder in themselves and none equate to criteria for REACTIVE ATTACHMENT DISORDER as such. A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders. Reactive attachment disorder denotes a lack of typical attachment behaviors rather than an attachment style, however problematic that style may be, in that there is an unusual lack of discrimination between familiar and unfamiliar people in both forms of the disorder. Such discrimination does exist as a feature of the social behavior of kids with atypical attachment styles. Both DSM-IV-IV and ICD-10 depict the disorder in terms of socially aberrant behavior in general rather than focusing more specifically on attachment behaviors as such. DSM-IV-IV emphasizes a failure to initiate or respond to social interactions across a range of relationships and ICD-10 similarly focuses on ambivalent social responses that extend across social situations. The relationship between patterns of attachment in the Strange Situation and REACTIVE ATTACHMENT DISORDER is not yet clear.
There is a lack of consensus about the precise meaning of the term "attachment disorder". The term is frequently used both as an alternative to reactive attachment disorder and in discussions about different proposed classifications for disorders of attachment beyond the limitations of the ICD and DSM-IV classifications. It is also used within the field of attachment therapy, as is the term reactive attachment disorder, to describe a range of problematic behaviors not within the ICD or DSM-IV criteria or not related directly to attachment styles or difficulties at all.
Research from the late 1990s indicated there were disorders of attachment not captured by DSM-IV or ICD and showed that REACTIVE ATTACHMENT DISORDER could be diagnosed reliably without evidence of pathogenic care, thus illustrating some of the conceptual difficulties with the rigid structure of the current definition of REACTIVE ATTACHMENT DISORDER. Research published in 2004 showed that the dis-inhibited form can endure alongside structured attachment behavior (of any style) towards the youngster's permanent caregivers.
Some authors have proposed a broader continuum of definitions of attachment disorders ranging from REACTIVE ATTACHMENT DISORDER through various attachment difficulties to the more problematic attachment styles. There is as yet no consensus, on this issue but a new set of practice parameters containing three categories of attachment disorder has been proposed by C.H. Zeanah and N. Boris. The first of these is disorder of attachment, in which a young youngster has no preferred adult caregiver. The proposed category of disordered attachment is parallel to REACTIVE ATTACHMENT DISORDER in its inhibited and dis-inhibited forms, as defined in DSM-IV and ICD. The second category is secure base distortion, where the youngster has a preferred familiar caregiver, but the relationship is such that the youngster cannot use the adult for safety while exploring the environment. Such kids may endanger themselves, cling to the adult, be excessively compliant, or show role reversals in which they care for or punish the adult. The third type is disrupted attachment. Disrupted attachment is not covered under ICD-10 and DSM-IV criteria, and results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. This form of categorization may demonstrate more clinical accuracy overall than the current DSM-IV-IV-TR classification, but further research is required. The practice parameters would also provide the framework for a diagnostic protocol.
Some research indicates there may be a significant overlap between behaviors of the inhibited form of REACTIVE ATTACHMENT DISORDER or DAD and aspects of disorganized attachment where there is an identified attachment figure.
An ongoing question is whether REACTIVE ATTACHMENT DISORDER should be thought of as a disorder of the youngster's personality or a distortion of the relationship between the youngster and a specific other person. It has been noted that as attachment disorders are by their very nature relational disorders, they do not fit comfortably into noslogies that characterize the disorder as centered on the person. Work by C.H. Zeanah indicates that atypical attachment-related behaviors may occur with one caregiver but not with another. This is similar to the situation reported for attachment styles, in which a particular parent's frightened expression has been considered as possibly responsible for disorganized/disoriented reunion behavior during the Strange Situation Procedure.
Although increasing numbers of childhood mental health problems are being attributed to genetic defects, reactive attachment disorder is by definition based on a problematic history of care and social relationships. Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. It has been suggested that types of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years. In the absence of available and responsive caregivers it appears that some kids are particularly vulnerable to developing attachment disorders.
There is as yet no explanation for why similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and dis-inhibited. The issue of temperament and its influence on the development of attachment disorders has yet to be resolved. REACTIVE ATTACHMENT DISORDER has never been reported in the absence of serious environmental adversity yet outcomes for kids raised in the same environment vary widely.
In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has been suggested that the roots of various forms of psychopathology, including REACTIVE ATTACHMENT DISORDER and post-traumatic stress disorder (PTSD), can be found in disturbances in affect regulation. The subsequent development of higher-order self-regulation is jeopardized and the formation of internal models is affected. Consequently the "templates" in the mind that drive organized behavior in relationships may be impacted. The potential for “re-regulation” (modulation of emotional responses to within the normal range) in the presence of “corrective” experiences (normative care-giving) seems possible. Like many other papers in this poorly-researched area many new avenues of enquiry are raised.
Epidemiological data are limited, but reactive attachment disorder appears to be very uncommon. The prevalence of REACTIVE ATTACHMENT DISORDER is unclear but it is probably quite rare, other than in populations of kids being reared in the most extreme, deprived settings such as some orphanages. There is little systematically gathered epidemiologic information on REACTIVE ATTACHMENT DISORDER. A cohort study of 211 Copenhagen kids to the age of 18 months found a prevalence of 0.9%.
Attachment disorders tend to occur in a definable set of contexts such as within some types of institutions, in the presence of repeated changes of primary caregiver or of extremely neglectful identifiable primary caregivers who show persistent disregard for the youngster's basic attachment needs, but not all kids raised in these conditions develop an attachment disorder. Studies undertaken on kids from Eastern European orphanages from the mid-1990s showed significantly higher levels of both forms of REACTIVE ATTACHMENT DISORDER and of insecure patterns of attachment in the institutionalized kids, regardless of how long they had been there. It would appear that kids in institutions like these are unable to form selective attachments to their caregivers. The difference between the institutionalized kids and the control group had lessened in the follow-up study three years later, although the institutionalized kids continued to show significantly higher levels of indiscriminate friendliness. However, even among kids raised in the most deprived institutional conditions the majority did not show symptoms of this disorder.
A 2002 study of kids in residential nurseries in Bucharest, in which the DAI was used, challenged the current DSM-IV and ICD conceptualizations of disordered attachment and showed that inhibited and dis-inhibited disorders could coexist in the same youngster.
There are two studies on the incidence of REACTIVE ATTACHMENT DISORDER relating to high risk and maltreated kids in the U.S. Both used ICD, DSM-IV and the DAI. The first, in 2004, reported that kids from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than kids from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the DSM-IV or ICD classified REACTIVE ATTACHMENT DISORDER or DAD. The second study, also in 2004, attempted to ascertain the prevalence of REACTIVE ATTACHMENT DISORDER and whether it could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD REACTIVE ATTACHMENT DISORDER and 22% as having ICD DAD, and 38% fulfilled the DSM-IV criteria for REACTIVE ATTACHMENT DISORDER. This study found that REACTIVE ATTACHMENT DISORDER could be reliably identified and also that the inhibited and dis-inhibited forms were not independent. However, there are some methodological concerns with this study. A number of the kids identified as fulfilling the criteria for REACTIVE ATTACHMENT DISORDER did in fact have a preferred attachment figure.
It has been suggested by some within the field of attachment therapy that REACTIVE ATTACHMENT DISORDER may be quite prevalent because severe youngster maltreatment, which is known to increase risk for REACTIVE ATTACHMENT DISORDER, is prevalent and because kids who are severely abused may exhibit behaviors similar to REACTIVE ATTACHMENT DISORDER behaviors. The APSAC Taskforce consider this inference to be flawed and questionable. Severely abused kids may exhibit similar behaviors to REACTIVE ATTACHMENT DISORDER behaviors but there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties. Further, many kids experience severe maltreatment and do not develop clinical disorders. Resilience is a common and normal human characteristic. REACTIVE ATTACHMENT DISORDER does not underlie all or even most of the behavioral and emotional problems seen in foster kids, adoptive kids, or kids who are maltreated and rates of youngster abuse and/or neglect or problem behaviors are not a benchmark for estimates of REACTIVE ATTACHMENT DISORDER.
There are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in which REACTIVE ATTACHMENT DISORDER arises, such as institutionalization or maltreatment. These are principally developmental delays and language disorders associated with neglect. Conduct disorders, oppositional defiant disorder, anxiety disorders, post-traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with REACTIVE ATTACHMENT DISORDER. Attachment disorder behaviors amongst institutionalized kids are correlated with attention and conduct problems and cognitive levels but nonetheless appear to index a distinct set of symptoms and behaviors.
Assessing the youngster's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the youngster should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing and social work support), psychotherapeutic interventions (including treating moms & dads for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and youngster development), and monitoring of the youngster's safety within the family environment
In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of REACTIVE ATTACHMENT DISORDER. Recommendations in the guidelines include the following:
1. "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the youngster, assessing the caregiver's attitudes toward and perceptions about the youngster is important for treatment selection."
2. "Kids who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments."
3. "Kids with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. After ensuring that the youngster is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers."
4. "The most important intervention for young kids diagnosed with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the youngster with an emotionally available attachment figure."
Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger kids are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the youngster with a different caregiver. These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status or care-giving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. Some of these treatment or prevention programs are specifically aimed at foster carers rather than moms & dads, as the attachment behaviors of infants or kids with attachment difficulties often do not elicit appropriate caregiver responses. Approaches include "Watch, wait and wonder", manipulation of sensitive responsiveness, modified "Interaction Guidance", "Preschool Parent Psychotherapy", "Circle of Security", "Attachment and Bio-behavioral Catch-up" (ABC), the New Orleans Intervention, and Parent-Youngster psychotherapy. Other treatment methods include Developmental, Individual-difference, and Relationship-based therapy (DIR, also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.
The relevance of these approaches to intervention with fostered and adopted kids with REACTIVE ATTACHMENT DISORDER or older kids with significant histories of maltreatment is unclear.
Outside the mainstream programs is a form of treatment generally known as attachment therapy, a subset of techniques (and accompanying diagnosis) for supposed attachment disorders including REACTIVE ATTACHMENT DISORDER. In general, these therapies are aimed at adopted or fostered kids with a view to creating attachment in these kids to their new caregivers. The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasize obedience and parental control. There is considerable criticism of this form of treatment and diagnosis as it is largely un-validated and has developed outside the scientific mainstream. There is little or no evidence base and techniques vary from non-coercive therapeutic work to more extreme forms of physical, confrontational and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. These forms of the therapy may well involve physical restraint, the deliberate provocation of rage and anger in the youngster by physical and verbal means including deep tissue massage, aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma. Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive, and are antithetical to attachment theory. The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the youngster rather than the caregiver. Kids may be described as "REACTIVE ATTACHMENT DISORDER kids" and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy.
The AACAP guidelines state that kids with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. However, the course of REACTIVE ATTACHMENT DISORDER is not well studied and there have been few efforts to examine symptom patterns over time. The few existing longitudinal studies (dealing with developmental change with age over a period of time) involve only kids from poorly run Eastern European institutions.
Findings from the studies of kids from Eastern European orphanages indicate that persistence of the inhibited pattern of REACTIVE ATTACHMENT DISORDER is rare in kids adopted out of institutions into normative care-giving environments. However, there is a close association between duration of deprivation and severity of attachment disorder behaviors. The quality of attachments that these kids form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited REACTIVE ATTACHMENT DISORDER. The same group of studies suggests that a minority of adopted, institutionalized kids exhibit persistent indiscriminate sociability even after more normative care-giving environments are provided. Indiscriminate sociability may persist for years, even among kids who subsequently exhibit preferred attachment to their new caregivers. Some exhibit hyperactivity and attention problems as well as difficulties in peer relationships. In the only longitudinal study that has followed kids with indiscriminate behavior into adolescence, these kids were significantly more likely to exhibit poor peer relationships.
Studies of kids who were reared in institutions have suggested that they are inattentive and overactive, no matter what quality of care they received. In one investigation, some institution-reared boys were reported to be inattentive, overactive, and markedly unselective in their social relationships, while girls, foster-reared kids, and some institution-reared kids were not. It is not yet clear whether these behaviors should be considered as part of disordered attachment.
There is one case study on maltreated twins published in 1999 with a follow-up in 2006. This study assessed the twins between the ages of 19 and 36 months, during which time they suffered multiple moves and placements. The paper explores the similarities, differences and comorbidity of REACTIVE ATTACHMENT DISORDER, disorganized attachment and post traumatic stress disorder. The girl showed signs of the inhibited form of REACTIVE ATTACHMENT DISORDER while the boy showed signs of the indiscriminate form. It was noted that the diagnosis of REACTIVE ATTACHMENT DISORDER ameliorated with better care but symptoms of post traumatic stress disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. At age three, some lasting relationship disturbance was evident.
In the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on maltreated as opposed to institutionalized kids was again highlighted. The girl's symptoms of disorganized attachment had developed into controlling behaviors—a well-documented outcome. The boy still exhibited self-endangering behaviors, not within REACTIVE ATTACHMENT DISORDER criteria but possibly within "secure base distortion", (where the youngster has a preferred familiar caregiver, but the relationship is such that the youngster cannot use the adult for safety while exploring the environment). At age eight the kids were assessed with a variety of measures including those designed to access representational systems, or the youngster's "internal working models". The twins' symptoms were indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), chaotic personal narratives, struggles with friendships, and emotional disengagement with her caregiver, resulting in a clinical picture described as "quite concerning". The boy still evidenced self-endangering behaviors as well as avoidance in relationships and emotional expression, separation anxiety and impulsivity and attention difficulties. It was apparent that life stressors had impacted each youngster differently. The narrative measures used were considered helpful in tracking how early attachment disruption is associated with later expectations about relationships.
One paper using questionnaires found that kids aged three to six, diagnosed with REACTIVE ATTACHMENT DISORDER, scored lower on empathy but higher on self-monitoring (regulating your behavior to "look good"). These differences were especially pronounced based on ratings by moms & dads, and suggested that kids with REACTIVE ATTACHMENT DISORDER may systematically report their personality traits in overly positive ways. Their scores also indicated considerably more behavioral problems than scores of the control kids.
* References provided by request.
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About Dr. Thomas L Miller
Dr. Thomas L Miller, MD is a Doctor primarily located in Angola, IN, with another office in Evansville, IN. He has 35 years of experience. His specialties include Emergency Medicine and Family Medicine. Dr. Miller is affiliated with Dekalb Health, Cameron Memorial Community Hospital and Parkview Noble Hospital. Dr. Miller has received 2 awards. He speaks English.
Dr. Thomas L Miller has the following 2 specialties
- Emergency Medicine
An emergency physician is a doctor who is an expert in handling conditions of an urgent and extremely dangerous nature. These specialists work in the emergency room (ER) departments of hospitals where they oversee cases involving cardiac distress, trauma, fractures, lacerations and other acute conditions.
Emergency physicians are specially trained to make urgent life-saving decisions to treat patients during an emergency medical crisis. These doctors diagnose and stabilize patients before they are either well enough to be discharged, or transferred to the appropriate department for long-term care.
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Thomas L Miller has the following 7 expertise
- Weight Loss
- Family Planning
- Weight Loss (non-surgical)
Dr. Thomas L Miller has 2 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Thomas L Miller is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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I have been a patient of Dr. Millers since I moved back to Angola almost 20 years ago. He is an excellent Dr. I have never really had any serious problems with him. He is a good man too. He tries his best to be empathetic with his patients. He will take time to talk with you, and make sure all your questions are answered. Dr, Miller knows most of his patients on a personal level because he takes the time to do so, its called good patient care. He genuinely cares for those he treats, and treats us like family. I challenge anyone to find a good doctor like Dr, Miller. One who treats more than your symptoms. They are sadly few and far between these days. God bless all who read this.
Dr. Miller has been our family doctor for over 16 years now & he has helped us so much. He's one doctor I am extremely comfortable with for caring for my children & highly trust with them. He has listened to me with my concerns & uses those concerns to help with treatment. I highly recommend Dr. Miller.
I love Dr. Miller, he's the best Doctor I've ever had, for myself & for my children! (Review doesn't refer to Ann the N.P.) He takes his time, answers all my/kids questions. Monica-one of the nurses is awesome too!! Sometimes there's a little bit of a wait time, but what do you expect when you have a Dr. who's actually willing to talk to and answer his patients questions.. You can talk to him about any concerns, he'll listen & take all things into account. I also have a child w/special needs who has high anxiety(!) and he does very well with him & my other 2 girls (not special needs). And he has saved MY life a few different times.. Even figured out a couple of medical issues that no other doctor-including the hospital(s)- couldn't figure out! That if things wouldn't have been caught when they had- I very well could not be here to write this review or to sick to do so!!!!!!! Give him a try & decide for yourself, you owe it to yourself (and family)..
Patients' Choice Award (2008, 2009, 2011, 2013, 2014, 2015, 2016)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2015, 2016)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Dr. Miller is affiliated (can practice and admit patients) with the following hospital(s).
35 Years Experience
Indiana University School Of Medicine
Graduated in 1983
Bell Memorial Hospital
Dr. Thomas L Miller accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Anthem Blue Preferred HMO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
- Ambetter from MHS HIX
- CIGNA HMO
- CIGNA Open Access Plus
- First Health PPO
FrontPath Health Coalition
- FrontPath Health Coalition
- Humana Choice POS
- Humana ChoiceCare Network PPO
Medical Mutual of Ohio
- MMOH SuperMed POS Select
- Multiplan PPO
PHP Northern IN
- PHP Select with Encircle
- PriorityHealth Priority PPO
- Sagamore Plus
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Take a minute to learn about Dr. Thomas L Miller in this video.
Dr. Thomas L Miller is similar to the following 3 Doctors near Angola, IN. | <urn:uuid:66d1a7b3-af2d-4cdd-9902-d177e294e7fb> | {
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이 문서는 사용자가 익숙하지 않은 워드프레스에서 사용하는 용어사전 이다.
An absolute path or full path is a unique location of a file or directory name within a computer or filesystem, and usually starts with the root directory or drive letter. Directories and subdirectories listed in a path are usually separated by a slash (/).
To find the absolute filesystem path of the directory containing a web page, copy the code below into a new text file, save the file as path.php (thus making a simple PHP web page), and move that file to your web server. Then direct your web browser to the URL address of that file (e.g. http://www.example.com/path.php).
$p = getcwd();
A full URI.
In WordPress; an Action is a PHP function that is executed at specific points throughout the WordPress Core.
For example: A developer may want to add code to the footer of a Theme. This could be accomplished by writing new function, then Hooking it to the wp_footer Action.
Custom Actions differ from custom Filters because custom Actions allow you to add or remove code from existing Actions. Whereas custom Filters allow you to replace specific data (such as a variable) found within an existing Action.
- See also: Filter, Hook, Terminology Confusion
- Related articles: Actions, Action Reference, add_action()
- Forum posts: Filters vs. Actions Discussion and Explanation
The admin bar is an area of the screen just above your site that lists useful admininstration screen links such as add a new post or edit your profile. The admin bar concept was added to WordPress in Version 3.1 and was replaced by the Toolbar in WordPress Version 3.3. Each user can use Administration > Users > Your Profile to turn on (or off) the admin bar when viewing the site or the Dashboard.
AJAX is a technique that web pages use to have the server perform certain processing without reloading the web page. For example, when you approve a comment in a WordPress blog, WordPress uses AJAX to change the comment’s status, and you see the change without having to reload the Comments screen.
Apache is short for Apache HTTP Server Project, a robust, commercial-grade, featureful, and freely-available open source HTTP Web server software produced by the Apache Software Foundation. It is the most commonly used web server on the internet, and is available on many platforms, including Windows, Unix/Linux, and Mac OS X. Apache serves as a great foundation for publishing WordPress-powered sites.
Please refer to Wikipedia for a definition (click the title, which is linked to that page).
An array is one of the basic data structures used in computer programming. An array contains a list (or vector) of items such as numeric or string values. Arrays allow programmers to randomly access data. Data can be stored in either one-dimensional or multi-dimensional arrays.
A one-dimension array seven (7) elements would be:
An example of two-dimensional array, 7 by 3 elements in size, would be:
ASCII (pronounced as “ask ee”) is a standard but limited character set containing only English letters, numbers, a few common symbols, and common English punctuation marks. WordPress content is not restricted to ASCII, but can include any Unicode characters.
ASCII is short for American Standard Code for Information Interchange.
- External links: ASCII (Wikipedia, with character set table)
A format for syndicating content on news-like sites, viewable by Atom-aware programs called news readers or aggregators.
When you are writing or editing your posts and pages, the changes you make are automatically saved every 2 minutes. In the lower right corner of the editor, you’ll see a notification of when the entry was last saved to the database.
Autosaves are automatically enabled for all posts and pages. There is only one autosave for each post/page. Each new autosave overwrites the previous autosave in the database.
An avatar is a graphic image or picture that represents a user.
- See also: Gravatar
- Related articles: Using Gravatars
- External links: Avatar (computing) at Wikipedia
The back end is the area that authorized users can sign into to add, remove and modify content on the website. This may also be referred to as “WordPress”, “admin” or “the administration area”.
Binaries refer to compiled computer programs, or executables. Many open source projects, which can be re-compiled from source code, offer pre-compiled binaries for the most popular platforms and operating systems.
A blog, or weblog, is an online journal, diary, or serial published by a person or group of people.
Blogs are typically used by individuals or peer groups, but are occasionally used by companies or organizations as well. In the corporate arena, the only adopters of the blog format so far have tended to be design firms, web media companies, and other “bleeding edge” tech firms.
Blogs often contain public as well as private content. Depending on the functionality of the CMS software that is used, some authors may restrict access — through the use of accounts or passwords — to content that is too personal to be published publicly.
블로깅은 자신의 블로그에 글을 작성하는 행위이다. 뭔가를 블로그한다는 것은 자신의 블로그에 뭔가에 대해 글을 작성하는 것이다. 저자가 인터넷에서 발견한 흥미있는 것에 링크하는(linking) 것도 포함한다.
The blogosphere는 is the subset of internet web sites which are, or relate to, 블로그(blogs) 또는 블로그와 관련있는 인터넷 웹 사이트의 하위 집합이다..
A 블로그롤는 각종 블로그나 뉴스 사이트에 대한 링크 목록이다. 블로그롤은 (피드(feeds))를 사용하여 각 사이트의 업데이트 내용을 추적하는 서비스에 의해 목록 형태로 작성된다(rolled) 그리고 업데이트 정보를 집계하는 형태로 목록을 제공한다. 워드프레스에 기본으로 포함되었던 블로그롤 (일명 links)이 버전 3.5에서 삭제되었다.
- See also: 블로그(Blog), Blogosphere, 피드(Feed), 뉴스리더(News reader)
- External links: News aggregator at Wikipedia
A variable or expression which evaluates to either true or false.
- External links: PHP Boolean data type
Each post in WordPress is filed under a category. Thoughtful categorization allows posts to be grouped with others of similar content and aids in the navigation of a site. Please note, the post category should not be confused with the Link Categories used to classify and manage Links.
A capability is permission to perform one or more types of task. Each user of a WordPress site might have some permissions but not others, depending on their role. For example, users who have the Author role usually have permission to edit their own posts (the “edit_posts” capability), but not permission to edit other users’ posts (the “edit_others_posts” capability). WordPress comes with six roles and over fifty capabilities in its role-based access system. Plugins can modify the system.
CGI (Common Gateway Interface) is a specification for server-side communication scripts designed to transfer information between a web server and a web-client (browser). Typically, HTML pages that collect data via forms use CGI programming to process the form data once the client submits it.
A character entity is a method used to display special characters normally reserved for use in HTML. For example, the less than (<) and greater than (>) are used as part the HTML tag structure, so both symbols are reserved for that use. But, if you need to display those symbols on your site, you can use character entities. For example:
<for the less than (<) symbol
>for the greater than (>) symbol
- Related articles: Fun Character Entities
A character set is a collection of symbols (letters, numbers, punctuation, and special characters), when used together, represent meaningful words in a language. Computers use an encoding scheme so members of a character set are stored with a numeric value (e.g. 0=A, 1=B, 2=C, 3=D). In addition, a collation determines the order (i.e alphabetic) to use when sorting the character set.
By default, WordPress uses the Unicode UTF-8 (utf8) character set for the WordPress MySQL database tables created during the installation process. Beginning with Version 2.2, the database character set (and collation) is defined in the wp-config.php file. Also note, the character set used for syndication feeds is set in the Administration > Settings > Reading panel.
- See also: Collation
- Related articles: Editing wp-config.php, Converting Database Character Sets
- External links: Character set at Wikipedia, Unicode at Wikipedia, UTF-8 at Wikipedia, Character sets and collation at MySQL
Collation refers to the order used to sort the letters, numbers, and symbols of a given character set. For example, because WordPress, by default, uses the UTF-8 (utf8) character set, and when the WordPress MySQL database tables are created during the installation process, MySQL assigns utf8_general_ci collation to those tables. Beginning with Version 2.2, the collation (and character set) used by WordPress is defined in the wp-config.php file.
- See also: Character set
- Related articles: Editing wp-config.php, Converting Database Character Sets
- External links: Collation at Wikipedia, Character set at Wikipedia, UTF-8 at Wikipedia, Character sets and collation at MySQL
Comments are a feature of blogs which allow readers to respond to posts. Typically readers simply provide their own thoughts regarding the content of the post, but users may also provide links to other resources, generate discussion, or simply compliment the author for a well-written post.
You can control and regulate comments by filters for language and content. Comments can be queued for approval before they are visible on the web site. This is useful in dealing with comment spam.
- See also: Blog
- Related articles: Comment-related plugins, Dealing with comment spam, Settings Discussion SubPanel
- External links: Hyperlink at Wikipedia
콘텐츠는 텍스트, 이미지 또는 글(posts)에 올려진 정보들이다. 웹 사이트의 구조 디자인과는 별개이다. 구조 디자인은 콘텐츠가 삽입되는 프레임워크(framework)를 제공하고, 그래픽 디자인을 포함하는 사이트의 프레젠테이션(presentation) 정보를 포함한다. 콘텐츠 관리 시스템(Content Management System)은, 웹 사이트의 구조 또는 그래픽이 아닌, 콘텐츠를 변경하고 수정한다.
콘텐츠 관리 시스템(Content Management System)
- See also: Blog
cPanel is a popular web-based administration tool that many hosting providers provide to allow users to configure their own accounts using an easy-to-use interface.
CSS, or Cascading Style Sheets, is a W3C open standards programming language for specifying how a web page is presented. It allows web site designers to create formatting and layout for a web site independently of its content.
- Related articles: CSS, Blog Design and Layout
- External links: CSS at W3C, Open standards at Wikipedia, W3C.org
CVS stands for Concurrent Versions System and is the software that used to be used coordinate WordPress development. As of February 2005, this function is carried out by Subversion (SVN).
For more information on Subversion, see Using Subversion.
In WordPress a Dashboard is the main administration screen for a site (a weblog), or for a network of sites. It summarizes information about the site or network, and also external information, in one or more widgets that the Dashboard user can enable, disable, and move around.
- Related articles: Dashboard Screen
A database in computing terms is software used to manage information in an organized fashion. WordPress uses the MySQL relational database management system for storing and retrieving the content of your blog, such as posts, comments, and so on.
In WordPress, the database version is a number that increases every time changes are made to the way WordPress organizes the data in its database. It is not the same as the version of the database software, MySQL.
For example, the database version in WordPress 3.3 was 19470, and the database version in WordPress 3.3.1 did not change. This tells anyone planning to use backed-up data from the older version that they do not need to check for changes in the structure of the data.
WordPress stores its database version in the database, as the option named “db_version” in every WordPress site’s “wp_options” table. (The table name prefix “wp_” may be missing or different in some cases.)
Every installation of WordPress has a default theme. The default theme is sometimes called the fallback theme, because if the active theme is for some reason lost or deleted, WordPress will fallback to using the default theme.
The WordPress default themes have been:
- Up to Version 2.9.2 the default theme was the WordPress Default theme (sometimes called Kubrick) and was located in the wp-content/themes/default folder.
- Version 3.0 – the Twenty Ten theme
- Version 3.2 – the Twenty Eleven theme
- Version 3.5 – the Twenty Twelve theme
- Version 3.6 – the Twenty Thirteen theme
- See also: Twenty Ten theme, Twenty Eleven theme, Twenty Twelve theme, Twenty Thirteen theme
- Related articles: Child Themes
Deprecated functions or template tags are no longer supported, and will soon be obsolete.
- Related articles: “Deprecated Functions” Category
A developer, or dev, is a computer programmer who is active in creating, modifying, and updating a software product.
DNS, the domain name system, is the system that maps domain names to IP addresses. When you use a web browser to visit a website, your browser first extracts the site’s domain name from the URL. Then it uses the DNS to find the IP address for that domain name. Then it connects to that IP address.
- External link: Domain Name System (Wikipedia)
DOM (Document Object Model) is a standard, platform-independent interface that allows programmers to dynamically access HTML and XML to control the content and structure of documents. DOM connects programming scripts to web pages.
A domain name is a name used for identification purposes on the Internet. In WordPress a domain name usually identifies a server where WordPress is installed. To make this work, the Internet’s domain name system (DNS) maps the domain name to a server’s IP address. For example, the domain name example.com maps to the IP address 220.127.116.11. Many domain names can map to the same IP address, allowing a single server to run many websites. For example, the the domain names www.example.com and example.net also map to the IP address 18.104.22.168.
- External link: Domain name (Wikipedia)
The draft post status is for WordPress posts which are saved, but as yet unpublished. A draft post can only be edited through the Administration Panel, Write Post SubPanel by users of equal or greater User Level than the post’s author.
An excerpt is a condensed description of your blog post and refers to the summary entered in the Excerpt field of the Administration > Posts > Add New SubPanel. The excerpt is used to describe your post in RSS feeds and is typically used in displaying search results. The excerpt is sometimes used in displaying the Archives and Category views of your posts. Use the Template Tag the_excerpt() to display the contents of this field. Note that if you do not enter information into the Excerpt field when writing a post, and you use the_excerpt() in your theme template files, WordPress will automatically display the first 55 words of the post‘s content.
An excerpt should not be confused with the teaser, which refers to words before the
in a post’s content. When typing a long post you can insert the
Quicktag after a few sentences to act as a cut-off point. When the post is displayed, the teaser, followed by a hyperlink (such as Read the rest of this entry…), is displayed. Your visitor can then click on that link to see the full version of your post. The Template Tag, the_content() should be used to display the teaser.
A feed is a function of special software that allows “Feedreaders” to access a site automatically looking for new content and then posting the information about new content and updates to another site. This provides a way for users to keep up with the latest and hottest information posted on different blogging sites. Some Feeds include RSS (alternately defined as “Rich Site Summary” or “Really Simple Syndication”), Atom or RDF files. Dave Shea, author of the web design weblog Mezzoblue has written a comprehensive summary of feeds. Feeds generally are based on XML technology.
Custom Filters differ from custom Actions because custom Actions allow you to add or remove code from existing Actions. Whereas custom Filters allow you to replace specific data (such as a variable) found within an existing Action.
- See also: Action, Hook, Terminology Confusion
- Related articles: Filters, Filter Reference, add_filter()
A footer area is a horizontal area provided by a theme for displaying information other than the main content of the web page. Themes may provide one or more footer areas below the content. Footer areas usually contain widgets that an administrator of the site can customize.
In a theme, footer areas are generated by a template file, typically named sidebar-footer.php.
- See also: Sidebar
- Related articles: Templates, Customizing Your Sidebar, Stepping Into Templates, Template Hierarchy
The front end is what your visitors see and interact with when they come to your website, www.YourSite.com.
FTP, or File Transfer Protocol, is rather predictably, a client-server protocol for transferring files. It is one way to download files, and the most common way to upload files to a server.
An FTP client is a program which can download files from, or upload files to, an FTP server.
As defined by Andy Skelton, Gallery, introduced with WordPress 2.5, is specifically an exposition of images attached to a post. In that same vein, an upload is “attached to a post” when you upload it while editing a post.
In the uploader there is a “Gallery” tab that shows all the uploads attached to the post you are editing. When you have more than one attachment in a post, you should see at the bottom of the Gallery tab a button marked “Insert gallery”. That button inserts a shortcode “” into the post. WordPress replaces that shortcode with an exposition of all images attached to that post. Non-image file types are excluded from the gallery.
Note: If you don’t see the “Insert gallery” button, it may be because you have not attached two images to the post.
The gettext system is a set of tools and standards for language translation, used by WordPress to provide versions in many languages. In WordPress a text string for translation may have a domain and a context. For example, a plugin might specify its own domain for translations, and a context might help translators to provide different translations of the same English word or phrase in different parts of the user interface.
- Related articles: WordPress in Your Language, Translating WordPress, I18n for WordPress Developers
- External links: gettext (Wikipedia), GNU gettext
GMT (“Greenwich Mean Time”, the time at the Royal Observatory in Greenwich, England) is the old name of the time zone from which all other time zones were measured. It has been replaced by UTC (“Universal Time, Coordinated”), but for most practical purposes UTC and GMT are the same, so the term GMT is still commonly used.
A gravatar is a globally recognized avatar (a graphic image or picture that represents a user). Typically a user’s gravatar is associated with their email address, and using a service such as Gravatar.com. The site owner to can configure their site so that a user’s gravatar is displayed along with their comments.
- How to Use Gravatars in WordPress
- See also: Avatar
- Related articles: Using Gravatars
- External links: Gravatar at Wikipedia
A hack is a bit of code written to customize or extend the functionality of a software product. Older versions of WordPress used a hack-based extension system, but versions 1.2 and above of WordPress use a Plugin API with hooks for extensions.
- See also: Hacking, Plugin
- Related articles: Changelog, Hacking WordPress, Plugin API
- External links: Open source at Wikipedia
Hacking is the process of writing code for, or contributing code to, a piece of software.
There is some controversy surrounding the meaning of this term. It began as a benign term meaning “to exercise proficiency” or “to alter or improve,” but the popular media have since construed it to mean “to break into a computer system, usually with malicious intent.” Many in the computer industry have recently begun trying to ‘take back’ the word from its popular mutation, and many have adopted the term cracking to replace the malicious interpretation. Because of the desire to reclaim the word, you will often find the term used in conjunction with open source projects, intended in its benign form. For more information about the history of the term, please see Wikipedia’s article on Hacker.
Hooks are specified, by the developer, in Actions and Filters. Here is a (hopefully) complete list of all existing Hooks within WordPress.
Because Hooks are required by Actions and Filter you may here the phrase “Action Hooks” and “Filter Hooks” used from time to time.
In technical and strict terms: a Hook is an event, i.e. event as understood by Observer pattern, invoked by the do_action() or apply_filters() call that afterwards triggers all the action or filter functions, previously hooked to that event using add_action() or add_filter(), respectively.
Actions, Filters and Hooks are also occasionally referred to as “action/filter hooks” or “action/filter/hook functions”.
A hosting provider is a company or organization which provides, usually for a fee, infrastructure for making information accessible via the web. This involves the use of a web server (including web server software such as Apache), and may involve one or more related technologies, such as FTP, PHP, MySQL, and operating system software such as Linux or Unix.
- Related articles: Hosting WordPress
A .htaccess file is a granular configuration file for the Apache web server software, used to set or alter the server’s configuration settings for the directory in which it is present, and/or its child directories.
- See also: chmod
- Related articles: htaccess for subdirectories, Using Permalinks, UNIX Shell Skills, Changing File Permissions
WordPress strives to conform to the XHTML standard.
An IP address is a unique number (e.g. 22.214.171.124) assigned to a computer (or other internet-capable information appliance, such as a network printer) to enable it to communicate with other devices using the Internet Protocol. It is a computer’s identity on the internet, and every computer connected to the internet is assigned at least one — although the methods of assigning these addresses, and the permanence and duration of their assignment, differ according to the use of the computer and the circumstances of its internet use.
Every web server is assigned an IP address as well, but often times hosting providers will assign multiple IP addresses to one computer, in the event that multiple web sites reside on the same physical server. This is the case with most inexpensive ‘managed’ or ‘group’ hosting packages.
Domain names were created to provide an easier means of accessing internet resources than IP addresses, which are cumbersome to type and difficult to remember. Every domain name has at least one corresponding IP address, but only a small number of IP addresses have a domain name associated with them, since only computers that are servers require domain names. The domain name system (DNS) is what maps domain names to IP addresses.
- External links: IP address (Wikipedia)
ISAPI (Internet Server Application Programming Interface) is a set of programming standards designed to allow programmers to quickly and easily develop efficient Web-based applications. Developed by Process Software and Microsoft Corporation, ISAPI is intended to replace CGI programs.
- External links: ISAPI at Wikipedia
Linux is an open source computer operating system, created by Linus Torvalds, similar in style to Unix. It is popular in web server and other high-performance computing environments, and has recently begun to gain popularity in workstation environments as well.
- External links: Linux at Shortopedia
Mac OS X
Mac OS X is an operating system specifically for modern Macintosh computers. The operating system was commercially released in 2001. It consists of two main parts: Darwin, an open source Unix-like environment which is based on the BSD source tree and the Mach microkernel, adapted and further developed by Apple Computer with involvement from independent developers; and a proprietary GUI named Aqua, developed by Apple.
- Related articles: UNIX Shell Skills
Meta has several meanings, but generally means information about. In WordPress, meta usually refers to administrative type information. As described in Meta Tags in WordPress, meta is the HTML tag used to describe and define a web page to the outside world (search engines). In the article Post Meta Data, meta refers to information associated with each post, such as the author’s name and the date posted. Meta Rules define the general protocol to follow in using the Codex. Also, many WordPress based sites offer a Meta section, usually found in the sidebar, with links to login or register at that site. Finally, Meta is a MediaWiki namespace that refers to administrative functions within Codex.
- External links: Wikipedia’s Article on Meta
Microformats provide a way for programs to read certain information in web pages without making the pages look any different to humans. They add semantics to the generic HTML markup in order for these programs to understand the meaning of specific parts of a web page content which is better recognized by humans. For example, a web page displaying a user’s profile could use microformats to make it easy for a program to extract the user’s contact information so that it can be added to an address book in a single operation. In WordPress, some themes and plugins support some microformats.
MIME stands for Multipurpose Internet Mail Extension and is an Internet standard that extends the format of email to support:
- Text in character sets other than ASCII
- Non-text attachments
- Message bodies with multiple parts
- Header information in non-ASCII character sets
MIME’s use, however, has grown beyond describing the content of email and now is often used to describe content type in general including for the web and as a storage for rich content in some commercial products.
Moblogging is the act of posting to one’s blog via a mobile device, e.g. mobile phone, smartphone or tablet. It is pronounced as mōbə-logging or mōb-logging, or sometimes as mŏb-logging in reference to smart mobs.
mod_rewrite is an extension module of the Apache web server software which allows for “rewriting” of URLs on-the-fly. Rewrite rules use regular expressions to parse the requested URL from the client, translate it into a different URL, and serve the content of this new URL under the original URL or pointing the client to make the new URL request.
Multisite is a feature of WordPress 3.0 and later versions that allows multiple virtual sites to share a single WordPress installation. When the multisite feature is activated, the original WordPress site can be converted to support a network of sites.
- Related article: Create A Network
WordPress also works with MySQL-compatible databases such as MariaDB and Percona Server.
Navigation is the term used to describe text on a page that, when selected, redirects you to a corresponding page elsewhere on the website. Navigation may sometimes be referred to as the menu, links and hyperlinks.
In the WordPress user interface, a network is a collection of separate sites created in a single WordPress installation by the multisite feature. The sites in a WordPress network are not interconnected like the things in other kinds of networks. They are very like the separate blogs at WordPress.com.
In WordPress code the network is known as the site and the sites are known as blogs.
- Related articles: Create A Network
A news aggregator or news (feed) reader is a computer program which tracks syndicated information feeds, via RSS, RDF, or Atom. Most news aggregators allow one to ‘subscribe’ to a feed, and automatically keep track of the articles one has read, similar to an email client tracking read emails.
- External links: News aggregator at Wikipedia
Nonce is used for security purposes to protect against unexpected or duplicate requests that could cause undesired permanent or irreversible changes to the web site and particulary to its database. Specifically, a nonce is an one-time token generated by a web site to identify future requests to that web site. When a request is submitted, the web site verifies if a previously generated nonce expected for this particular kind of request was sent along and decides whether the request can be safely processed, or an notice of failure should be returned. This could prevent unwanted repeated, expired or malicious requests from being processed.
Nonce is usually included in a hidden HTML form field or as a part of an URL and therefore sent with a request by submitting a form field or visitting a link. If a request is not verified, the web site could generate a new nonce in its response and prompt the user to intentionally confirm the repetition of the request. In WordPress, the response message is “Are you sure you want to do this?” by default.
- Related articles: WordPress Nonces
Open source is simply programming code that can be read, viewed, modified, and distributed, by anyone who desires. WordPress is distributed under an open source GNU General Public License (GPL).
- Related articles: GPL, License
- External links: Open Source Initiative, Open Source at Wikipedia, Source Code at Wikipedia
Output Compression is the removal of white spaces, carriage returns, new lines and tabs from your HTML document. This reduces the file size of the HTML document without changing the functionality.
- Related articles: Output Compression
A Page is often used to present “static” information about yourself or your site. A good example of a Page is information you would place on an About Page. A Page should not be confused with the time-oriented objects called posts. Pages are typically “timeless” in nature and live “outside” your blog.
The word “page” has long been used to describe any HTML document on the web. In WordPress, however, “Page” refers to a very specific feature first introduced in WordPress version 1.5.
Perl is an acronym for Practical Extraction and Report Language, but it’s most commonly spelled as a proper name. It’s a very popular and powerful scripting language used for web applications, although its use is being largely replaced by PHP in the mainstream. One of its strengths lies in its speedy and effective use of regular expressions. Its unofficial motto is, “There’s More Than One Way To Do It,” or “TMTOWTDI,” owing to the extreme flexibility of the syntax.
WordPress does not use Perl, and it is therefore not required.
A permalink is a URL at which a resource or article will be permanently stored. Many pages driven by Content Management Systems contain excerpts of content which is frequently rotated, making linking to bits of information within them a game of chance. Permalinks allow users to bookmark full articles at a URL they know will never change, and will always present the same content.
Permissions are security settings restricting or allowing users to perform certain functions. In the case of files on Unix or Linux systems, there are three types of permissions: read, write, and execute. In the case of MySQL databases, there are many more:
DELETE, etc. — although MySQL refers to them as privileges.
- Related articles: Changing File Permissions
PHP is a recursive acronym for PHP: Hypertext Preprocessor. It is a popular server-side scripting language designed specifically for integration with HTML, and is used (often in conjunction with MySQL) in Content Management Systems and other web applications. It is available on many platforms, including Windows, Unix/Linux and Mac OS X, and is open source software.
WordPress is written using PHP and requires it for operation.
- Related articles: Hacking WordPress
- External links: PHP Website, PHP for Designers — by WordPress lead developer Matthew Mullenweg, PHP at OnLAMP
In general computer terms, “ping” is a common utility used in a TCP/IP environment to determine if a given IP Address exists or is reachable. Typically, Ping is used to diagnose a network connection problem. Many times you will be asked, “Can you ping that address?”. That means, does the Ping utility return a success message trying to reach the “problem” IP Address?
- External links: Ping at Wikipedia
핑백은 글의 저자에게 그의 글(블로그 글)에 당신이 링크하였다는 사실을 알려준다. 어떤 블로그에 당신이 작성한 글에 포함하고 있는 링크가 핑백이 가능한 블로그로 연결된다면, 그 블로그의 저자는 핑백 형태로 당신이 그의 글에 링크했다는 사실을 알게된다.
A Plugin is a group of php functions that can extend the functionality present in a standard WordPress weblog. These functions may all be defined in one php file, or may be spread among more than one file. Usually, a plugin is a php file that can be uploaded to the “wp-content/plugins” directory on your webserver, where you have installed WordPress. Once you have uploaded the plugin file, you should be able to “turn it on” or Enable it from the “Plugins” page in the administration interface of your weblog. The WordPress source code contains hooks that can be used by plugins.
Within the context of the WordPress community, a port is a bit of code that has been rewritten to be compatible with WordPress. For example, if someone wrote a plugin for MoveableType, WordPress users may want to find a port of that plugin for WordPress. Port can also be used as a verb: to rewrite a piece of software for a different platform/language.
- External links: Porting at Wikipedia
“기사(articles)”라고도 하고, 때로는 “블로그(blogs)”라고 잘못 사용하기도 한다. 워드프레스에서, “글(posts)”은 블로그를 채우기 위해 작성하는 기사(articles)이다.
A few lowercase words separated by dashes, describing a post and usually derived from the post title to create a user-friendly (that is readable and without confusing characters) permalink. Post slug substitutes the “%posttitle%” placeholder in a custom permalink structure. Post slug should not be changed and is especially useful if the post title tends to be long or changes frequently.
The status of a post, as set in the Administration Panel, Write Post SubPanel is either: Published (viewable by everyone), Draft (incomplete post viewable by anyone with proper user level), or Private (viewable only to WordPress users at Administrator level).
- Related articles: Post Status
Post type refers to the various structured data that is maintained in the WordPress posts table. Native (or built-in) registered post types are post, page, attachment, revision, and nav-menu-item. Custom post types are also supported in WordPress and can be defined with register_post_type(). Custom post types allow users to easily create and manage such things as portfolios, projects, video libraries, podcasts, quotes, chats, and whatever a user or developer can imagine.
- Related articles: Post Types
The process behind the scenes. See below. 🙂
- Related articles: Query Overview, Custom Queries, WP Query, WP User Query
- See also: query string, query variable
A sequence of codes in a Uniform Resource Identifier (URI) that a web page uses to determine what dynamic data to display. The query string in a URI comes after an initial question mark, and may contain several parameters separated by ampersands. WordPress uses query strings to indicate criteria to search for specific posts or sets of posts in the database. The use of query strings is generally believed to impede the indexing of dynamic pages by search engines. For this reason, it is often desirable to use a method such as mod_rewrite to reduce exposure of query strings to search engines and other site visitors.
A variable passed through the query string. For example, in the query string ?category_name=tech&feed=atom, there are two query variables: category_name with a value of “tech”, and feed with a value of “atom”.
A Quicktag is a shortcut, or one-click button, that inserts HTML code into your posts. The <em> (emphasis) and </em> (stop emphasis) HTML tags are example of Quicktags. Some Quicktags, such as <!–contactform–>, insert HTML comment code that is used by plugins to replace text or perform certain actions.
Resource Description Framework. A language used to describe the locations of resources on the web. WordPress can produce output in RDF format that describes the locations of posts. Like RSS, RDF is used for content syndication.
A relative path is the location of a file in relation to the current working directory and does not begin with a slash (/). This is different from an absolute path which gives an exact location.
A relative URI (sometimes called a relative link) is a partial URI that is interpreted (resolved) relative to a base URI.
On the World Wide Web, relative URIs come in two forms:
A relative URI with an absolute path is interpreted relative to the domain root:
/images/icecream.jpg → http://domain.example<strong>/images/icecream.jpg</strong>
A relative URI with a relative path is interpreted relative to the URL of the current document. E.g., on the web page http://domain.example/icecream/chocolate.html,
<strong>strawberry.html</strong> → http://domain.example/icecream/<strong>strawberry.html</strong>
Recordset refers to the group of records or result returned from a database query.
“Really Simple Syndication“: a format for syndicating many types of content, including blog entries, torrent files, video clips on news-like sites; specifically frequently updated content on a Web site, and is also known as a type of “feed” or “aggregator”. An RSS feed can contain a summary of content or the full text, and makes it easier for people to keep up to date with sites they like in an automated manner (much like e-mail).
The content of the feed can be read by using software called an RSS or Feed reader.
Feed readers display hyperlinks, and include other metadata (information about information) that helps people decide whether they want to read more, follow a link, or move on.
The original intent of RSS is to make information come to you (via the feed reader) instead of you going out to look for it (via the Web).
Programs called news aggregators permit users to view many feeds at once, providing ‘push’ content constantly. See Category:Feeds for Codex resources about bringing RSS feeds into WordPress. See also RDF Site Summary.
A written language is Right-to-left when its script flows from the right side of the page to the left.
- Related articles: Right-to-Left Language Support
Web Robots are programs which traverse the Web automatically. They are also called Web Wanderers, Web Crawlers, and Spiders. Search Engines are the main Web Robots. Some Web Robots look for a file named robots.txt on your web server to see what and where they should look for content and files on your web server. Some Web Robots ignore this file.
- Related articles: Search Engine Optimization for WordPress
- External links: Google information about robots.txt, The Web Robots Page
A role gives users permission to perform a group of tasks. When a user logs in and is authenticated, the user’s role determines which capabilities the user has, and each capability is permission to perform one or more types of task. All users with the same role normally have the same capabilities. For example, users who have the Author role usually have permission to edit their own posts, but not permission to edit other users’ posts. WordPress comes with six roles and over fifty capabilities in its role-based access system. Plugins can modify the system.
In WordPress a screen is a web page used for managing part of a weblog (site) or network. The term ‘screen’ is used to avoid confusion with ‘page‘, which has a specific and different meaning in WordPress. For example, the web page used to manage posts is known as the Posts Screen.
A shell is a program which interacts directly with an operating system such as MS-DOS, Unix/Linux, Mac OS X, or others — but it is most commonly associated with Unices. It is often referred to as a ‘console’ or ‘command line’, because it is controlled using typed commands rather than mouse or graphical interface input.
Most often, when interacting with a remote computer (as one would when configuring WordPress), an additional “faux” shell is involved called SSH.
Some popular shell programs are:
A sidebar is a vertical column provided by a theme for displaying information other than the main content of the web page. Themes usually provide at least one sidebar at the left or right of the content. Sidebars usually contain widgets that an administrator of the site can customize.
In a theme, sidebars are generated by a template file, typically named sidebar.php.
- See also: Footer area
- Related articles: Sidebars, Templates, Customizing Your Sidebar, Stepping Into Templates, Template Hierarchy
In the WordPress user interface, a site can simply be the website created by WordPress, or it can be a virtual website created as part of a network by the multisite feature. A site in a network is virtual in the sense that it does not have its own directory on the server, although it has its own URL and it might have its own domain name.
In WordPress code the site is the website created by WordPress. If multisite is in use, then the site is the network website and each virtual website is known as a blog.
- Related article: Create A Network
A slug is a few words that describe a post or a page. Slugs are usually a URL friendly version of the post title (which has been automatically generated by WordPress), but a slug can be anything you like. Slugs are meant to be used with permalinks as they help describe what the content at the URL is.
Example post permalink: http://wordpress.org/development/2006/06/wordpress-203/
The slug for that post is “wordpress-203”.
Smileys (also called Smilies or Emoticons) are stylized representations of a human face, usually displayed as yellow buttons with two dots for the eyes, and a half mouth. Smileys are often used in WordPress Plugins. By default, WordPress automatically converts text smileys to graphic images. When you type 😉 in your post you see when you preview or publish your post.
Related article: Using Smilies
Once upon a time, SPAM was an animal by-product that came in a can and was fodder for many Monty Python sketches, but since the world-wide adoption of the internet as an integral part of daily life, Spam has become synonymous with what is wrong with the internet. Spam, in general terms, is an email or other forms of unsolicited advertising. Spam is very easy to spread throughout the internet, and works on the principle that if you send out thousands, or hundreds of thousands of unsolicited advertisements, scams, or other questionable methods of making money, that you only need a very small percentage of people to be fooled and you will make lots of money.
Common spam these days comes from online gambling sites and those trying to sell drugs for “male enhancement.” Lately, web logs, or blogs, as we call them, have been targeted by spammers to try to increase their site ratings in the search engines. Spammers use various methods to distribute their electronic junk mail, and employ bots, or computer programs to quickly and easily send email or comments to millions of addresses and IPs all over the world.
Spammers can be difficult to track down as they often hijack peoples’ email and IP addresses. When this happens, it may appear a friend sent you the spam, but in fact, the spammer’s bot grabbed your friend’s email address and used it to hide the true source of the spam. WordPress developers and community members are constantly working on more and better ways to combat these annoying spammers as they clog the internet with their garbage. You can help by offering your talents, ideas, suggestions, or just by being vigilant and installing any of the currently-available spam combating tools.
- External links: SPAM at Wikipedia
SSH stands for Secure Shell. It is a communication protocol for connecting to remote computers over TCP/IP. Various authentication methods can be used which make SSH more secure than Telnet.
SSL stands for Secure Sockets Layer and is the predecessor to Transport Layer Security. These are cryptographic protocols for secure communications across an unsecured network like the Internet.
- External links: SSL at Wikipedia
In computer science a string is any finite sequence of characters (i.e., letters, numerals, symbols and punctuation marks).
Typically, programmers must enclose strings in quotation marks for the data to be recognized as a string and not a number or variable name.
- External links: String at Wikipedia
- Related articles: Using Subversion
- External links: Subversion access at wordpress.org, Subversion book at red-bean.com
See RSS: Really Simple Syndication
A Tag is a keyword which describes all or part of a Post. Think of it like a Category, but smaller in scope. A Post may have several tags, many of which relate to it only peripherally. Like Categories, Tags are usually linked to a page which shows all Posts having the same Tag. Tags can be created on-the-fly by simply typing them into the Tag field. By default, tags can be assigned only to the Post and custom post types.
Tags can also be displayed in clouds which show large numbers of Tags in various sizes, colors, etc. This allows for a sort of total perspective on the blog, allowing people to see the sort of things your blog is about most.
Many people confuse Tags and Categories, but the difference is easy: Categories generally don’t change often, while your Tags usually change with every Post and are closer to the topic of the Post.
A tagline is a catchy phrase that describes the character or the attributes of the blog in a brief, concise manner. Think of it as the slogan, or catchline for a weblog.
Task Based Documentation
Task based, or task oriented documentation is writing that takes you through a process/task step-by-step; it is succinct, lacks jargon, is easily understood, and structured entirely around performing specific tasks.
- In order to get to Z, you need to:
- Step x
- Step y
- Step z
Keep in mind that people who need to know how to perform a task usually need answers quick!
A taxonomy allows for the classification of things. In WordPress, there are two built-in taxonomies, categories and tags. These taxonomies help further classify posts and custom post types. Also, custom taxonomies can be defined.
Telnet is a communications protocol used to establish a connection to another computer. Telnet runs on top of TCP/IP and is typically used in conjuction with terminal emulation software to login to remote computers. Telnet is inherently insecure and has largely been replaced by SSH
- External links: Telnet at Wikipedia
In WordPress a template is a file that defines an area of the web pages generated by a theme. For example, there is typically a template for the header area at the top of the web pages, a template for the content, a template for the sidebars, and so on. The templates are like building blocks that make up the complete web page.
A text editor is a program which edits files in plain text format, as compared to binary format. Using a non-text based word processing program (e.g. using Microsoft Word to edit PHP scripts) can cause major problems in your code. This is because non-text based word processing programs insert extra formatting into text files, and can corrupt the files when they need to be interpreted by the interpreter. An editor like Notepad does not insert any extra formatting.
Edit WordPress Files with a text only editor.
Some examples of file formats which need to be edited as plain text:
Some examples of text editor programs:
- BBEdit (Classic Mac OS, Mac OS X, $$$)
- Boxer Text Editor (Windows)
- Coda (Mac OS X, Shareware)
- Codelobster (Windows, Freeware)
- Crimson Editor (Windows, Freeware)
- EditPad (cross-platform)
- EditPlus (Windows)
- Editra (cross-platform, Open Source, Free)
- emacs (Unices, Windows, Mac OS X, Open Source, Free)
- Fraise (Mac OS X, Open Source, Free, based on Smultron)
- gedit (Unices)
- JEdit (cross-platform)
- Kate (Unices)
- Komodo Edit (cross-platform, Open Source, Free)
- Kwrite (Unices)
- Notepad++ (Windows, Open Source, Free)
- phpDesigner (Windows)
- pico (Unices)
- PSPad (Windows, Free)
- Smultron (Mac OS X, Open Source, Free/$) Smultron 4 (req OS-X Lion) (v.cheap in MacApp store)
- SubEthaEdit (Mac OS X, $)
- Sublime Text 2 (Windows, Linux, Mac OS X)
- TextEdit (comes with Mac OS X)
- TextMate (Mac OS X, $)
- TextPad (Windows)
- TextWrangler (Mac OS X, Free)
- vim (Unices, Windows, Mac OS X, Open Source, Free)
- Notepad2 (Windows, Freeware)
- WebTide Editor (Windows, Linux, Mac OS X, Freeware, Java)
Some examples of non-plain text formats that require special software for editing:
- Microsoft Word documents
- Microsoft Excel spreadsheets
- Images, such as JPEG, PNG, or GIF
Some examples of software which can edit text, but which are NOT regarded as basic text editors and NOT recommended for use on WordPress files:
- Microsoft Word
- Microsoft Works
- Microsoft Excel
- Adobe Photoshop
- Adobe Illustrator
- Adobe Dreamweaver
A theme is a collection of files that work together to produce a graphical interface with an underlying unifying design for a weblog. A theme modifies the way the weblog is displayed, without modifying the underlying software. Essentially, the WordPress theme system is a way to skin your weblog.
The Toolbar is an area of the screen just above that site that lists useful admininstration screen links such as add a new post or edit your profile. The Toolbar was added in Version 3.1 as Admin Bar and in Version 3.3 it was replaced by the Toolbar. The toolbar can be turned on/off from the User Profile Screen.
다른 저자의 글에 링크를 하지 않았더라도, 트랙백은 그 저자에게 자신의 블로그에 게시했던 것과 관련 있는 글이 게시 되었음을 알려준다. 다른 저자는 그의 글을 칭찬하거나, 그가 게시한 글과 비슷하거나 또는 더 나은 글이 게시되었다는 사실을 앉아서 알게 된다. 핑백과 트랙백으로, 블로그는 서로 연결되어 있다. 학술 논문과 교과서 한 장(chapter)의 마지막에 있는 감사의 글 및 참조와 같은 것이라고 생각해라.
A Transient is temporal data identified by a custom name, stored in the web server database or memory for fast access. This temporal nature and use of fast memory caching is their primary distinction from Options.
Twenty Ten theme
Starting with Version 3.0, the Twenty Ten theme became the default (and fallback) theme. As described in 2010: A Theme Odyssey, the Twenty Ten theme serves as a good example theme that includes new theme-based features, and looks nice on a public site. Twenty Ten is a community-developed theme.
Up to Version 2.9.2, the default theme was the Kubrick theme and was housed in the wp-content/themes/default folder. The Twenty Ten theme is housed in the wp-content/themes/twentyten folder and was the only theme in the WordPress distribution.
Twenty Eleven theme
Starting with Version 3.2, the Twenty Eleven theme was the default (and fallback) theme. Twenty Eleven is a community-developed theme that emphasizes Post Formats, random theme header images, customizable layouts and colors, HTML 5 improvements, and adherence to WordPress coding standards. It was replaced as the default in Version 3.5 by the Twenty Twenty theme and remains bundled with WordPress.
Twenty Twelve theme
Starting with Version 3.5, the Twenty Twelve theme became the default (and fallback) theme. Twenty Twelve is a fully responsive theme that looks great on any device. Features include a front page template with its own Widgets, an optional display font, styling for Post Formats on both index and single views, and an optional no-sidebar page template.
Twenty Thirteen theme
A widely supported and preferred character encoding system.
For a computer to display letters (or any text characters), it needs to enumerate them – create an index of characters it knows how to display. These indexes are known as character sets. This is invaluable for users hosting WordPress in a non-English language.
The most widely used collections of these character sets are the iso-8859 with iso-8859-1 and iso-8859-15 (which contains the euro sign and some characters used in Dutch, French, Czech and Slovak) being the most common; they are also known as Latin1 and Latin9. These character sets use 8 bits (a single byte) for each character, allowing for 255 different characters (256, counting null). However, when considering that Latin-based languages aren’t the only ones in the world (think Japanese or Hebrew), 255 characters aren’t nearly enough.
There is a wide index of characters known as Unicode. Unicode has so many characters that sometimes more than 16 bits (2 bytes!) are required to represent them. Furthermore, the first 127 characters of Unicode are the same as the first 127 of the most widely used character set – iso-8859-1. For this purpose, UTF, the Unicode Translation Format, was created. UTF uses different numbers of bits for characters, and allows for the entire range of Unicode to be used. What you should probably know is:
- UTF-8 is an 8-bit-minimum type of UTF. There are also UTF-16 and UTF-32.
- If your document is in a Latin-based encoding, you probably don’t need to change anything about it for it to be UTF.
- A single UTF document can be in various languages with no need to switch encodings halfway through.
- External links: Joel Spolsky on Unicode
Unix, or UNIX, is a computer operating system developed at AT&T’s Bell Laboratories starting back in 1969. Initially designed with the objective of creating an OS written in a high level language rather than assembly, a majority of web servers currently run on different “flavors” of this high-performance OS, or on Linux, developed as a Unix-like operating system.
Unix Time, or a timestamp, is a method of tracking time by determining the approximate number of seconds from a particular event. That event is called an Epoch. Since this time format is only off by a few seconds each century, it is usually considered good enough for most applications.
Unix time is (currently) a ten digit number, and looks like this: 1229362315. WordPress often uses a Unix timestamp internally to track time. The human readable times and dates you see are converted from Unix Time or from a MySQL DATETIME field.
UTC (“Universal Time, Coordinated”) is the basis of international time standards from which time zones around the world are calculated. For most purposes it is the same as the older GMT standard.
- External link: UTC (Wikipedia)
A web server is a computer containing software for, and connected to infrastructure for, hosting, or serving, web sites written in HTML. The most common web server software on the internet is Apache, which is frequently used in conjunction with PHP, Perl, and other scripting languages.
It is possible to create one’s own web server, hosted on any speed of internet connection, but many people choose to purchase packages from hosting providers, who have the capacity and facilities to provide adequate bandwidth, uptime, hardware, and maintenance for frequently-visited web sites.
- Related articles: Hosting WordPress
In WordPress a widget is a self-contained area of a web page that performs a specific function, or the code that generates such a self-contained area. For example, WordPress has a built-in widget that displays a list of pages in a weblog’s sidebar, and it has another built-in widget that displays a list of recent comments in the Dashboard. Plugins and themes can provide additional widgets.
Furthermore, a “Widget Area” is a pre-defined location, in the code of your WordPress Theme, that allows users to place Widgets into.
The XHTML Friends Network. A decentralised project to have inter-blog links that represent relationships between bloggers. XFN links resemble
<a href="http://www.photomatt.net/" rel="friend met">Photo Matt</a>.
WordPress strives to conform to the XHTML 1.0 Transitional standard.
XML, or Extensible Markup Language, is written in Standard Generalized Markup Language (SGML) and essentially allows you to define your own markup language. XML is extremely useful in describing, sharing, and transmitting data across the Internet. Typically used in conjunction with HTML, XML defines data and HTML displays that data.
- External links: Extensible Markup Language (XML) Resources at W3C org XML 4.0 FAQ, Overview of SGML Resources at W3C org
XML-RPC is Extensible Markup Language-Remote Procedure Call. A Remote Procedure Call (RPC) allows you to call (or request) another application and expect that application to honor the request (answer the call). So, XML-RPC allows a user (or developer) to send a request, formatted in XML, to an external application.
- Related articles: XML-RPC Support
- External links: Dave Winer’s XML-RPC for Newbies, XML-RPC Home Page, Apache XML-RPC, XML-RPC for PHP Homepage, XML-RPC at Wikipedia
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Karen C Alleyne has the following 2 specialties
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Karen C Alleyne has the following 13 expertise
- Personality Disorder
- Bipolar Disorder
- Depressive Disorder
- Sleep Disorders
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Mental Illness
- Holistic Health
- Manic Depressive Disorder
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
- Mood Disorders
Dr. Karen C Alleyne has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 16
Patients' Choice Award (2015, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
On-Time Doctor Award (2015, 2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Compassionate Doctor Recognition (2014, 2015)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Lsu Health Sciences
Dr. Karen C Alleyne accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
- CareFirst BlueChoice Advantage
- CareFirst BluePreferred PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Dr. Karen C Alleyne is similar to the following 3 Doctors near Silver Spring, MD. | <urn:uuid:fcc6e6b5-ee81-4f67-be54-5048ac7a0d95> | {
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ICD-10-CM Code H91.92
Unspecified hearing loss, left ear
Billable CodeBillable codes are sufficient justification for admission to an acute care hospital when used a principal diagnosis.
H91.92 is a billable ICD code used to specify a diagnosis of unspecified hearing loss, left ear. A 'billable code' is detailed enough to be used to specify a medical diagnosis.
The ICD code H91 is used to code Hearing loss
Hearing loss, also known as hearing impairment, or anacusis, is a partial or total inability to hear. An affected person may be described as hard of hearing. A deaf person has little to no hearing. Hearing loss may occur in one or both ears. In children hearing problems can affect the ability to learn language and in adults it can cause work related difficulties. In some people, particularly older people, hearing loss can result in loneliness. Hearing loss can be temporary or permanent.
|ICD 9 Code:||389|
The international symbol of deafness and hearing loss
- DRG Group #154-156 - Other ear, nose, mouth and throat diagnoses with MCC.
- DRG Group #154-156 - Other ear, nose, mouth and throat diagnoses with CC.
- DRG Group #154-156 - Other ear, nose, mouth and throat diagnoses without CC or MCC.
Equivalent ICD-9 Code GENERAL EQUIVALENCE MAPPINGS (GEM)
This is the official approximate match mapping between ICD9 and ICD10, as provided by the General Equivalency mapping crosswalk. This means that while there is no exact mapping between this ICD10 code H91.92 and a single ICD9 code, 389.9 is an approximate match for comparison and conversion purposes. | <urn:uuid:fccf341e-fee5-4051-a8d0-f62e3a87b95b> | {
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|Guide for beginners and administrators|
Begin with PC
PC basics: history
1946 ENIAC (Electronic Numerical Integrator and Computer) - First electronic computer introduced in 1946 in Penn State University, USA. It contained 18 thousand vacuum tubes and thousands of capacitors, resistors and relays. Cooling was provided by two jet engines. It weighed 30 tons and took up 150 m2. It consumed 180 kW of power and it could perform roughly 5000 operations per second. Programming was executed by manipulating switches. It was used by American army.
1960/1970 - The Unix operating system was founded.
1967 The Advanced Research Projects Agency Network (ARPANET), the predecessor of Internet, was founded.
1971 The Intel's first microprocessor: 4004
1975 MITS Altair 8800 - A milestone in the history of personal computers introduced in the Popular Electronics Magazine. It was sold for 395 USD. Paul Allen and Bill Gates began the development of BASIC for Altair and founded Microsoft.
1976 Steve Jobs and Steve Wozniak founded the Apple Computer company and began the sale of the Apple I PC. It had no keyboard, monitor or source, it was just a basic system unit in a wooden box.
1977 Apple II
1981 IBM PC. Intel 8088 Processor, 16KB memory, floppy disk 160 KB and black/white monitor 11,5", operating system Microsoft MS-DOS 1.0. At the beginning of 80's, 80 % of all computers were using the MS-DOS OS, the rest were using other operating system, mostly MAC OS and Unix.
1984 IBM PC AT. Intel 80286 8 MHz Processor, 512 KB RAM, floppy disk 1,2 MB, HDD 12 MB and 12" monitor.
1985 Microprocessor Intel386™
1987 Apple Macintosh II. It was based on CPU Motorola MC68020, 16 MHz. Other components varied: 40 - 80MB HDD, from xxx KB up to 68MB RAM.
1989 The Intel486™ processor
1991 WWW (World Wide Web) was founded
1992 Microsoft Windows 3.1 was brought on the market and sold more than 25 million licenses within the first year. Intel: 80286,
1994 Linux 1.0 was introduced.
1995 Microsoft Windows 95 was brought on the market. Intel® Pentium® Pro Processor
1996 Windows NT 4.0
1997 Intel® Pentium® II, AMD-K6® processor
1998 Microsoft Windows 98 was brought on the market.
1999 Microsoft introduced the Internet Explorer 5 . More than 1 million copies of IE 5 were downloaded within a week. Some other new products appeared on the market: Microsoft: Office 2000; Intel: Pentium III. AMD Athlon™ processor. With the upcoming year of 2000, everybody feared that machines which used 2 digits in a year would not be able to process a year with 4 digits. However, most worries proved pointless.
2000 Windows ME and Windows 2000 Professional and Server. Intel® Pentium® 4 processor. AMD Athlon™ 1Ghz processor.
2001 Windows XP, Office XP
2003 News: Microsoft Windows 2003 Server, Microsoft Office 2003. AMD introduced AMD Opteron and AMD Athlon™ 64 processors, built on the AMD64 technology.
2006 Intel® Core™2 Processors
July 2006 - Microsoft ended the support for Windows 98 and ME - no new updates will be released
2007 - New products on the market: Windows Vista, Windows Longhorn Server, Office 2007. Prices of processors and PCs continuously fall. PCs with Internet connection are predicted to be part of every household. Speculations about OS market leaders arise. Linux popularity grows, though mostly on servers. Parameters of a standard PC: CPU 2Ghz and higher, 512MB RAM (preferably 1GB and higher). 80GB disks and higher become a must. Graphic cards of high quality and DVD drives are recommended. LCD replace older CRT monitors.
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Lupus Get the facts about lupus, including symptoms, risk factors, and the different types.
- Menopause Facts about menopause, including the stages, symptoms, and types.
- Ulcerative Colitis Facts about ulcerative colitis, including causes, signs and symptoms.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Anna E Hatic has the following 1 specialty
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Anna E Hatic has the following 7 expertise
- Weight Loss
- Weight Loss (non-surgical)
Dr. Anna E Hatic has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 3 of 3
Dr Hatic is not only knowledable but also shares her knowledge in an understandable way. She really cares about the patient and is open to discussion about options in the care of the patient. I know many doctors and believe she is quite exceptional when it comes to interactive wth the patient. I'm happy to call her my Doc!
17 Years Experience
Ohio State University College Of Medicine
Graduated in 2001
Dr. Anna E Hatic accepts the following insurance providers.
- Anthem Blue Access PPO
- Anthem Blue Preferred HMO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- HealthSpan Access PPO
Medical Mutual of Ohio
- MMOH SuperMed PPO Plus
Premier Health Plan
- Premier HealthOne
SIHO Insurance Services
- SIHO Network
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsFamily Health, 5735 Meeker Rd, Greenville, OH
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. James H Kim has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. James H Kim has the following 8 expertise
- Newborn Medicine (Neonatology)
- Weight Loss
- Weight Loss (non-surgical)
- Family Planning
Dr. James H Kim is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 5 of 8
This last visit was the thing that finally pushed me over the edge to NEVER return to this office. First of all I called for an emergency visit and was told they couldn't squeeze me in and I would have to wait until the next day. When I finally got to get in there after dealing with what was wrong, as always Dr Kim tried pushing blood tests on me as well as tellin me his wife could give me a pelvic exam. It is noted in my file that I already have othe doctors for those specific things, why am I still having this PUSHED on me?! As I'm leaving I made sure I asked again if I would get a phone call for my lab results since the doctor completely avoided that, the receptionist told me I would. 5 days passed with no phone call and when I called them, Dr Kim did not apologize. Just told me "mistakes happen" and I should have called them. If I'm told ill get a call of my results, I should no matter what. I'm beyond angry and am with this place every time I go. I'm definitely finding a new doctor after this!
Patients' Choice Award (2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
46 Years Experience
Seoul National University
Graduated in 1972
Dr. James H Kim accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Anthem Blue Access PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL Blue Advantage HMO
- BCBS IL HMO Illinois
- BCBS IL PPO
Coventry Health Care
- Coventry Health and Life IL PPO
- Coventry HealthAmerica PPO
- Coventry IL PPO
- Coventry PPO Platinum
- First Health PPO
- HealthLink PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana National HMO
- Humana Preferred PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Dr. James H Kim is similar to the following 3 Doctors near Grayslake, IL. | <urn:uuid:5feaf9c8-f67e-41b1-b921-17b04266fd97> | {
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A little over a year ago, Silicon Graphics, Inc. (SGI, http://www.sgi.com) announced a new 64-bit supercomputing platform called the Altix 3000. In a break from its tradition of building large machines with MIPS processors running the IRIX operating system, the Altix uses Intel's Itanium 2 processor and runs -- you guessed it -- Linux. Unlike Beowulf-style Linux clusters, SGI's cache-coherent, shared-memory, multi-processor system is based on NUMAflex, SGI's third-generation, non-uniform memory access (NUMA) architecture, which has proven to be a highly-scalable, global shared memory architecture based on SGI's Origin 3000 systems.
A little over a year ago, Silicon Graphics, Inc. (SGI, http://www.sgi.com) announced a new 64-bit supercomputing platform called the Altix 3000. In a break from its tradition of building large machines with MIPS processors running the IRIX operating system, the Altix uses Intel’s Itanium 2 processor and runs — you guessed it — Linux. Unlike Beowulf-style Linux clusters, SGI’s cache-coherent, shared-memory, multi-processor system is based on NUMAflex, SGI’s third-generation, non-uniform memory access (NUMA) architecture, which has proven to be a highly-scalable, global shared memory architecture based on SGI’s Origin 3000 systems.
In fact, the Altix 3000 uses many of the same components — called bricks — that the Origin uses. These bricks mount in racks and may be used in various combinations to construct a desired system. The C-brick is the computational module housing the CPUs and memory; the M-brick is a memory expansion module; the R-brick is a NUMAflex router interconnect module; the D-brick is a disk expansion module; the IX-brick is a base system I/O module; and the PX-brick is a PCI-X expansion module. It’s the C-bricks in the Altix that are different from those in the Origin, because the ones in the Altix are based on Intel’s Itanium 2 instead of MIPS processors.
The Altix C-brick (described in Figure One) consists of two nodes, each containing two Itanium 2 processors with their own cache. The front-side buses of these processors are connected to custom ASICs referred to as SHUBs. The SHUBs interface the two processors to the memory DIMMs, to the I/O subsystem, and to other SHUBs via the NUMAflex network components. The SHUBs also interconnect the two nodes in a C-brick at the full bandwidth of the Itanium 2 front side bus (6.4 GB/sec).
|Figure One: A block diagram of the Altix C-brick|
The global shared memory architecture, implemented through SGI’s NUMAlink interconnect fabric, provides high cross-sectional bandwidth and allows performance scaling not usually obtained on commodity Beowulf clusters. While some coarse grained applications scale just fine on Beowulf clusters, others need the high bandwidth and very low latency offered by a machine like the Altix. Still other applications are best implemented as shared-memory applications using many processors.
The Altix provides a platform for all these models of parallelism on a 64-processor system running a single copy of Linux, a single system image (SSI). In addition, eight systems can be interconnected with NUMAlink in a dual “fat tree” topology, yielding a 512-processor cluster with as much as 16 TB of global shared memory. The Altix supports MPI and SGI’s Message Passing Toolkit (MPT) for distributed memory parallelism, and OpenMP, SHMEM, and POSIX threads for shared memory parallelism.
The Altix is a promising platform for those who can afford it. Or, for those who want to start small, SGI just released the Altix 350, a department-sized version of the Altix, which scales to sixteen processors.
While the Altix is good news for SGI (since the company will benefit from moving away from completely proprietary hardware and software), it’s great news for Linux and high-performance computing. SGI has contributed much of their work on the Linux kernel back to the community. Moreover, adoption of Linux by large computer vendors like SGI helps dispel the fear, uncertainty, and doubt (FUD) spread by vendors of proprietary, closed operating systems.
While the Altix system is not flawless — Oak Ridge National Labs (ORNL) has experienced problems with MPI/ OpenMP hybrid codes, compiler bugs, optimization problems, and utilization problems requiring specific process/thread placement — the Altix runs pure MPI and pure shared memory applications requiring lots and lots of memory very well right out of the box. While the kinds of problems ORNL’s encountered are expected on new architectures haven’t fully matured, SGI’s willingness to pursue and resolve any problems is very encouraging.
A Chat with SGI
I recently got the chance to interview Dave Parry and Rich Altmeier of SGI and discuss the Altix. Parry is Senior Vice President and General Manager of the Servers and Platforms Group, and Altmeier is Vice President of the Software and Storage Group. Their enthusiasm for their machine and for the Open Source community process were evident throughout our discussion.
FORREST HOFFMAN: What is the market for the SGI Altix?
DAVE PARRY: The markets are different for the 3000 and the 350 series. The 3000 is a high-end product by the standards of Linux, and even a higher-end product than the RISC [Reduced Instruction Set Chipset] systems that compete with it. We see the largest customer adoption of the 3000 in large research institutions and national laboratories — like the Department of Energy’s Oak Ridge National Laboratory and Pacific Northwest National Laboratory, NASA’s Ames Research Center, and others — and in technical commercial organizations of the automotive, engineering, and pharmaceutical industries.
The 350 is a little different. It’s a lower end product targeted at department use. We expect to see it as a “baby brother” to the 3700. The 350 scales to sixteen processors, and we’re now partnering with Voltaire to offer clustered versions of the 350 using their InfiniBand interconnect solutions.
HOFFMAN: What about the SGI Origin, the IRIX operating system, and MIPS processors? Will SGI continue offering these products?
PARRY: We’ll continue to offer Origin, but in the very long term, our architectural and revolutionary research and development will be directed toward the Altix line. Of course the NUMAflex architecture is the same for both the Origin and Altix systems. We’re leveraging the knowledge gained from the Origin 2000 and 3000, but switching to the Itanium 2 processor — which offers higher peak and application performance than MIPS RISC — and running Linux.
[Altix and Origin] are independent, in the sense that the Origin is MIPS and IRIX only, while the Altix is Itanium 2 and Linux only. However, much of the design was carried over [from the Origin to the Altix]. On the software side, the years of development that went into IRIX is being ported over as improvements to Linux. Under Linux, that software is either being contributed to the community or, in a few cases, being put out as new products.
RICH ALTMEIER: Another advantage of Altix is the tons of other software available for Linux. SGI isn’t the only source of software, as is the case with the MIPS environment.
HOFFMAN: Will we see future MIPS and IRIX releases?
PARRY: Yes. MIPS processors will undergo evolutionary enhancements, and we continue providing on-going releases of IRIX. We have a sustaining engineering strategy [for MIPS and IRIX] to protect the investments of our existing customers.
ALTMEIER: Future IRIX releases will provide bug fixes and feature enhancements as we’ve done for almost six years now.
HOFFMAN: What about your high-end graphics customers? Are they shifting to Altix?
PARRY: Some of that customer base is transitioning from proprietary systems to open systems, but other transitions are occurring in high-end graphics. For instance, we are moving from large, monolithic graphics pipes to aggregation of multiple graphics pipes. Today, we have [the Onyx4] UltimateVision using 32 graphics processors on one shared memory backbone to provide the composition capabilities that you’d expect only from large graphics clusters. We are seeing customer interest in graphics on Altix and Linux, but lots of customers are still using and buying new Onyx systems.
HOFFMAN: Will the Altix evolve as Intel’s Itanium processor matures?
PARRY: Yes. We had an internal effort to develop the Altix using the original Itanium processor. We built that system on the same architecture as the Origin 3000. That system was used by Rich’s group for early development work on NUMA capability, scalability, and I/O performance. The 3700 was introduced just over a year ago with the Itanium 2 (code named “McKinley”), then as “Madison” [Intel's follow-on Itanium 2 processor] became available last June or July, we began offering those as well.
HOFFMAN: What’s next for Altix? Will you continue scaling to higher processor counts or will you backfill with smaller systems like the 350?
PARRY: Yes to both. We intend to push the Altix product out in all directions. We will be building larger, more scalable versions of the 3700, as well as pushing on more optimal price-to-performance solutions and having better software and broader third party hardware support.
ALTMEIER: You haven’t seen the top end!
HOFFMAN: Your advertised configurations scale nodes to 64 processors, but I know here at Oak Ridge National Laboratory we’re running a single Linux image on a 256 processor Altix with reasonable success.
PARRY: We’ve been shipping systems with up to 64 processors in a single Linux kernel, and we’ve been consistently growing the memory size of the supercluster as it scales from 128 processors to 256, and, as of last December, to 512 processors, all in a single coherent shared memory environment with each chunk being managed by a single operating system image. At the same time we’ve had a beta program, and will soon productize the 128 processor [configuration]. The 256 processor [configuration] isn’t a product yet, but we already have a NASA customer running a single system image on 512 processors.
ALTMEIER: We persistently advance the kernel’s support for scaling. This is a “must-accomplish” kind of task for SGI.
HOFFMAN: Were dramatic modifications in the kernel required to support the Altix and NUMA architecture?
ALTMEIER: The surgery is not as radical as all that, and we tried to work very closely with the Linux community. Only a handful of technologies were required to get the kernel working on the system, including NUMA support (for discontiguous memory, some virtual memory enhancements, and local memory allocation), the “O(1)” scheduler (needed for large processor counts), kernel lock improvements (in which SGI was a participant), and a variety of bug fixes that were contributed back to the community. We’ve checked most of our work back in at kernel.org. We’ve not hacked up the kernel for our hardware and you can get the standard kernel.org kernel to run on the machine.
HOFFMAN: Is SGI responsible for adding NUMA support in the 2.6 kernel?
ALTMEIER: We participated in development of NUMA support in 2.6, but many others contributed as well, including NEC, IBM, and other community participants. We see tremendous value in these Linux community efforts. We are impressed by the broad range of testing and [the number of] people hammering on the system. Bugs are fixed very quickly.
HOFFMAN: What other contributions has SGI made to the Linux community?
ALTMEIER: Our XFS high-performance journaling filesystem recently entered the 2.4.25 maintenance stream. It has been in 2.6 longer, but it’s been five years since we first did the GPL release. It was a long road, but we have a very strong commitment to Linux and the community process. We think it facilitates the whole ecosystem [of software], resulting in stronger products with more features.
We’ve made other contributions as well. I already mentioned kernel enhancements like CPUMemSets for processor and memory placement, the Linux kernel debugger called kdb, kernprof for kernel profiling, lockmeter, and DISCONTIG. A variety of other filesystem, storage, and graphics work, many ported from IRIX, are open source projects from SGI. Other products are not open source, like the CXFS cluster filesystem. which makes a SAN really useful by allowing all machines shared access the filesystem.
PARRY: While CXFS isn’t an open source project, it’s not a closed proprietary product. It’s offered on IRIX, Solaris, Mac OS X, Linux, Windows, and AIX. Most HPC [high performance computing] customers have a rich mixture of heterogeneous systems, but want to manage all their data as one entity. CXFS enables customers to have a single solution for direct filesystem performance and get the benefits of aggregation.
HOFFMAN: Are you happy with the Intel compilers?
ALTMEIER: The Intel compilers are doing a good job. The Itanium is the fastest processor on the planet and we want the compiler to deliver that performance to scientific applications. Although we’re happy, we’re never satisfied.
HOFFMAN: I know some people have experienced problems with complex hybrid MPI/OpenMP codes on the Altix because of Intel’s implementation of OpenMP in the 7.x compilers. Is that fixed by the 8.0 compilers? Are there new problems in the 8.0 compilers?
|Figure Two: Don Maxwell (left) and Sergey Shpanskiy administer RAM, the SGI Altix 3700 supercluster at Oak Ridge National Laboratory. RAM has 256 1.5 GHz Intel Itanium 2 processors, 2 TB of global shared memory, 12 TB of disk storage, and a peak performance of 1.5 teraflops.|
ALTMEIER: We focused first on MPI and on OpenMP second, so there was some catching up to do.
PARRY: The level of maturation and improvement in OpenMP in the last nine months has been phenomenal. A year ago it was lackluster. Now with 8.0 we are seeing really solid OpenMP performance.
ALTMEIER: In the 8.0 compiler, Intel upgraded the front end, but some of the fine tuning isn’t quite there and a number of algorithms are not giving the results we want. 8.0 provided functional enhancements, but some optimizations have regressed a bit. These problems should be quickly rectified. We’re working closely with Intel to ensure that they are.
HOFFMAN: Some scientific applications do not scale well on typical Beowulf-style clusters. Are you finding that to be the case on the Altix?
PARRY: We were surprised, having been down this path with Origin and IRIX. We knew there would be things we had to fix, but were confident that we would be able to get to a system that scaled well for HPC workloads. In fact, we got better scalability than we expected.
ALTMEIER: My theory is that Linux design centers around short code paths, often not aimed at SMP [symmetric multi-processing] at all. There’s nothing better than a low-level thing for which we can crank operations per second. SMP-parallelized code is not the only way to get the operations per second you need. For typical kinds of intense compute workloads, people are seeing good scalability.
HOFFMAN: Any final thoughts?
ALTMEIER: We have this great ccNUMA [cache-coherent non-uniform memory access] architecture that is fundamentally a shared memory machine offering a productive programming environment. It’s a finely tuned machine from the processors to the compilers to the run-time libraries. We think it’s criminal to see someone not getting superior performance, and we work to correct that situation. The Altix augments clusters very well. It fits right in with Beowulf cluster environments that customers may already be using.
PARRY: One of the things we’re most proud of with Altix is that we made a decision early on in the product life-cycle to do things that hadn’t been done with Linux systems before.
We’re seeing, using a powerful processor and an open source environment, that we are delivering capabilities that no one else can deliver.
Our goal on the Origin and now on Altix is to provide an environment that will work well with mixed applications. Regardless of the programming style or parallel algorithm, our system competes with any other at running MPI jobs and delivers capabilities like OpenMP, and “pthreads” [POSIX threads] at the same time on the same system.
People often ask if a code is a cluster application or a shared memory application. We think it’s more important to consider whether it’s an implicitly or explicitly parallel application. Depending on the answer, you usually either cast the application onto a big SMP or a large cluster with a high performance, low latency interconnect. The Altix provides both on the same architecture, all running a single system image.
Forrest Hoffman is a computer modeling and simulation researcher at Oak Ridge National Laboratory. He can be reached at email@example.com. | <urn:uuid:9d68c392-bfb2-4764-a14c-4bd2781ebee0> | {
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
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Dr. Raymond P Dipasquo has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Raymond P Dipasquo has the following 6 expertise
- Weight Loss
- Family Planning
Dr. Raymond P Dipasquo has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 36
Probably the worst doctor I've ever been too. Spends 4 mins tops and you have to wait at least an hour because he comes in an hour after his first patient. I made an appt with him to be the first patient and didn't get seen for well over an hour and everyone in the office made it seem like on he's actually here on time. It's disrespectful to patient's, our time is valuable too. Then refused to fill some of my medications that I've been on for over 5 years and they aren't even controlled medications. I've just never seen such a negative and incompetent doctor who obviously doesn't know much. I went to a new doctor and they said he's know for all of this and they also refilled my medications with no problem at all. She was baffled and said it sounds like he's stuck inn the 1950s
Dr. Dipasquo is a nice guy and he takes the time with you. However, he will not call you to talk about test results even when you state that you have questions. He has his nurse call and Sarah is a witch! She is the main reason I left. Read all the other reviews about her. She's bad for the practice. I know of two other people leaving because of her. Rude, rude, rude!!!!
Dr dipasquo saved my life. I have been able to hold n love two of my 7grandbabies, because of him. Dr dipasquo LISTENED TO "ME", unlike another doctor I had been seeing other Dr was treating me for an,ULCER. Dr dipasquo had successfully diagnosed me with stage one esophageal cancer, which is totally unheard of. His staff, especially his nurse, has always gone over and beyond!!!!! Thank god for all !!!!!!! You would be so very fortunate to be his patient
Patients' Choice Award (2012)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2012, 2013)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
35 Years Experience
Chicago College Of Osteopathic Medicine
Graduated in 1983
Dr. Raymond P Dipasquo accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry Health and Life IL PPO
- Coventry HealthAmerica PPO
- Coventry IL PPO
- Coventry MO PPO
- Coventry PPO Platinum
- CoventryOne PPO Network
- First Health PPO
- HealthLink PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana National HMO
- Humana Preferred PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsHeart Care Center Of Illinois, 12701 W 143rd St Ste 250, Homer Glen, IL
Take a minute to learn about Dr. Raymond P Dipasquo in this video.
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Note: This report is greater than 5 years old. Findings may be used for research purposes, but should not be considered current.
This report is from AHRQ's Data Points Publication Series.
From 2001 to June 2011, the number of centers providing proton beam therapy grew from 3 to 10. From 2006 to 2009, the number of Medicare beneficiaries receiving proton beam therapy nearly doubled.
The near doubling of Medicare beneficiaries receiving proton beam therapy from 2006 to 2009 was due to a 68 percent increase in use for "conditions of possible benefit," mostly prostate cancer, with no increase in use for commonly accepted indications.
Prostate cancer is the most common condition for which a Medicare beneficiary recieves proton beam therapy.
CMS has yet to issue a national coverage rule for proton beam therapy or its specific indications.
Proton beam radiotherapy is a form of external beam radiation that offers better precision for localized dosage than other types of external beam radiotherapy. Because proton beams deposit most of their energy during the final portion of their trajectory, they diminish the risk of damage to tissue surrounding the tumor and thus allow for higher treatment doses with fewer side effects. Proton beam radiotherapy has been used in research applications since the 1950s and entered clinical practice in the United States in 1990.
No randomized controlled trials and only a few well-conducted cohort studies have compared proton beam radiation to other treatments. In the absence of evidence of clinical superiority, proton beam radiotherapy has gained acceptance based on a theoretical advantage for the treatment of specific cancers. Agreement is strongest for the use of proton radiotherapy for (1) tumors surrounded by critical structures such as the eye, brain, and spinal cord that preclude or complicate resection or other radiation techniques, or (2) tumors for which other treatments are not very effective. For example, proton beam radiotherapy is preferred for solid tumors in children because it minimizes detrimental effects of radiation on developing structures surrounding the tumor and reduces the risk of long-term side effects.
In January 2001, three proton beam treatment centers were operating in the United States (Loma Linda, California; Massachusetts General Hospital in Boston; and the University of California, San Francisco). By 2006, three additional centers had opened at Indiana University in Bloomington, M.D. Anderson Cancer Center in Houston, and the University of Florida in Gainesville, followed in 2009 by another in Oklahoma City. By June 2011, the United States was home to 10 proton beam treatment centers, with many more proposed or under construction
The number of proton beam centers also increased worldwide, from 17 centers operating outside of the United States in 2001 to 29 in 2011.
The Centers for Medicare & Medicaid Services (CMS) has yet to release a national coverage or noncoverage determination for proton beam radiotherapy, so local Medicare administrative contractors (previously known as fiscal intermediaries or carriers) have the authority to develop local coverage decisions (LCDs). Local advisory committees (with membership primarily comprising physicians) provide input for developing LCDs, which specify conditions for payment of claims, including acceptable procedure and diagnosis codes. The first LCDs for proton beam radiotherapy went into effect in 2009, prior to which LCDs included proton beam radiotherapy along with external beam radiotherapy in general but without identifying specific indications.
Currently, LCDs vary by contractor regarding their indications for coverage of proton beam radiotherapy, but most LCDs include one or more of the following:
- A list of conditions for which proton beam radiotherapy is medically reasonable (e.g., eye, brain, and spinal cord) and a second list of conditions for which proton beam radiotherapy may be medically reasonable if specified requirements are met and documentation is adequate (e.g., lung, prostate).
- A requirement that the medical record include evidence of benefit for proton beam radiotherapy over other treatment modalities.
- A requirement (for some indications) that the patient be treated as part of a clinical trial.
- Special documentation requirements for prostate cancer.
- A statement that proton beam radiotherapy will be evaluated on a case-by-case basis. Providers must contact the contractor to discuss indications and payment.
Despite the rarity of commonly accepted indications such as tumors of the eye, skull base, and spinal cord, use of proton beam radiotherapy has accelerated in the last decade. Proponents argue that the theoretical advantages of the proton beam's precision apply to more common conditions such as prostate cancer and non-small cell lung cancer; however, no evidence exists for the comparative effectiveness or harms of this therapy. Financial factors may in part be driving this trend of including more common conditions among the indications for proton beam therapy, since expanding its use allows for faster recovery of the substantial investment needed to construct a proton beam center. A major concern among detractors of proton therapy is cost; one report cited costs of providing proton therapy that were more than double those of other radiation therapies. The difference in Medicare payment rates for proton beam radiotherapy versus other radiation therapies is not trivial.
Payment rates (which include both Medicare trust fund reimbursement and patient cost sharing) for proton beam radiotherapy vary by the type of facility providing the services and its location. Hospital-based treatment centers receive payments based on the Hospital Outpatient Prospective Payment System (HOPPS) ambulatory payment classifications (APCs), which are wage adjusted according to provider location. Rates for payments to freestanding centers are set by local Medicare administrative contractors based on Healthcare Common Procedure Coding System (HCPCS) codes. APC codes 664 and 667 and HCPCS codes 77520, 77522, 77523, and 77525 are used to bill for proton beam radiotherapy. Changes in payment for proton beam therapy between 2006 and 2009 varied across providers. Hospital outpatient-based facilities experienced a rate decrease from 2007 to 2009 followed by a return to 2007 levels in 2010 and 2011. Freestanding centers experienced variable changes. Some contractors reduced payment rates approximately 5 percent from 2008 to 2009, while others granted small increases (1 percent) in rates during the same period.
This report details the increased use of proton beam radiotherapy among Medicare beneficiaries from 2006 to 2009 in terms of both recipients and indications. | <urn:uuid:81cf7b37-0197-4b29-92ca-9e975e241247> | {
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Autism Spectrum Disorder
Get the facts about Autism Spectrum Disorder (ASD), including the different types and the most common symptoms.
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Dr. Eddy E Berges has the following 1 specialty
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
Dr. Eddy E Berges has the following 9 expertise
- Multiple Sclerosis (MS)
- Nerve Conduction Studies
- Alzheimer's Disease
- Primary Headache Disorders
- Migraine Disorder
Dr. Eddy E Berges has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 40
Dr. Berges is the only choice for my insurance that is closest to me, so I will provide you a detailed experience. As you know, reviews are subjective, but I will try to provide additional details to portray my experience/perspective of him. My first visit went fairly normal, when you come into his office you go to the front, write your name down, and check in with the receptionist for your scheduled appointment. You are asked for your copay(variable based on insurance), and then once you sign and receive a copy of your receipt you wait until you are called. Mr. Berges greets you as you enter his office. I filled out the initial paperwork prior to sitting down with him and none of that information was discussed. It was strictly neurological issues. He did perform some physical checks on my knee cap and arm and leg. When he asked about what was wrong I explained my circumstances, looked up some relevant information from the hospital, and he decided to prescribe epilepsy medicine. My second visit is where you can understand the ways in which Dr. Berges dismisses, minimizes, and behaves in ways that one may describe as that of someone who believes they are superior to you. After I took my MRI and EEG I wrote down a series of questions about my medication, and made my second appointment, which did not happen until a month later. Perhaps doctors sometimes don't have the time to answer their patients' questions, and I can understand that if you must take priority over more important matters for your private practice, however these questions were given a month prior. When I first entered the office I mentioned that I did not take the medication, and he was somewhat upset. This is not something to be upset about, as a doctor he must know that there is nothing he can do to force the pills into my body outside of the boundaries of his office. When the questions were brought up, he asked in my best translation from Spanish to English "What are these questions of yours?" "What is this fear that you have?" I felt speechless and I asked about taking them for the rest of my life. In hindsight I can see how he understood that it was fear, but that was not an appropriate demeanor to express to a patient who is cautious about incorporating medicine into their routine for the rest of their life. He did not take the time to answer the questions one by one. I ended up asking a few of them just before I left the office with a "Yes, Sir", "Yes, Sir" one after the other. Before I left the office he said "Portese bien," which is a phrase commonly used in Spanish from adult to child, or the equivalent of "Be good," "Behave yourself." Dr. Berges can say to me that I am an adult, but he cannot say that he says those lasting words to all of his patients. When other reviewers say the he may be belligerent, unprofessional, insensitive, egotistical, or presumptuous, understand that these are probably ways of being treated that not everyone notices or considers a strong first impression, but they can be observed if your circumstances with this doctor cause him to feel like you're resisting his treatment. TLDR; Doctor did not answer questions after a month between appointment, told me to behave myself, felt somewhat offended by me not taking his prescribed medication.
Dr. Berges is affiliated (can practice and admit patients) with the following hospital(s).
Medical College Of Georgia
Dr. Eddy E Berges accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- AvMed Empower
- Avmed Choice
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS Florida myBlue
- Florida Blue BlueCare HMO
- Florida Blue BlueOptions
- Florida Blue BlueSelect
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry FL Employer Group PPO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana HMO
- Humana HMO Premier
- Humana HMO Select
- Humana National POS
- Humana Preferred PPO
- Humana Tampa Bay CoreNet
- Humana Tampa Bay HUMx HMOx
- Multiplan PPO
- PHCS PPO
UHC of the River Valley
- Neighborhood Health Partnership Commercial
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsEddy E Berges Md, 2706 W Saint Isabel St Ste A, Tampa, FL
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I. LONG TERM CARE DEFINED
Long term care can be defined as that care which is expected to last for no less than thirty days. Long term care normally involves services of a custodial nature, the assistance necessary for a person to perform activities of daily living (ADL). Because of the custodial nature of the care required, long term care, absent long-term care insurance, is only marginally covered by Medicare and supplemental insurance policies with the majority of the cost of care borne by the individual. When the individual’s resources have been depleted to a prescribed limit, the federal government with state involvement will pay for some or all of the cost of long term care under the Medicaid or Medi-Cal program.
II. THE MEDICARE SYSTEM
In most cases, you first look to Medicare or your Health Maintenance Organization (HMO) for the costs of long term or nursing home care. For purposes of this discussion alone, we will consider an HMO to be equivalent to Medicare and a supplemental insurance policy. Medicare was established in 1965 as a national medical insurance program designed to provide health care benefits to the elderly and handicapped. It is not a public benefits or social welfare program as the costs of Medicare are, for the most part, covered payroll deductions. While the program is federally funded, Medicare is actually administered by private organizations and large insurance companies, called Medicare fiscal intermediaries, carriers and peer review organizations. These organizations actually handle the day to day operations of the Medicare program including the processing of all claims, deciding which claims to pay, the amount of payment for the claim and the first stages of all appeals and complaints. As private contractors, the intermediaries have a financial incentive to interpret Medicare regulations very restrictively and to rely on extensive computerization and screening procedures to evaluate claims. As you can see by its very design, Medicare is not intended to provide unlimited medical coverage. To compound the problem further, the Medicare system usually delegates the initial authority to approve or deny benefits to the actual health care provider. Unfortunately, the bulk of the health care provider’s training as to coverage is supplied by Medicare carriers and intermediaries. Further, the health care providers are often under financial pressure to deny or restrict coverage. For these reasons, it is easy to see why Medicare is often viewed by the persons it serves as an inhuman bureaucracy that denies or reduces claims arbitrarily. Even with its significant problems, Medicare remains the major source of payment for most medical services provided to the elderly.
Medicare will pay for inpatient hospital care that is medically necessary for that particular treatment or diagnosis. The Medicare coverage is limited to 90 days of inpatient hospital care for each “spell of illness.” After 90 days of hospitalization, the patient may draw on his/her 60 lifetime reserve days if any remain. The concept of “spell of illness” is central to both coverage and deductible payment requirements. A spell of illness begins on the day a patient first receives inpatient care and ends when the patient has not been in a hospital or skilled nursing facility inpatient for 60 consecutive days. For example, if a person spends 90 days as an inpatient at the hospital, is then released home and returns with a different illness or injury after only 30 days, Medicare would consider the new injury or illness under the previous spell of illness and would refuse coverage.
The issue of remaining in the hospital too long is not a common problem for most elders. In fact, there has been a steady trend in the past few years toward releasing patients “quicker and sicker.” This is due to Medicare’s use of the Diagnostically-Related Group (DRG) system. Under the DRG system, a set price that a hospital will be paid is established for almost every medical procedure without regard to the actual length of the hospital stay. If the patient remains in the hospital longer than provided for under the DRG, the additional costs of care fall on the hospital. If the patient is discharged in less time than called for under the DRG, the hospital benefits. As should be obvious, the DRG system creates a strong financial incentive for hospitals to terminate Medicare coverage as soon as possible. Once the hospital announces that Medicare coverage is terminated, the patient is faced with the option of being discharged or remaining in the hospital at the patient’s expense. Unfortunately, where the elderly patient cannot afford to stay in the hospital on private pay but is too weak or ill to return home to live alone or be cared for by an aging spouse, the only feasible alternative is placement in a skilled nursing facility (SNF).
III. MEDICARE AND SKILLED NURSING FACILITIES: LIMITED COVERAGE
Medicare will pay for a maximum of 100 days of coverage in a skilled nursing facility per spell of illness provided that the patient requires more than custodial care alone. It is important to understand that this figure is a maximum, not a guarantee; actually obtaining the maximum 100 days of coverage may be a rare occurrence. Medicare coverage in a skilled nursing facility is not automatic and is subject to numerous restrictions. In order to receive any Medicare coverage, the person in the SNF must have been hospitalized for at least three days prior to admission to the skilled nursing facility. The three day requirement does not include the day of discharge. Once the three day hospital stay requirement has been met, the person must be admitted to a Medicare-certified skilled nursing facility within 30 days of the discharge from the hospital. Under this provision, a person can be discharged to home after meeting the required three day hospital stay and then, if within 30 days of the discharge, be admitted to a skilled nursing facility. The placement in the SNF must be to treat a medical condition that was treated in the hospital and that treatment must be prescribed by the patient’s physician. Further, it must be determined that the placement in the SNF is the most efficient and economical means of providing the required treatment. Even after all of these requirements have been met, Medicare will only continue coverage for as long as the patient needs skilled nursing or rehabilitation services. The absence of a need for skilled nursing services and/or the failure to progress with rehabilitation are the most common reasons for discontinuance of Medicare coverage in a skilled nursing facility.
Although a person may be placed in a skilled nursing facility, there is no guarantee that s/he requires skilled nursing services. Skilled nursing service is usually defined as that care that is so complex and complicated it can only be provided by or coordinated by a registered nurse. Services that consist of assistance with a person’s Activities of Daily Living are considered “custodial” and not skilled care. The need for skilled care must be determined to exist seven days a week. If a person does not require skilled nursing seven days a week, s/he can still retain Medicare coverage in a skilled nursing facility if rehabilitation is required and the person progresses. Where the patient plateaus, Medicare coverage will be discontinued.
Once Medicare coverage is terminated, whether due to the lack of need for skilled care, the diminution of progress or simply because the 100 days have run, the costs of long term care in a skilled nursing home fall on the individual. This is true in most cases even where the patient has a supplement insurance policy that provides for more than 100 days of coverage in a skilled nursing facility since most supplements only cover Medicare approved services.
At the termination of Medicare coverage, the cost of long-term care falls on the person requiring skilled nursing facility services. The average private pay rate for a skilled nursing facility in the State of California is $8,189.00 per month (2017). This rate may be significantly higher where the skilled nursing unit is part of an acute medical hospital.
IV. MEDI-CAL COVERAGE IN A SKILLED NURSING FACILITY
Medi-Cal is actually the California enhanced federal Medicaid program. Unlike Medicare, Medi-Cal is restricted to those in need of assistance and is based on a resource limitation. The program is coordinated by the California Department of Health Services and administered through the local Social Welfare office. Medi-Cal will pay for the costs of long-term care in a skilled nursing facility provided that you are properly placed but will not cover the costs of care in facilities providing lower levels of care such as “retirement housing,” “board and care” or residential care facilities.
As a starting point to qualifying for Medi-Cal in a skilled nursing home facility, you must first be either aged (65 years of age or older), disabled (as determined by the Social Security Administration) or blind. Once you have met one of these basic requirements, you must then prove that you do not possess non-exempt assets in excess of the allowable resource limit. This statement is of little assistance unless we understand the concept of Medi-Cal “exempt” and “non-exempt” assets.
A. MEDI-CAL EXEMPT ASSETS:
A Medi-Cal exempt resource is an asset that the applicant may retain without adversely affecting the applicant’s eligibility. By definition, a Medi-Cal non-exempt resource is everything that is not exempt (not surprisingly, this is a governmental definition). The following is a brief description of the most common Medi-Cal exempt assets allowable for both single and married applicants. Later in the discussion, we will consider some of the special rules and allowances for married couples where one spouse is in long-term care.
(1) Principal Residence: Currently, a person’s principal residence is exempt without regard to value, equity or size. Once the Deficit Reduction Act is implemented, however, the State will restrict the allowable value of the principal residence. Although we anticipate the value limitation to be $750,000.00, the details and methods for valuation are still unknown at this time. The principal residence may be a fixed or mobile home, be located on land or water and includes all of the land surrounding or touching the principal residence. It also includes any other buildings or structures located on the land surrounding or touching the principal residence. By definition, the principal residence could be a home, duplex, apartment complex, hotel, the house in which you reside along with every other lot and house that touches your principal residence. As is obvious, this is one of the most significant exemptions allowed under the Medi-Cal program. In order to maintain the exemption, you must either live on the property, have a spouse, child under the age of 21 or a dependent relative (normally a disabled child) who lives on the property or, where none of the above exist, maintain a “subjective intent to return” to the residence. The subjective intent merely requires that if you are absent from your residence for any purpose including placement in a skilled nursing facility, you intend to return to the residence if and when you are able. The intent need not be based on reality but merely represent a desire to return. The intent should be expressed in writing. Any real property not determined to be your principal residence may be considered non-exempt.
(2) Property Used in a Trade or Business: All land, buildings, inventories, vehicles and other equipment that form a part of your business are exempt. This exemption is extremely valuable for protecting farm land and grazing acreage not surrounding or touching the principal residence.
(3) Property Necessary for Employment or Self-Support: Equipment, inventory, licenses and materials necessary for employment or self-support are excluded from Medi-Cal countable resources. However, the Department of Health Services has taken the position that rental property that produces income for self-support is not exempt.
(4) Motor Vehicle: You can own one motor vehicle as exempt whether you still drive or not as long as the vehicle can be used to meet your transportation needs (shopping, visits, medical appointments, etc.). There is no limit on the value of the vehicle. You cannot exempt a recreational or commercial vehicle if you have any other type of vehicle.
(5) Personal Effects: You can retain your furnishings, furniture, clothing, heirlooms, wedding and engagement rings and some jewelry (limited to $100.00 if you are single and unlimited if you are married and one spouse is institutionalized) as exempt. It is also possible to exempt collectibles such as art, coins, guns, dolls and musical instruments.
(6) Burial Plots, Vaults or Crypts: All burial plots, vaults and/or crypts that will be used by any member of the applicant’s immediate family is exempt without regard to the number or value of such items.
(7) Irrevocable Burial Arrangement: An irrevocable burial trust or prepaid burial contract for funeral, cremation or interment is exempt without regard to total value. In addition, each applicant and/or spouse can set aside an additional $1,500.00 in a revocable burial fund for unexpected burial costs.
(8) Life Insurance: All term or group insurance is exempt since there is no cash surrender value attached to such policies. In addition, if the total face value of all of a person’s whole life insurance does not exceed $1,500.00, the cash surrender value of the policies is exempted.
(9) Individual Retirement Accounts (IRAs): The principal amount in a non-institutionalized spouse’s IRAs, 401K accounts, Deferred Retirement Compensation Plans and other retirement type of accounts belonging to the non-institutionalized spouse are fully exempt, whether the accounts are paying minimum distributions (after age 70 1/2) of principal and interest or not. This retirement income, however, will be considered in determining the applicant’s share of cost as discussed below.
B. MEDI-CAL UNAVAILABLE AND NON-EXEMPT ASSETS:
All assets that are not exempt are considered non-exempt and will be valued and included in your Medi-Cal excess resources. There is one exception to this statement. Any assets that are not available to you will not be included as part of your excess resources.
(1) Availability of Assets: In order for an asset to be available, you must have the legal right, power and authority to liquidate that asset. If you own an asset with another person who is unwilling to sell the asset, you may have legal right to the asset but, without securing court involvement, you do not have the power to liquidate the resource. Medi-Cal, in that case, would not count the asset as part of your non-exempt resource limit. While the issue of unavailability may help to qualify you for Medi-Cal benefits when you have excess resources, it is not a good idea to put a great deal of reliance on the approach. Unavailable resources are considered available at your death and the State may place a claim for benefit recovery against those previously unavailable assets.
(a) Individual Retirement Accounts (IRAs): The one area where unavailability is beneficial both for qualifying and for later protection against a death claim for benefit recovery is work-related retirement plans owned by the institutionalized person. As stated earlier, IRAs, 401K accounts, Deferred Retirement Compensation Plans and other retirement type of accounts belonging to the non-institutionalized spouse are fully exempt. Unfortunately, those same accounts belonging to the institutionalized spouse are not considered as exempt. If the accounts are paying out periodic payments of both income and principal, the retirement accounts belonging to the institutionalized spouse will be considered unavailable and the principal amount held in the account(s) will not be included in the non-exempt resource valuation. If not paying out periodic payments of principal and interest, the institutionalized spouse’s retirement accounts will be considered available non-exempt resources. When a person reaches age 70 1/2, s/he should begin making minimum distributions from the retirement accounts. This minimum distribution is considered a periodic payment of principal and income even if only made once each year. Persons under the age of 70 1/2 can also receive periodic payments of principal and income but such action should not be taken without first consulting with your accountant and/or attorney.
(2) Ownership and Valuation of Non-Exempt Assets: If an asset is not classified as exempt and is available to the applicant, Medi-Cal will treat that asset as a non-exempt resource and add its value to the applicant’s property reserve. Since the applicant’s property reserve is used to determine Medi-Cal eligibility, two major issues must be considered: (1) ownership; and, (2) valuation.
(a) Ownership and Transfer of Asset Penalties: The issue of ownership is often confusing and may create unexpected problems. In the case of a single Medi-Cal applicant, issues of ownership normally involve assets held in joint tenancy with a child or loved one. First, ownership in joint tenancy must be equal. If you place a child on title to real property in joint tenancy, you each own a one-half interest in that property. Second, placing a person on title to your asset(s) normally constitutes a transfer or gift of an interest in that asset and may subject you to a period of ineligibility if the transfer occurs within thirty (30) months of your Medi-Cal application (please note this period is sixty (60) months in all other States besides California). Unfortunately, placing another person on your asset(s) does not always constitute a gift and/or a reduction in your total assets.
To constitute a gift and/or reduction to your total assets, the transfer of an interest in your assets must be complete and irrevocable. For example, if I give my son $1,000.00, the gift is completed with the transfer of the money and irrevocable since my son did not agree to later return my funds. If the transfer of this money occurred within 30 months of my Medi-Cal application, the gift would have to be disclosed and may involve some period of ineligibility. A different result occurs if I intend to transfer $1,000.00 to my son by placing his name in joint tenancy on my bank account which contains $2,000.00. In that case, merely placing my son’s name on my account does not constitute a completed and/or irrevocable gift. At any time before my son withdraws the money, I can revoke the gift merely by withdrawing the funds myself. The gift only becomes complete upon my son’s withdrawal. Therefore, any period of ineligibility for Medi-Cal only begins with such a withdrawal and only to the amount withdrawn.
It is also very important to realize that placing another person on title to your asset(s) may allow access to those assets to the other person’s creditors should your co-owner be sued or experience financial problems.
In the case of a married couple, the issue of ownership for Medi-Cal eligibility purposes is straight forward but not always fair. Medi-Cal considers all assets owned by either or both spouses to be available for the care of the Ill Spouse. While this approach may seem appropriate in a long-standing first marriage, it is much less so in a short-term second marriage. Take Husband (H) and Wife (W) for example. H and W have been married for less than one week. W, who brought all of the assets to this marriage as her separate property, had H sign a pre-nuptial agreement that stipulated that the assets were W’s separate property. H is now in a skilled nursing facility and will require Medi-Cal assistance to pay the $5,500.00 per month cost. Medi-Cal will not distinguish between separate and community property in this case and will consider all of the assets available to either spouse in determining H’s eligibility.
(b) Methods for Valuating Non-Exempt Assets: As with issues of ownership, the value of a non-exempt asset is critical to establishing Medi-Cal eligibility. The following methods of valuation are allowable under Medi-Cal law:
(i) Non-Exempt Real Property: California real property that is not exempt may be valued at the tax assessed value less encumbrances. This may be extremely favorable where the property has been held for a long period of time and is protected under Proposition 13. If the property is co-owned, the applicant will be credited with the taxed assessed portion of his/her interest. The creation of co-ownership may constitute a transfer subject to the 30 month look back period (discussed below) and a period of ineligibility.
(ii) Bank Accounts: A bank account is valued according to the balance of funds remaining in the account at the time of application. Medi-Cal will consider the full account to belong to the applicant unless the co-owner can establish that s/he contributed to the account.
(iii) Stocks. Bonds. Mutual Funds. Brokerage Investment Accounts: The value of the stocks, bonds, mutual funds and/or brokerage accounts is determined according to the valuation of the assets at the time of application. If the consent of all owners of the assets is required to sell or liquidate, the value of the applicant’s interest alone will be applied to the applicant’s property reserve. The addition of a person to an asset or account will constitute a transfer and may result in a period of ineligibility if the addition occurred within 30 months of application for Medi-Cal.
(iv) Life Insurance Policies: If the total face value of all whole life insurance policies belonging to the applicant exceeds $1,500.00, then the cash surrender value of all of those whole life insurance policies will be included in the applicant’s property reserve. If the face value of all of the whole life insurance policies is less than $1,500.00, the cash surrender value of all of the policies is disregarded. Term life insurance without a cash surrender value is not included in the above calculations and/or as part of the property reserve.
(v) Promissory Notes: A promissory note is valued at the remaining amount owed on the note (principal) or the market value of the note (discounted value) if the note were to be sold. Co-ownership in a note reduces the value charged to the applicant but may constitute a transfer if the co-owner’s name was merely added without adequate compensation.
(vi) Deferred Annuity: The surrender value of a deferred annuity is included in an applicant’s Medi-Cal property reserve. It is treated in much the same manner as a traditional certificate of deposit bank account.
(vii) Individual Retirement Accounts (IRAs): As stated earlier, the full value of an IRA belonging to a Medi-Cal applicant is considered available and included in the property reserve unless it is paying out periodic payments of principal and interest.
C. ASSET LIMITATION FOR MEDI-CAL QUALIFICATION:
The value of each Medi-Cal non-exempt asset is added together to arrive at the property reserve valuation. Based on that valuation Medi-Cal will determine if the applicant is eligible to receive Medi-Cal benefits. In order to qualify for Medi-Cal, an applicant cannot exceed the following property reserve limits:
(1) Asset Limitation for a Single Person: A single person will qualify for and remain eligible to receive Medi-Cal benefits when his/her property reserve (non-exempt assets) does not exceed $2,000.00 on the last day of the month.
(2) Asset Limitation for a Married Couple: Qualification for a married couple usually falls into one of two general categories: (1) a married couple living together; and, (2) a married couple with one spouse in a skilled nursing facility (SNF).
Normally, where both spouses are either both living outside of a skilled nursing facility or both living in a skilled nursing facility, the couple is considered to be living together. If a married couple apply for Medi-Cal while living together, both partners will receive benefits. A married couple living together will qualify for and remain eligible to receive Medi-Cal benefits when the couple’s total non-exempt assets do not exceed $3,000.00 on the last of the month.
If one spouse of a married couple is in a skilled nursing facility (Institutionalized Spouse) while the other is not (Community Spouse), the Institutionalized Spouse will become eligible for Medi-Cal benefits when the couple’s total non-exempt assets do not exceed $120,900.00 (2017) on the last day of the month of application. Thereafter, the Community Spouse may acquire assets in excess of $120,900.00 while the Institutionalized Spouse remains eligible for Medi-Cal benefits in the skilled nursing facility. Ninety (90) days after qualifying for Medi-Cal benefits, the Institutionalized Spouse’s name cannot appear on non-exempt assets totaling more than $2,000.00 on the last day of the month.
D. MEDI-CAL’S TREATMENT OF INCOME & SHARE OF COST:
The role of income in the Medi-Cal long term care system is extremely important but often misunderstood. Simply stated, a single person or married couple’s income does not have any effect on Medi-Cal eligibility. This is not to suggest, however, that an applicant or beneficiary’s income is not considered in the Medi-Cal process.
(1) Single Person’s Share of Cost: Once a single person or institutionalized spouse has been determined eligible for Medi-Cal long-term care benefits, the monthly co-payment for that Medi-Cal must be calculated. This monthly co-payment is referred to as, “share of cost.”
In the case of a single Medi-Cal beneficiary, the share of cost calculation is fairly straight forward. All of the beneficiary’s monthly income is first determined. Included in that income is the beneficiary’s Social Security, Railroad Retirement, pension, quarterly adjustments to pension (normally associated with the State Teacher’s Retirement System), Individual Retirement Account (IRA) distributions, interest and dividends (whether actually received, retained or reinvested), rent (including rental of an exempt principal residence) and certain goods and services contributed by family and/or friends (referred to as “in-kind income”). From the total gross monthly income, the Beneficiary’s Medicare premium is deducted. The beneficiary is then entitled to retain $35.00 per month for his/her personal needs allowance. And finally, the beneficiary may retain sufficient monthly income to pay for his/her monthly Medicare supplemental insurance (Medigap) premium. The remaining monthly income must be sent to the skilled nursing home as the single beneficiary’s share of cost. Medi-Cal will pay the remainder of the beneficiary’s monthly cost of care directly to the skilled nursing facility.
(2) Married Couple’s Share of Cost: The determination of the share of cost for a married couple where one spouse is institutionalized and one is not is much more difficult. As with the single person, all of the monthly income received by both spouses is counted toward the monthly share of cost. And, as with the single person, the Medi-Cal beneficiary may retain sufficient income to pay for the beneficiary’s Medicare premium, the monthly personal needs allowance ($35.00) and the beneficiary’s Medicare supplemental insurance premium. After the above deductions have been calculated, the non-institutionalized or Community Spouse is given an election.
The Community Spouse is entitled to retain a minimum monthly needs allowance (MMMNA) of $3,023.00 (2017) from all income received by both spouses, or all of the income received in the Community Spouse’s name alone, whichever is greater. To better understand this election, consider the following hypothetical case:
Henry (H) and Wanda (W) are married. H was placed in a skilled nursing facility last month and has just qualified for Medi-Cal long-term care benefits. After all allowable deductions for H’s Medicare premium, his personal needs allowance ($35.00), and H’s Medicare supplemental insurance premium, the couple receives a total monthly income of $4,500.00. Of this total, H receives $3,500.00 per month in Social Security and Pension benefits while W receives $1,000.00 from her Railroad Retirement. Since W has the option of retaining $2,980.50 per month from all income received in both spouse’s names, or all the income received in W’s name alone, whichever is greater, W will select the guaranteed $3,023.00 as her minimum monthly needs allowance (MMMNA). If, however, W is the institutionalized spouse and H is the Community Spouse, H will select all of the income that comes in H’s name alone since that income ($3,500.00) is greater than the guaranteed $3,023.00 alternative.
(3) Method of Paying the Share of Cost: While the share of cost is determined for each month, the actual allocation is normally accomplished on a yearly basis at the time of establishing eligibility and each redetermination thereafter. If the amount of income changes from the date of eligibility or the last redetermination, the beneficiary, his/her spouse or the beneficiary’s authorized representative must report the changed income within 10 days of the change. Failure to report changes of income or assets can result in a determination of ineligibility, overpayment or both.
It is important to note from the above discussion that Medi-Cal does not alter the method in which a person receives his/her income. If the beneficiary receives his/her Social Security and/or pension through the direct deposit process, the direct deposits will continue after Medi-Cal eligibility has been determined. It is the responsibility of the beneficiary, his/her spouse or authorized representative to provide the skilled nursing facility with the established monthly share of cost.
E. MEDI-CAL POST-MORTEM RECOVERY OF ASSETS:
The above-described system continues until the Medi-Cal recipient recovers, becomes ineligible or dies. If a person recovers or becomes ineligible for Medi-Cal benefits, Medi-Cal, in contrast to common belief, does not attempt to recover the benefits paid during the recipient’s life.
It is important to note that the term “lien” is not used in describing the recovery program. Medi-Cal rarely imposes a lien on a recipient’s assets during the recipient’s life. Instead, Medi-Cal defers reimbursement for the benefits paid to or on behalf of an individual until that person’s death. This post death recovery is referred to as a death claim.
**2017 Medi-Cal Recovery Reform Update** The Medi-Cal post-mortem recovery laws were changed and will affect those who die on or after January 1, 2017. For individuals who died prior to January 1, 2017, the old recovery rules still apply. This overview will outline recovery for deaths occurring prior to January 1, 2017 and any changes to the law for deaths on or after January of 2017 will be addressed in bold as indicated.
As a starting point, currently Medi-Cal can only recover for those benefits paid to or for an individual who was over age 55. Any benefits paid to or for that person prior to reaching age 55 are not recoverable under current law. Beginning January 1, 2017, individuals who were under the age of 55 but “permanently institutionalized” will also be subject to recovery claims. Further, recovery is limited to the amount of benefits paid (after age 55) or the value of the deceased Medi-Cal recipient’s “Estate,” whichever is less. To better understand recovery, let’s look first examine the Medi-Cal Recovery System as it relates to a single Medi-Cal recipient.
(1) Recovery Against a Single Person’s Estate: John, a 75 year old single man, has been in a skilled nursing facility and on Medi-Cal long-term care for the past six years. After “spending down,” John owns a Medi-Cal exempt residence valued at $100,000.00 held in joint tenancy with John’s son, Fred, an exempt vehicle worth $7,000.00 held in John’s name alone and approximately $1,500.00 in a checking account held in John’s name with Fred as an agent. At John’s death, Medi-Cal has paid $75,000.00 for John’s benefit.
John dies, passing his Estate to his son, Fred, by right of survivorship through joint tenancy. Under California Probate Code ‘215, Fred must notify the Department of Health Services (DHS) of John’s death. The notification required involves sending a copy of John’s death certificate to the Director of DHS in Sacramento, California. Merely informing the local County Welfare worker of John’s death is not sufficient and does not constitute formal notice.
Once the Department of Health Services has been notified of John’s death, DHS will send a creditor’s claim to Fred. That claim should describe each and every service paid for by Medi-Cal by date. Fred should examine the services for accuracy. Once Fred has determined that the creditor’s claim is accurate, Fred should determine the value of John’s Estate. Since John was on Medi-Cal and limited to not more than $2,000.00 of non-exempt assets, the bulk of John’s Estate is made up of exempt resources.
(a) House: Although the house was held in joint tenancy with Fred and is not part of John’s probate estate, for deaths occurring prior to January 1, 2017 the State of California will include John’s one-half (2) interest in the house in John’s Estate for recovery purposes. This is due to California’s 1993 expanded definition of “Estate” which includes everything in which John had any legal title or interest at the time of John’s death including all assets passing by joint tenancy, tenancy in common, by survivorship, by life estate, in a living trust or any other similar arrangement. Since the house is worth $100,000.00 at John’s death and John owned a one-half (2) interest in the house, the State can assert a $50,000.00 claim against the house.
(1) For deaths occurring on or after January 1, 2017, only assets considered part of the decedent’s “Probate estate” would be subject to recovery. As the house was held in joint tenancy at John’s death, it would be exempt from recovery and sole ownership would pass to John’s son Fred.
(b) Vehicle: Since the vehicle is held in John’s name alone, the State may assert a claim in the amount of $7,000.00 against the vehicle. Claims against vehicles are rare but have occurred.
(c) Checking Account: The $1,500.00 checking account was owned by John with Fred able to sign for John as an agent under a power of attorney. As the authority of an agent ends upon the death of the principal (John), Fred cannot claim any ownership interest in the account and the State can recover the entire $1,500.00 checking account.
The value of John’s Estate for recovery purposes is $58,500.00 ($50,000.00 interest in house, $7,000.00 interest in the vehicle and $1,500.00 interest in the checking account). The State has paid $75,000.00 for John’s care. As the State’s claim is greater than the recoverable value of John’s Estate, Fred would pay the State $58,000.00 if he died prior to January 1, 2017 and $8,500.00 if he died on or after January 1, 2017. The State will release the unpaid remainder. Fred is not liable for the difference. If, on the other hand, John’s recoverable estate was greater than the State’s claim, Fred would pay the State claim and the remainder would go to John’s heirs under his Will.
As should be clear from the above, the use of a living trust, joint tenancy or similar arrangements did not protect the assets of a single Medi-Cal recipient from State recovery if he/she died prior to January 1, 2017. The State is prohibited from recovery, however, when the Medi-Cal recipient leaves a minor, blind or disabled child even if that child is not a beneficiary of the Medi-Cal recipient’s assets. The State may also be prevented from recovery where such an action would cause a hardship. Historically, however, the hardship waivers were few and far between. Effective January 1, 2017, however, the State will be required to waive a claim for substantial hardship when the estate is a homestead of modest value. This would be for homes whose fair market value is 50 percent (50%) or less of the average price of homes in the county where it is located.
Also beginning January 1, 2017, only assets considered part of the decedent’s “Probate estate” will be subject to recovery. Therefore, living trusts, joint tenancies and similar arrangements, when used appropriately, would effectively avoid recovery at the death of a single individual. However, it is rarely, if ever, advisable for a single person to own assets in joint tenancy with another person, particularly his/her primary residence. Sound legal advice as to the liability exposure, negative tax consequences, and Medi-Cal ramifications should be sought prior to transferring any property into joint tenancy. Although maintaining ownership of the home in a living trust will avoid recovery at death, renting out the home while the Medi-Cal recipient is in skilled nursing will adversely affect his/her share of cost, and sale of the home may cause the Medi-Cal recipient to lose his/her Medi-Cal coverage.
(2) Recovery Against a Married Person’s Estate: While recovery against the Estate of a single Medi-Cal recipient is fairly straightforward, the same was not true for recovery against the Estate of a married Medi-Cal recipient. To better understand the previous rules of recovery of assets belonging to a deceased married Medi-Cal recipient, it is helpful to review the manner in which recovery was made in the relatively recent past. To simplify the matter, let’s examine Herman (H) and Wanda (W).
H and W were married for fifty years and had three children, one of whom is permanently disabled. Upon placement in the skilled nursing facility, H and W owned a small amount of cash and investments. W was able to qualify H without much trouble and H remained in the skilled nursing facility for approximately two years. At the time of placement and for the remainder of H’s life, the couple owned and maintained a principal residence held in the names of H and W as joint tenants. The residence was worth approximately $150,000.00. H and W both received Social Security income and a small pension totaling less than $2,000.00 per month. While H was receiving Medi-Cal, W did not have to pay a monthly share of cost or co-payment. The couple owned $84,000.00 in non-exempt assets and W had removed H’s name from those assets while H was still competent.
At H’s death, W notified the local Medi-Cal case worker by phone and sent a copy of H’s death certificate to the Department of Health Care Services (DHCS) in Sacramento as required by law. A few weeks later, W received a letter from DHCS claiming that the State had spent $100,000.00 on H’s care. Included with the letter was a simple form requesting information concerning the assets owned by H at his death including all of those assets held in joint tenancy. W replied to the request for information and waited for a response.
Within a few months, W received a legal form entitled, “Creditor’s Claim,” wherein W was informed that H owed the Department of Health Services $100,000.00 and to send the payment to the Sacramento office. W did not have $100,000.00 and did not respond to the Claim. Without providing any further notice or an opportunity to be heard, the Department simply recorded a lien against H and W’s house. W was not aware such a lien had been imposed until two years following H’s death when she sold the house to move closer to her children. Upon the close of escrow, W received a check for $50,000.00 and the Department received H’s share of the sales proceeds.
As should be clear from the above, the State of California recovered its payments through the use of an unnoticed and unheard lien procedure. That procedure, in failing to provide adequate notice and an opportunity for hearing, was a violation due process. Based on the Department’s due process failure, the State of California was permanently enjoined and prohibited from recovering against the Estate of a deceased Medi-Cal recipient spouse without first providing the surviving spouse adequate notice of the State’s recovery intent and allowing for a hearing by that spouse to object to the action.
In response to the injunction, the State of California reformed its recovery procedure involving assets belonging to a deceased Medi-Cal recipient’s spouse. Those procedures are in effect for deaths occurring prior to January 1, 2017 and are as follows:
At the death of a spouse who had received Medi-Cal benefits at any time after reaching age 55, the Department of Health Care Services must be notified. The Department may then (and does) inquire into the assets belonging to the deceased spouse at his/her death. Thereafter, the Department must defer recovery until the death of the second spouse. Further, the recovery at the second spouse’s death is restricted only to those assets that passed to the surviving spouse from the deceased Medi-Cal recipient spouse.
Although the Department continues to utilize this approach for deaths occurring prior to January 1, 2017, there remain many unanswered questions. For example, if H left W his interest in the house and W later sold the house, was the State entitled to the proceeds from the sale at W’s death or only a share of the house? What if W invested the proceeds in Internet stock and increased the value of the proceeds, is the State entitled to share in the appreciation? On the other hand, what if W invested her money and lost all of the sales proceeds, is the State entitled to seek other funds belonging to W at her death?
As you can see, there remai many unsettled issues involving recovery against a deceased spouse who received Medi-Cal benefits subsequent to reaching age 55. And, as in the past, recovery is easily avoided by taking action during a recipient’s lifetime.
In response to the ambiguous and often unequitable application of recovery laws at the death of the second spouse, the Medi-Cal Recovery Reform Act was adopted to greatly simplified this issue. Beginning January 1, 2017, if an individual is survived by a spouse or domestic partner, a claim is prohibited and forever barred. Additionally, effective January 1, 2017, the State will no longer be able to recover for basic health services (such as doctor’s office visits) provided by Medi-Cal unless they are related to nursing home care, or home and community based services. Cost of premiums, co-pays, and deductibles paid on behalf of Qualified Medicare Beneficiaries (QMBs), Specified Low-Income Medicare Beneficiaries (SLMBs), Qualifying Individuals, Qualified Disabled and Working Individuals who are categorized as a group of dual eligibles are also not recoverable.
3. **Summary of Medi-Cal Recovery Reforms 2017**: Senate Bills 33 and 833 incorporated the Medi-Cal recovery reform provisions, which severely restrict Medi-Cal recovery for those who die on or after January 1, 2017. The new recovery law:
- Prohibits claims on the estates of surviving spouses and registered domestic partners;
- Limits recovery for those 55 years of age or older (or under 55 if permanently institutionalized) to services provided in nursing homes or in community based services. Thus, no longer recovery for basic health services such as doctor’s visits, prescription drugs, managed care reimbursements, unless serveces are related to nursing home care or home/community based services);
- Limits recovery to only those assets subject to California probate;
- Restricts the amount of interest the State can charge on liens;
- Creates a substantial hardship waiver for homesteads of modest value (i.e. a home worth 50% or less of the average price of homes in that county); and
- Requires the State to provide each current or former Medi-Cal recipient with a copy of the amount of Medi-Cal expenses that may be recoverable.
As should be obvious from the above discussion, Long Term Care Planning for Medi-Cal eligibility is highly technical and complex. If done improperly, it can result not only in ineligibility and/or recovery, but can have adverse tax and estate consequences as well. For this reason, consultation with a qualified attorney specializing in Long Term Care Planning is money well spent. To find a Certified Elder Law Attorney in your area, please contact the National Academy of Elder Law Attorneys at (520) 881-4005 or visit www.nelf.org or www.naela.org.
About the Authors: Neil A. Harris is the founding attorney for The Estate and Long Term Care Planning (LTC Center). The LTC Center, staffed by Certified Elder Law Attorneys Neil A. Harris and Nicole R. Plottel, provides a wide range of legal services designed specifically for the elderly and those with special needs. Mr. Harris was one of the first attorneys to become certified as an Elder Law Attorney, with almost thirty (30) years of specialty experience in Estate Planning and Long Term Care Planning. Ms. Plottel is one of only 15 attorneys in California to be dual certified in both Elder Law and Estate Planning, Trust & Probate Law. For more information, please call (530) 893-2882 or visit www.HarrisPlotttel.com.
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
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Dr. Chetan K Patel has the following 1 specialty
- Orthopaedic Surgery
Dr. Chetan K Patel has the following 31 expertise
- Spinal Cord Compression
- Torticollis (Wry Neck)
- Spinal Stenosis
- Minimally Invasive Surgical Procedures
- Spinal Fusion
- Knee Surgery
- Joint Pain/Swelling
- Sports Medicine
- Back Injuries
- Spinal Osteophytosis (Spondylosis)
- Osteoarthritis (Hand and Wrist)
- Hip Osteoarthritis
- Lower Back Pain
- Neck Pain
- Bone Fracture
- Spinal Arthritis (Spondylarthritis)
- Carpal Tunnel Syndrome
- Herniated Disc
- Joint Replacement
- Spinal Fractures
- Head and Neck Disorder
- Knee Osteoarthritis
Dr. Chetan K Patel is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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From scheduling an appointment to checking in to completing the new patient process was an exercise in chaos. Staff and physician were rude, uncaring and unprofessional. The doctor was arrogant and condescending. I don't care how good he thinks he is or how good the marketing campaign portrays him to be, I will never step foot in that office again.
Compassionate Doctor Recognition (2015)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Patients' Choice Award (2015)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Dr. Patel is affiliated (can practice and admit patients) with the following hospital(s).
22 Years Experience
University Of Michigan Medical School
Graduated in 1996
Dr. Chetan K Patel accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- Florida Blue BlueCare HMO
- Florida Blue BlueOptions
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry FL Employer Group PPO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana HMO
- Humana HMO Premier
- Humana HMO Select
- Humana National POS
- Humana Preferred PPO
- Multiplan PPO
- PHCS PPO
UHC of the River Valley
- Neighborhood Health Partnership Commercial
Locations & DirectionsThe Spine Health Institute, 711 E Altamonte Dr Ste 210, Altamonte Springs, FL
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Bowel Incontinence Facts about bowel incontinence, including causes & who's most at risk.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Colonoscopy Facts about colonoscopy, including how and why it's done.
- Colorectal Cancer Facts about Colorectal cancer, including symptoms and treatment options
- Crohn's Disease Facts about Crohn’s Disease, including how it affects the body.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
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About Dr. Cecilia R Terrado
Dr. Cecilia R Terrado, MD is a Doctor primarily located in Sacramento, CA, with another office in Rocklin, CA. She has 21 years of experience. Her specialties include Gastroenterology and Internal Medicine. Dr. Terrado is affiliated with Mercy Hospital of Folsom and Mercy San Juan Medical Center. Dr. Terrado has received 1 award. She speaks English.
Dr. Cecilia R Terrado has the following 2 specialties
A gastroenterologist is a specialist in diagnosis and treatment of conditions involving the digestive/gastrointestinal (GI) tract. These doctors are experts on how food moves through the digestive system and is chemically broken down, with nutrients being absorbed and waste excreted. You might see this kind of doctor if you are experiencing any number of stomach issues, some of which might be severe diarrhea, irritable bowel syndrome, hemorrhoids, ulcers, acid reflux, Crohn's disease and more.
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Cecilia R Terrado has the following 10 expertise
- Ulcerative Colitis
- Abdominal Pain
- Irritable Bowel Syndrome (IBS)
- Celiac Disease
- Acid Reflux Disease (Gastroesophageal Reflux / GERD)
- Acid Reflux Disease (GERD)
- Hepatitis C
Dr. Cecilia R Terrado has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
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On-Time Doctor Award (2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Dr. Terrado is affiliated (can practice and admit patients) with the following hospital(s).
21 Years Experience
Wright State University Boonshoft School Of Medicine
Graduated in 1997
Mt Carmel Medical Center
Dr. Cecilia R Terrado accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
Blue Cross California
- BC CA California Care Small Group HMO
- Blue Cross CA PPO Prudent Buyer Small Group
- Blue Cross CA Advantage PPO Preferred DirectAccess Plus
- Blue Cross CA California Care Large Group HMO
- Blue Cross CA PPO Prudent Buyer Individual
- Blue Cross CA PPO Prudent Buyer Large Group
- Blue Cross CA Pathway X HMO
- Blue Cross CA Pathway X PPO
- Blue Cross CA Select PPO
- Blue Cross CA Select Plus HMO
Blue Shield California
- BS CA Platinum 90 PPO
- Blue Shield CA Access Plus HMO
- Blue Shield CA Bronze 60 PPO SHOP
- Blue Shield CA Bronze Full PPO 4500
- Blue Shield CA PPO
- Blue Shield CA Platinum Access+ HMO 25
- Blue Shield CA Silver 70 PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Health Net CA HMO Employer Group
- Health Net CA PPO
- Health Net SmartCare Large Group
- Humana Choice POS
- Multiplan PPO
- UHC West SignatureValue HMO
Western Health Advantage
- Western Health Advantage
Locations & Directions
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Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- Alzheimer's Disease Facts about Alzheimer’s Disease, including the symptoms and stages.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Chronic Pain Facts about chronic pain, including body parts most commonly affected.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Diabetic Neuropathy Facts about diabetic neuropathy, including the symptoms and doctors.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
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Dr. Peter C Roblejo has the following 2 specialties
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
Dr. Peter C Roblejo has the following 9 expertise
- Migraine Disorder
- Alzheimer's Disease
- Migraine Disorders
- Multiple Sclerosis (MS)
- Nerve Conduction Studies
Dr. Peter C Roblejo is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 5 of 14
On-Time Doctor Award (2016)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Compassionate Doctor Recognition (2015)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
20 Years Experience
University Of Medicine And Dentistry Of New Jersey Robert Wood Johnson Medical School
Graduated in 1998
Dr. Peter C Roblejo accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
HIP of NY
- Emblem HIP Select PPO
- Horizon BCBS OMNIA - TIER2
- Horizon Direct Access
- Horizon HMO
- Horizon OMNIA
- Horizon POS
- Horizon PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Oxford Freedom
- Oxford Health Garden State
- Oxford Liberty
- Oxford Metro
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Dr. Peter C Roblejo is similar to the following 3 Doctors near Miami, FL. | <urn:uuid:d9c51c0e-80ed-40d5-b877-e1d3280f4a9c> | {
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Arrhythmia Facts about arrythmia, inclding the types, symptoms and causes.
- Atrial Fibrillation Facts about atrial fibrillation, including symptoms and risk factors.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Coronary Artery Angioplasty with Stent Coronary artery angioplasty with stent facts, including who needs it.
- Coronary Heart Disease Get the facts about coronary heart disease.
- Deep Vein Thrombosis Facts about deep vein thrombosis (DVT), including symptoms & causes.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Erectile Dysfunction Facts about erectile dysfunction (ED), including causes.
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Dr. Karl H Lembcke has the following 2 specialties
- Cardiovascular Disease
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Karl H Lembcke has the following 13 expertise
- Blood Clot
- High Cholesterol
- Heart Diseases
- Heart Block
- High Cholesterol (Hypercholesterolemia)
- Acute Coronary Syndrome (ACS)
- Unstable Angina
- Heart Attack
- Heart Failure
Dr. Karl H Lembcke has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 10
Dr Lembcke always puts me at ease, his staff is always friendly. You feel like a part of the family. While he doesn't mince words, he has a way of informing you without making you feel like he's talking down to you. He explains things in terms anyone can understand. His staff has also gone out of their way to help me with things, when my regular Dr's office was closed. There is always plenty of parking space and very few delays in seeing you at your appointment time.
On-Time Doctor Award (2014, 2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Patients' Choice Award (2012, 2013, 2014, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2013, 2014)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Albert Einstein College Of Medicine
Dr. Karl H Lembcke accepts the following insurance providers.
- AvMed Empower
- AvMed Engage
- Avmed Choice
- BCBS Florida myBlue
- Florida Blue BlueCare HMO
- Florida Blue BlueOptions
- Florida Blue BlueSelect
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry FL Employer Group HMO Open Access
- Coventry FL Employer Group PPO
- Multiplan PPO
- PHCS PPO
UHC of the River Valley
- Neighborhood Health Partnership Commercial
- UHC Choice Plus POS
- UHC Options PPO
Locations & DirectionsCardiovascular Center South Fl, 7400 SW 87th Ave Ste 100, Miami, FL
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Get the facts about allergic asthma, including who gets it and what the most common symptoms are.
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Dr. Sonja R Stiller has the following 2 specialties
- Emergency Medicine
An emergency physician is a doctor who is an expert in handling conditions of an urgent and extremely dangerous nature. These specialists work in the emergency room (ER) departments of hospitals where they oversee cases involving cardiac distress, trauma, fractures, lacerations and other acute conditions.
Emergency physicians are specially trained to make urgent life-saving decisions to treat patients during an emergency medical crisis. These doctors diagnose and stabilize patients before they are either well enough to be discharged, or transferred to the appropriate department for long-term care.
- Pulmonary Disease
A pulmonologist is a physician who specializes in the diagnosis and treatment of conditions related to the lungs and respiratory tract.
These specialists are similar to critical care specialists in that their patients often require mechanical ventilation to assist their breathing.
Pulmonologists diagnose and treat patients with conditions such as asthma, cystic fibrosis, asbestosis, pulmonary fibrosis, lung cancer, COPD, and emphysema. Exposure and inhalation of certain toxic substances may also warrant the services of a pulmonologist.
Some of the tools and tests pulmonologists use to diagnose a patient are a stethoscope in order to listen for abnormal breathing sounds, chest X-rays, CT scans, blood tests, bronchoscopy, and polysomnography.
Dr. Sonja R Stiller has the following 3 expertise
Dr. Sonja R Stiller has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 1 of 1
23 Years Experience
Philadelphia College Of Osteopathic Medicine
Graduated in 1995
Dr. Sonja R Stiller accepts the following insurance providers.
- Anthem Blue Access PPO
- Anthem Blue Preferred HMO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
- BCBS MI PPO Plans Group Enrollees
Medical Mutual of Ohio
- MMOH SuperMed POS Select
- MMOH SuperMed PPO Plus
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsCenter For Advanced Vein Care Llc, 7200 Mentor Ave, Mentor, OH
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Metastatic Melanoma The facts about metastatic melanoma, a serious skin cancer.
- Skin Cancer Get the facts about skin cancer, including the types and symptoms.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Acne Important facts about acne and what causes it.
- Alopecia Alopecia facts; different types of hair loss & what can cause it.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Facelift Facts about facelifts, including the different types of procedures.
- Facial Wrinkles and Lines Find out what causes facial wrinkles and lines.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Robert T Hayman has the following 3 specialties
- Pediatric Dermatology
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
A dermatologist is a doctor who has extensive training and knowledge of the skin, scalp, hair and nails and treats conditions that affect those areas. These doctors will evaluate any abnormality, blemish or lesion on the skin in order to determine the cause and will determine a course of treatment.
Dermatologists provide patients with full body scans in order to identify any signs that are indicative of an illness that requires treatment, such as skin cancer. These specialists may also provide cosmetic services, such as mole removal, scar diminishing treatments and even botox and face lifts.
Dr. Robert T Hayman has the following 18 expertise
- Diaper Rash
- Hives (Urticaria)
- Atopic Dermatitis
- Acne (Acne Vulgaris)
- Skin Diseases
- Skin Care
- Acne Rosacea
- Skin Cancer
- Pediatric Diabetes
Dr. Robert T Hayman has 2 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Robert T Hayman is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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I could say he save us from lots of mental stress and my son's worse eczema problem. After lots of Dr..I went to Dr Robert Hayman..when he saw my child first time and gave me two type of ointment. That is the day I thank to the God and took a long breath...My son got better in one week...which my physician and other Dr.(from Elmhurst Hospital) can't provide me in one and half year. Thanks Dr. Hayman, God Bless You.
Compassionate Doctor Recognition (2014, 2015)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
On-Time Doctor Award (2014)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Patients' Choice Award (2014)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Dr. Robert T Hayman accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS MA Blue Care Elect PPO
- BCBS MA Preferred Blue PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Connecticare Flex Connecticut
- Empire Blue Priority EPO
- Empire HMO
- Empire PPO
- Empire Prism EPO Blue Priority
- First Health PPO
HIP of NY
- Emblem HIP Select PPO
- Healthfirst NY HMO ABCD
- Humana Choice POS
- Humana ChoiceCare Network PPO
MVP Health Plan
- MVP Preferred PPO
- Multiplan PPO
- PHCS PPO
- Oxford Freedom
- Oxford Liberty
- Oxford Metro
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsPediatric Dermatology, 2001 Marcus Ave Ste S40, New Hyde Park, NY
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ABC check Airway, Breathing Circulation
ACLS Advanced Cardiac Life Support (ACLS) Certification
ADAAG ADA Accessibility Guidelines for Buildings and Facilities
AD/HD Attention-Deficit/Hyperactivity Disorder
ADL activities of daily living ADLs are basic activities that a person does on a daily routine. These include dressing, bathing, eating,
and using the bathroom. (assessing skills of daily living)
AED Automatic External Defibrillator:Do you need an AED? by Mayo Clinic Staff
A special training program is helping spread the word about the importance of knowing how to use an
automatic external defibrillator. Video by Web MD recommends Red Cross Project Lifesaver.
A fib Atrial Fibrillation
AHCD Advance Health Care Directives and Living Wills
AIP Acute Intermittent Porphyria a group of inherited disorders of heme biosynthesis,
characterized by attacks of severe abdominal pain, peripheral neuropathy and mental disturbances.
Porphyria by Mayo clinic Staff.
a.k.a. also known as
ALS Amyotrophic lateral sclerosis (ALS), sometimes called Lou Gehrig's disease, is a rapidly progressive, invariably fatal neurological disease that attacks
the nerve cells.
AR AORTIC REGURGITATION or Aortic valve regurgitation is a condition that occurs when your heart's aortic valve doesn't close tightly
ASAP As Soon As Possible
BANANA BANANA is an acronym for Build Absolutely Nothing Anywhere Near Anything (or Anyone).
The term is most often used to criticize the ongoing opposition of certain interest groups to land development.
BD Binswanger's disease (BD), also called subcortical vascular dementia, is a type of dementia caused by widespread, microscopic areas of
damage to the deep layers of white matter in the brain. The damage is the result of the thickening and narrowing (atherosclerosis) of arteries that
feed the subcortical areas of the brain. Atherosclerosis (commonly known as "hardening of the arteries") is a systemic process that affects blood vessels
throughout the body
BFF Best Friends Forever
BP Blood Pressure A blood pressure reading has a top number (systolic) and bottom number (diastolic). The ranges are:
Normal: Less than 120 over 80 (120/80)
Prehypertension: 120-139 over 80-89
Stage 1 high blood pressure: 140-159 over 90-99
Stage 2 high blood pressure: 160 and above over 100 and above
People whose blood pressure is above the normal range should consult their doctor about steps to take to lower it.
BLS Basic Life Support (BLS) Certification
BMP Basic Metobolic Panel This panel measures the blood levels of sodium, potassium, calcium, chloride, carbon dioxide, glucose,
blood urea nitrogen, and creatinine
B.S. Bachelor of Science degree, typically earned at a University after completing four years of study.
BUN Blood Urea Nitrogen kidney function blood test
CASL Chartered Advisor for Senior Living is a designation earned through The American College in Bryn Mawr , PA.
This is the premier college for insurance and financial services studies.
CBC Complete Blood Count
C DIFF Clostridium difficile (klos-TRID-e-uhm dif-uh-SEEL) often called C. difficile or C. diff, is a bacterium that can cause symptoms ranging from
diarrhea to life-threatening inflammation of the colon. Illness from C. difficile most commonly affects older adults in hospitals or in long term care facilities and typically occurs
after use of antibiotic medications.
CERT The Community Emergency Response Team(CERT) Program educates people about disaster preparedness for hazards that may
impact their area and trains them in basic disaster response skills, such as fire safety, light search and rescue, team organization, and disaster
CEU Continuing Education Unit is a measure used in continuing education programs, particularly those
required in a licensed profession in order for the professional to maintain the license.
CEUs are offered as an add-on to training courses completed through the American Red Cross.
CFP Certified Financial Planner is a designation earned through the College of Financial Planning.
CFRE Certified Fund Raising Executive
CFS Chronic Fatigue Syndrome
CHAOS Can't Have Anyone Over Syndrome
CHF Congestive heart failure (CHF),or heart failure, is a condition in which the heart can't pump enough blood to the body's organs.
CIDP Chronic inflammatory demyelinating polyneuropathy (CIDP) is a neurological disorder characterized
by progressive weakness and Impaired sensory function in the legs and arms.
CIS Compromised Immune System
CIT Crisis Intervention Team programs are local initiatives designed to improve the way law enforcement and the community
respond to people experiencing mental health crises. They are built on strong partnerships between law enforcement,
mental health provider agencies and individuals and families affected by mental illness.
CLU Chartered Life Underwriter is a designation earned through the American College in Bryn Mawr, PA
This is the premier college for insurance and financial services studies.
CMA Comparable Market Analysis used in Real Estate property value assessment
Current Market Analysis on the Property including Estimated Value from US SEARCH
CNA Certified Nursing Assistant
COBRA Continuation of Health Coverage
CO OP Consumer Operated and Oriented Plans
COPD Chronic Obstructive Pulmonary Disease
CPR Cardiopulmonary resuscitation (CPR) is a first-aid technique used to keep victims of cardiopulmonary arrest alive and to prevent brain damage while
more advanced medical help is on the way. CPR has two goals: keep blood flowing throughout the body keep air flowing in and out of the lungs.
CSF Cerebral Spinal Fluid
CTRS Certified Therapeutic Recreation Specialist
CVA CEREBROVASCULAR ACCIDENT a.k.a. STROKE Stroke Pictures Slideshow: A Visual Guide to Understanding Stroke
d.b.a. "doing business as" using a registered fictitious name
DLA Daily Living Activities Daily Living Aids
DME Durable Medical Equipment
DNR Do Not Recessitate is a request not to have cardiopulmonary resuscitation(CPR) if your heart stops or if you stop breathing.
'Do not resuscitate' vs. 'allow natural death' an article By Jennifer Booth Reed, USA TODAY
DPOA durable Power of Attorney
DRT Digital Retinal Imaging
DSM-IV Diagnosis and Statistical Manual of Mental Health Disorders is the standard classification of mental disorders used by mental health
professionals in the United States DSM-5 in May 2013
DSS Missouri Dept. of Social Services
DVT Deep Vein Thrombosis occurs when a blood clot forms in a deep vein, usually in the lower limbs.
SHEER FLIGHT SOCKS
EOB Explanation of Benefits. Insurance notice with itemized charges for services, which services or charges
are not covered, and deductibles. Read Carefully. Errors occur in the medical code, or procedures
were not administered. Typically, with Medicare, you will receive two EOBs for each service.
One from Medicare Part A,B or D and the other from a supplemental private insurance provider
which patient pays separately to cover 20 % Medicare co-pay.
ERCP Endoscopic retrograde cholangiopancreatography (ERCP) uses a dye to highlight the bile ducts in you pancreas.
During ERCP, an endoscope is passed down your throat, through your stomach and into the upper part of your small intestine.
ESL English as a Second Language
FBS Fasting Blood Sugar
FOA Funding Opportunity Announcement
FSBO For Sale by Owner: typically used referring to home-sellers.
FYI For Your Information
GAD Generalized Anxiety Disorder (GAD)
GOMER Get Out of My Emergency Room. Medical slang. Typically an old demented noncommunicative patient
An old person that takes up room in the hospital and doesn't have the common decency to die. Definition taken from an episode of Scrubs.
GRI Graduate of Realtors Institute National Association of Realtors earned designation
HAS Holmes-Aide Syndrome (HAS) Holmes-Adie syndrome (HAS) is a neurological disorder affecting the pupil of the eye and the
autonomic nervous system. It is characterized by one eye with a pupil that is larger than normal and constricts slowly in bright light
(tonic pupil), along with the absence of deep tendon reflexes, usually in the Achilles More Information found by Ashely.
HCD Health Care Directive The Go Wish game helps focus in a positive way on values and wishes about end-of-life care.
HDHP high deductible health plan
HDL d High-density lipoprotein "good" CHOLESTEROL
HELOC Home Equity Line Of Credit
IRS Internal Revenue Service. Have a Tax problem? Need Help?
KS Karposi's Sarcoma
LDLC Low-density lipoprotein "bad" CHOLESTEROL
LOL Laugh Out Loud
LPC Licensed Professional Counselor
LPN Licensed Practical Nurse or licensed vocational nurses (LVNs), care for the sick, injured, convalescent,
and disabled under the direction of physicians and registered nurses.
Training lasting about 1 year is available in about 1,200 State-approved programs mostly in vocational or technical schools.
LSW Licensed Social Worker
M.Ed. Masters of Education degree, earned by some Licensed Professional Counselors.
MFL Main Floor Laundry. Highly recommend caregiver install one, if you do not have one.
MI Myocardial Infarction a.k.a. heart attack
Myocardial ischemia occurs when blood flow to your heart muscle is decreased by a partial or complete blockage of your heart's arteries
(coronary arteries). The decrease in blood flow reduces your heart's oxygen supply.
MIP Mortgage Insurance Premium
MO modus operandi: manner of working
MPT Masters of Physical Therapy
MRI magnetic resonance imaging
MSRP Manufacturer's Suggested Retail Price
MSW Masters of Social Work
NCS nerve conduction study
NP Nurse Practitioner Nurse practitioners are one of four types of advanced practice nurses that provide care to patients. The advance practice nurse is a
registered nurse who has a master's degree (MSN). Missouri NPs may practice independently and may specialize in areas including
family or women's health, medical, surgical, pediatric, gerontological, school, adult, neonatal, and more.
NT Night Terrors
OCD Obsessive Compulsive Disorder
OI Opportunistic Infections are mild to severe infectious diseases in a compromised host. The
infections are caused by microorganisms that normally do not cause serious disease in healthy people.
OS Operating System for your computer.
OTC Over-the-Counter-medications and supplements
OT Occupational Therapy
PA Physician's Assistant
PALS Pediatric Advanced Life Support (PALS) Certification
pdf printable document format. computer term for fliers and forms available as a document for print out.
PE Pulmonary Embolism
PET POSITRON EMISSION TOMOGRAPHY SCAN
PCP PNEUMOCYSTIS CARINII PNEUMONIA
Ph.D. Doctorate of Philosophy, earned by some Licensed Professional Counselors.
PID Pelvic inflammatory disease (PID) is an infection of the female reproductive organs.
PITI Principle, Interest, Taxes, Insurance, reference:mortage
PMI Private Mortgage Insurance
PK Preacher's Kid
PPA Partnership for Prescription Assistance
PPACA The Patient Protection a n d Affordable Care Act pdf
PRN "As the situation arises." used in treatment plan for some medication and therapy
PT Physical Therapist
PTA Physical Therapy Assistant
PTSD Posttraumatic Stress Disorder (PTSD)
PVD PERIPHERAL VASCULAR DISORDERS
QOL quality-of-life (QOL)
RN Registered Nurse
RICE Rest-Ice-Compress-Elevate Sprains and Strains Treatment
RT 1. Respiratory Therapist 2. Recreational Therapist 3. Reminiscence Therapy
RWHFY Are we having FUN yet? Is this the FUN part?
SAD Seasonal Affective Disorder Social Anxiety Disorder (Social Phobia)
SD SCHIZOAFFECTIVE DISORDER SCHIZOPHRENIA
SLE SYSTEMIC LUPUS ERYTHEMATOSUS an inflammatory, autoimmune disease that affects nearly every organ system in the body
SNF Skilled Nursing Facility a.k.a. nursing home
SSI Supplemental Security Income through Social Security
STAT Stat, an abbreviation of the Latin statim, a medical term meaning "immediately"
STD Sexually Transmitted Disease
TIA Transient Ischemic Attack
TIF Tax Increment Financing Local Tax Increment Financing (Local TIF) permits the use of a portion of local property and sales taxes to assist funding the
redevelopment of certain designated areas within your community. Areas eligible for Local TIF must contain property classified as a "Blighted", "Conservation" or an
"Economic Development" area, or any combination thereof, as defined by Missouri Statutes.
TKO Total Knock Out
TMI Too Much Information
TMJ TEMPOROMANDIBULAR JOINT DISORDER Temporal Mandibular Joint Disorder
TPO Thyroid peroxidase (TPO), an enzyme normally found in the thyroid gland, plays an important role in the production of thyroid hormones.
A TPO test detects antibodies against TPO in the blood.
TSH Thyroid Stimulating Hormone
TYG trust your gut.
|Treading water in all the "ALPHABET SOUP?"
need help interpreting letters and phrases bantered about as a second language?
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|LEFT click on underlined word for link to another site with more detailed information.
After you finish reading definition, and separate window did not open,
click on the "back" arrow to return to this page.
Restless legs syndrome (RLS) is a neurological disorder characterized by unpleasant sensations in the legs and an
uncontrollable urge to move them for relief.
Ventricular tachycardia is a rapid heart beat initiated within the ventricles,
characterized by 3 or more consecutive premature ventricular beats.
Registered Financial Consultant earned through the International Association of Registered Financial Consultants.
LMT Licensed Massage Therapist - means licensed by the state they reside in and have completed requirements of education and training.
NCTMB Nationally Certified Therapist of Massage and Bodywork - achievement of additional education, training and maintaining a higher level
Nationally approved CEU's (Continuing Educational Units)
Registered nurses (RNs), record patients’ medical histories and symptoms, help to perform diagnostic tests and analyze
results, operate medical machinery, administer treatment and medications, and help with patient follow-up and rehabilitation.
A bachelor’s of science degree in nursing (BSN), take about 4 years to complete. ADN programs, take about 2 to 3 years to
complete. Diploma programs, administered in hospitals, last about 3 years. Generally, licensed graduates of any of the three
types of educational programs qualify for entry-level positions as staff nurses.
Check Your Symptoms
Need information as you determine what to do about your symptoms?
Get help figuring them out by answering a series of questions. To get started, click on male or female,
regardless of age, then the part of the body that is troubling you. Use the Symptom Checker to select parts of
the body where you are experiencing symptoms
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make informed decisions.
This information is not meant to replace professional help.
We encourage you to seek professional advice from a qualified accountant, lawyer, realtor, loan
officer,physician or other medical professional.
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not accept on-line monetary donations,does not retain any gathered personal information. We will not share
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Family Caregivers are In Good Company is a website with links to articles and products
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Although the sites linked to
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have been reviewed and selected by family caregivers, the presence of a link does not represent an
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information found in their site.
This information is not meant to replace professional help.
We encourage you to seek professional advice from a qualified accountant, lawyer, realtor, loan
officer, physician or other medical professional.
NonSteroidal Anti-Inflammatory Drugs -- are among the most common pain relief medicines in the world.in addition to dulling pain NSAIDs also
lower fever and reduce swelling. Aspirin (Bufferin, Bayer, and Excedrin), Ibuprofen (Advil, Motrin, Nuprin), Ketoprofen (Actron, Orudis), Naproxen (Aleve)
An individual retirement account in which a person can set aside after-tax income up to a specified amount each year.
Earnings on the account are tax-free,tax-free withdrawals may be made after age 59 1/2 . Some banks and credit unions offer products
were small amounts can be added like a savings account, after an initial investment is made.
One such product is a ROTH IRA CD.
A Health Savings Account (HSA) allows individuals and/or employers
to contribute pretax dollars to pay for medical expenses including over-the-counter, prescription, and
vision health essentials - not covered by insurance policies.
Unlike a Flexible Spending Account (FSA), unused funds do not disappear at year-end. HSA dollars
roll-over year-over-year, which means that account holders build up balances to pay for medical expenses.
Account holders submit expense deductions on Schedule A,Form 1040 to the IRS.
"against medical advice" code entered on chart if you refuse medical care, or leave a medical facility before staff
think you are ready. Remember, you have the right leave a.m.a. Do your research. Trust your gut. Sometimes
YOU do know what is best for you and your caregivee. Consider legal and financial consequences.
The Certified Residential Specialist (CRS) is the highest designation awarded to sales associates in the residential sales field. The CRS
designation recognizes professional accomplishments in both experience and education. National Association of Realtors earned designation
"cover your anatomy" "COVER YOUR ASSETS" do your research.
Read the fine print when making decisions always consider legal and financial issues.
You are your own best defense. Know your rights. Don't be bullied.Be prepared.
ELECTROMYOGRAPHY measures electrical activity of the muscles at rest and when they are used.
A Flexible Spending Account (FSA) allows consumers to deduct pre-tax dollars from their paychecks and deposit those
funds in employer-sponsored accounts to pay for medical expenses - including over-the-counter, prescription, and
vision health essentials. Consumers then submit expense receipts to healthcare administrators for reimbursement.
Frontotemporal dementia (FTD) describes a clinical syndrome associated shrinking of the frontal and temporal
anterior lobes of the brain. Originally known as Pick’s disease,
HEMOGLOBIN A1C Blood test which monitors sugar metabolism over a two to three month period.
Difficult to "cheat" on THIS test!A1C test goes by many other names, including glycated hemoglobin, glycosylated hemoglobin, hemoglobin A1C and HbA1c.
Human papillomavirus is the name of a group of viruses that includes more than 100
different strains or types.
In Case of Emergency Code: label contact people with ICE in your cell phone
for emergency personnel. ex: ICE 1:Nancy/sister ICE 2:Jessica/daughter
Multi-infarct dementia (MID) is a common cause of memory loss in the elderly.
MID is caused by multiple strokes (disruption of blood flow to the brain).
GARBAGE IN GARBAGE OUT GIGO, this is a famous computer axiom meaning that if invalid data is entered into a system, the resulting output will
also be invalid. Although originally applied to computer software, the axiom holds true for all systems, including, for example, decision-making systems.
SPF (sun protection factor): measures the length of time a product protects against skin reddening
from UVB, compared to how long the skin takes to redden without protection.
UVA (ultraviolet-A): long- wave solar rays of 320-400 nanometers (billionths of a meter). Although less likely than UVB to
cause sunburn, UVA penetrates the skin more deeply, and is considered the chief culprit behind wrinkling, leathering, and other aspects of "photoaging." The latest
studies show that UVA not only increases UVB 's cancer-causing effects, but may directly cause some skin cancers, including melanomas.
UVB (ultraviolet-B): short-wave solar rays of 290-320 nanometers. More potent than UVA in
producing sunburn, these rays are considered the main cause of basal and squamous cell
carcinomas as well as a significant cause of melanoma.
Diethylstilbestrol (DES) is a synthetic estrogen that was developed to supplement a woman's natural estrogen production.
First prescribed by physicians in 1938 for women who experienced miscarriages or premature deliveries,
MSA Medical Savings Account Archer MSAs An Archer MSA is a tax-exempt trust or custodial account that you set up with a U.S. financial
institution (such as a bank or an insurance company) in which you can save money exclusively for future medical expenses. You (or your employer) can contribute up to
75% of the annual deductible of your HDHP (65% if you have a self-only plan) to your Archer MSA. You must have the HDHP all year to contribute the full amount. If you do
not qualify to contribute the full amount for the year, determine your annual deductible limit by using the worksheet for line 3 in the Instructions for Form 8853, Archer MSAs
and Long-Term Care Insurance Contracts
Editors note: One of our caregivers suggested,
" The 'SOUP' page should have at least one soup recipe..."so here is a book of soup recipes for your ordering pleasure, comfort and joy!
It is a downloadable eBook, so you don't even need to wait for shipment! Or if you prefer, order soup mixes on-line: Connor Creek and more.
Home Access HIV $31.74
Are you unable to open or read a pdf ? Adobe® Reader® XI software is the free trusted standard for reliably viewing, printing, and
annotating PDF documents. It's the only PDF file viewer that can open and interact with all types of PDF content, including forms and
multimedia. click here to download.
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Lupus Get the facts about lupus, including symptoms, risk factors, and the different types.
- Menopause Facts about menopause, including the stages, symptoms, and types.
- Ulcerative Colitis Facts about ulcerative colitis, including causes, signs and symptoms.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
About Dr. Douglas A Katula
Dr. Douglas A Katula, MD is a Doctor primarily located in New Albany, OH, with another office in Columbus, OH. He has 29 years of experience. His specialties include Internal Medicine, Hospice & Palliative Medicine and Hospitalist. Dr. Katula has received 3 awards. He speaks English.
Dr. Douglas A Katula has the following 3 specialties
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
- Hospice & Palliative Medicine
Hospitalists are physicians who specialize in the care of patients in the hospital. The majority of hospitalists are board-certified internists and have completed the same training as other internal medicine doctors including medical school, residency and board certification examination.
Hospitalist activities include patient care, teaching, research, and leadership related to hospital care. They have more expertise in caring for complicated hospitalized patients on a daily basis since, unlike other specialists or primary care doctors, they spend most of their day in the hospital.
They often coordinate the care of their patients and act as the central point of communication among the different doctors and nurses involved in the patient's care. They are also the main physician for family members to contact for updates on a loved one.
Dr. Douglas A Katula has the following 4 expertise
- Chest Pain
- Gastrointestinal Bleeding
Dr. Douglas A Katula has 2 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Douglas A Katula is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
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Patients' Choice Award (2012, 2016)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2014, 2016)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
On-Time Doctor Award (2016)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
29 Years Experience
Ohio State University College Of Medicine
Graduated in 1989
Riverside Methodist Hospital
Dr. Douglas A Katula accepts the following insurance providers.
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry HealthAmerica PPO
- First Health PPO
FrontPath Health Coalition
- FrontPath Health Coalition
- Humana Choice POS
- Humana ChoiceCare Network PPO
- UHC Choice Plus POS
- UHC Navigate POS
Locations & Directions
Take a minute to learn about Dr. Douglas A Katula in this video.
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What is Medical Coding?
For those who are new to the medical billing and medical coding field, a great question to begin with is; “What is Medical Coding?” Starting with what Medical Coding encompasses is helpful. Medical Coding covers several aspects including medical procedures and services, certain diagnoses, and can also relate to medical equipment. It is the process whereby medical record documentation is translated in to five digit procedure or supply codes and three to seven character diagnosis codes. Medical coding is a form of communication between insurance companies and other healthcare professionals.
Another way to answer this question is to think of Medical Coding as a translation. For example: you go to the doctor because you fractured your kneecap. Well, what the doctor (or medical coder) sends off to the insurance company is as follows: S82.001A, Initial encounter for closed fracture of patella. In this case, S82.001A is the proper medical code. There are specific medical codes to identify the medical encounter, diagnosis and/or procedure.
The codes assigned are standard codes from the CPT® (Current Procedural Terminology), ICD-10-CM
(International Classification of Diseases) and the HCPCS (Healthcare Common Procedure Coding System) manuals. Codes are updated on a quarterly, however coding manuals are only published annually. Medical Coders are hired to ensure proper code assignment and sequencing to identify services rendered and supplies provided to the patient. Reimbursement is just one factor in the medical coding process.
Some have described medical coding like completing a puzzle. If medical coding sounds like the career for you, MCHC offers online and live classes to teach you everything you need to know to become a certified medical coder! | <urn:uuid:78235c2b-96ca-4092-8d81-03571c85e1dc> | {
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One of the roles of a medical coder is to take information from the patient health record and report the correct codes to document patient diagnoses and procedures. One example of this is that medical coders must correctly assign present on admission (POA) indicators.
What Does POA Mean?
POA is a way for the hospital to determine which conditions existed before the patient came to the hospital and which conditions existed after admittance. Correct POA identification and use of POA indicators are important: they directly affect how insurance providers, Medicare, and patients are billed.
POA in medical coding includes any condition that develops during any outpatient encounter. This can include the emergency department, observation, and outpatient surgery.
For example, if you were admitted to the hospital with a strong cough and were having difficulty breathing, and if you were diagnosed with pneumonia, the pneumonia would be considered a condition that was present on admission. However, if you had no difficulties breathing at first and only started coughing after you were admitted, your cough would not be considered present on admission.
What Is a POA Indicator?
A POA indicator is the data element, shown as a single letter, that a medical coder assigns based on whether a diagnosis was present when the patient was admitted or not. .
A Present On Admission (POA) indicator is required on all diagnosis codes for the inpatient setting except for admission. The indicator should be reported for principal diagnosis codes, secondary diagnosis codes, Z-codes, and External cause injury codes.
What Are the Different POA Indicators?
Coders must use one of five different POA indicators when they are billing for POA conditions:
Y–Yes, present at the time of inpatient admission
N–No, not present at the time of inpatient admission
U–Unknown, documentation is insufficient to determine if condition is present on admission and you cannot speak to the physician to figure it out
W–Clinically undetermined, provider is unable to clinically determine whether condition was present on admission or not
E–Exempt, unreported/not used, some facilities will leave these blank, others will use the letter “E”
Historically, the exempt POA diagnosis codes were listed in the guidelines of the ICD-10-CM book. However, in 2017 the AMA publication stopped printing the list of POA exempt diagnoses. For a list of exempt codes, please reference https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding.html. This information is available in several formats. The POAexemptCodes2017.zip is recommended, and from there the information can be viewed in word or excel format. The Add, Delete, and Revise files in that compressed folder are corrections and additions to the previous POA exempt list.
All codes listed in that reference are exempt from POA status. An “E” is used in the training program to represent exempt status. When using the 3M encoder, the software will mark all POA exempt codes for you. If coding by hand, this list will need to be referenced.
For more information on POA indicators please see Appendix I, Present on Admission Reporting Guidelines of the official ICD-10-CM guidelines https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2019-ICD10-Coding-Guidelines-.pdf and appendix B, Reporting of the Present on Admission Indicator of the ICD-10-CM and ICD-10-PCS Coding Handbook.
Are POA Indicators Required on Outpatient Claims?
Inpatient care means that you are admitted to a hospital on the orders of a doctor. You become classified as an inpatient as soon as you are admitted.
Outpatient care covers many categories, including the ER, same day surgery, observation, and radiology, and more. Even with a hospital stay, your care might be considered an outpatient service. If your doctor orders observation of your condition or tests to help diagnose your condition while you are in the hospital, you can still officially be an outpatient.
For some outpatient surgeries, you may receive the surgery at a hospital but not be admitted. It is not until a doctor orders admission that you are considered inpatient and a medical coder needs to determine POA indicators.
Present on admission indicators are used as a form of recording for inpatient billing. POA indicators are not used or required on outpatient claims. However, conditions that develop during an outpatient encounter that lead toward an inpatient admission are considered POA.
What Is Considered Present on Admission?
This is a great question. It’s difficult to generalize. Some conditions are very obvious and can be easily identified, while others are not so simple. The easiest to determine are external conditions like broken bones or major cuts and injuries.If the patient came in with the condition, the POA is a yes. If the condition develops after the patient was admitted, the POA would be a no.
But some conditions are not as easy to see. It is important for coders to be clear on patients’ exact conditions to accurately reflect the care given at a hospital and to be able to select the correct POA indicator.
Learning medical coding can feel intimidating. When you are first shown the complexities and requirements involved, it’s difficult to know what’s going on. It sometimes feels like people are speaking a different language.
Career Step has a certification program that will teach you everything you need to know about medical coding and help you become certified in the field. This program gets you up to speed with the medical coding field and lets you learn at your own pace. The program can take anywhere from 4–12 months to complete before you can start your career as a medical coder. | <urn:uuid:67c4d40b-562c-4ccd-ab16-ba4b7b2f5836> | {
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Last month's column addressed alcohol use disorder (AUD), connecting the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), definitions and diagnostic criteria with the 2018 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) documentation and coding requirements.
This month's column will explain alcohol-induced conditions in the context of AUD. Alcohol-induced conditions are complications directly due to AUD. Most of these conditions also occur independently of AUD. ICD-10-CM requires that the clinician specifically document a connection between these conditions and AUD for them to be coded as “alcohol-induced.” DSM-5 diagnostic criteria also require that other causes be ruled out before documenting a condition as an alcohol-induced condition.
DSM-5 lists and defines certain alcohol-induced conditions (Table 1). Most of these are also listed in ICD-10-CM, which provides multiple codes in category F10 that combine AUD and its associated conditions into one code (Table 2) based on the use/abuse/dependence distinction and clinical circumstances. ICD-10-CM uses the term “uncomplicated” to identify AUD without an alcohol-induced condition.
Intoxication (drunkenness) is an alcohol-induced condition defined by DSM-5 as problematic behavior or psychological changes (often seen after more than two drinks) associated with one or more of several symptoms: slurred speech, incoordination, unsteady gait, nystagmus, impaired attention or memory, or altered level of consciousness. ICD-10-CM provides several codes for alcohol intoxication.
These codes apply to any kind of alcohol intoxication, due to ingestion of a beverage or any other method of consumption, since ICD-10-CM defines a “poisoning” as the toxic effect of a nonmedicinal substance or as a therapeutic drug taken improperly.
Intoxication accompanied by delirium is generally consistent with an “acute toxic encephalopathy” due to alcohol. When this is present, both toxic encephalopathy (code G92) and alcohol-induced delirium (sequenced after G92) should be documented and coded, along with the “toxic effect” code, which should be sequenced first. Delirium should be considered a symptom of the underlying medical condition of toxic encephalopathy.
Documentation of just “alcoholic encephalopathy” results in the assignment of code G31.2, which is reserved for nervous system degeneration like alcoholic cerebellar or cerebral degeneration. It represents a chronic, permanent, structural encephalopathy, not an acute, reversible encephalopathic process—hence the need to document an acute toxic encephalopathy resulting from alcohol intoxication.
The key features of alcohol-induced psychoses are delusions and hallucinations, but they must be distinguished from schizophrenia which is not induced by alcohol. However, AUD may precipitate psychotic episodes in patients with underlying schizophrenia.
According to the DSM-5, persistent neurocognitive disorders (“dementia”) that can be due to AUD include “major” amnesic-confabulatory types (e.g., Korsakoff and Wernicke-Korsakoff) and nonamnesic-confabulatory types, which are identified in ICD-10-CM as amnestic and persistent dementia. Major implies significant cognitive decline that interferes with independent function.
Other alcohol-induced disorders commonly occur with AUD: anxiety disorders, mood disorders, sexual dysfunction, and sleep disorders. If a patient has AUD and any of these disorders, it should always be clarified in the record whether the conditions are related.
Anxiety disorders are numerous (e.g., generalized anxiety, several phobias, and panic disorder) and commonly overlap. They share the features of excessive fear and anxiety and related behavioral disturbances. Mood disorders include depression and other related conditions having complex DSM-5 definitions. Sexual dysfunction includes such things as erectile dysfunction, sexual interest/desire disorders, and other significant disturbances in sexual function.
DSM-5 identifies 10 sleep disorders or groups of disorders, some of which may be alcohol-induced, including insomnia, hypersomnia, and circadian rhythm disturbance. Others, like narcolepsy or sleep apnea, are not related to alcohol.
Finally, clinicians may decide that another condition not specifically listed by ICD-10-CM as an AUD is actually caused by alcohol and document it as such.
In summary, proper diagnosis and coding of AUD and alcohol-induced conditions are complex and challenging. The ICD-10-CM code classification in large part follows DSM-5 definitions with highly specific codes that combine the types of AUD and alcohol-induced conditions.
Clinicians must determine whether a patient has mild, moderate, or severe AUD based on the DSM-5 diagnostic criteria, as well as documenting any alcohol-induced conditions. Clarification of whether a particular condition is due to AUD or not is always needed in the medical record.
A general understanding and basic working knowledge of the diagnostic standards and interrelationships of these conditions contributes to the quality of care, precise documentation, and accurate coding. | <urn:uuid:04d16b5f-9355-4f70-9b76-eb57136b8980> | {
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The Parallax P8X32A Propeller is a multi-core processor parallel computer architecture microcontroller chip with eight 32-bit reduced instruction set computer (RISC) central processing unit (CPU) cores. Introduced in 2006, it is designed and sold by Parallax, Inc.
The Propeller microcontroller, Propeller assembly language, and Spin interpreter were designed by Parallax's cofounder and president, Chip Gracey. The Spin programming language and Propeller Tool integrated development environment (IDE) were designed by Chip Gracey and Parallax's software engineer Jeff Martin.
On August 6, 2014, Parallax Inc., released all of the Propeller 1 P8X32A hardware and tools as open-source hardware and software under the GNU General Public License (GPL) 3.0. This included the Verilog code, top-level hardware description language (HDL) files, Spin interpreter, PropellerIDE and SimpleIDE programming tools and compilers.
Each of the eight 32-bit cores (termed a cog) has a central processing unit (CPU) which has access to 512 32-bit long words (2 KB) of instructions and data. Self-modifying code is possible and is used internally, for example, as the boot loader overwrites itself with the Spin Interpreter. Subroutines in Spin (object-based high-level code) use a call-return mechanism requiring use of a call stack. Assembly (PASM, low-level) code needs no call stack. Access to shared memory (32 KB random-access memory (RAM); 32 KB read-only memory (ROM)) is controlled via round-robin scheduling by an internal computer bus controller termed the hub. Each cog also has access to two dedicated hardware counters and a special video generator for use in generating timing signals for Phase Alternating Line (PAL), National Television System Committee (NTSC), Video Graphics Array (VGA), servomechanism-control, and others.
Speed and power management
The Propeller can be clocked using either an internal, on-chip oscillator (providing a lower total part count, but sacrificing some accuracy and thermal stability) or an external crystal oscillator or ceramic resonator (providing higher maximum speed with greater accuracy at higher total cost). Only the external oscillator may be run through an on-chip phase-locked loop (PLL) clock multiplier, which may be set at 1x, 2x, 4x, 8x, or 16x.
Both the on-board oscillator frequency (if used) and the PLL multiplier value may be changed at run-time. If used correctly, this can improve power efficiency; for example, the PLL multiplier can be decreased before a long no operation wait needed for timing purposes, then increased afterward, causing the processor to use less power. However, the utility of this technique is limited to situations where no other cog is executing timing-dependent code (or is carefully designed to cope with the change), since the effective clock rate is common to all cogs.
The effective clock rate ranges from 32 kHz up to 80 MHz (with the exact values available for dynamic control dependent on the configuration used, as described above). When running at 80 MHz, the proprietary interpreted Spin programming language executes approximately 80,000 instruction-tokens per second on each core, giving 8 times 80,000 for 640,000 high-level instructions per second. Most machine-language instructions take 4 clock-cycles to execute, resulting in 20 million instructions per second (MIPS) per cog, or 160 MIPS total for an 8-cog Propeller.
Power use can be reduced by lowering the clock rate to what is needed, by turning off unneeded cogs (which then use little power), and by reconfiguring I/O pins which are unneeded, or can be safely placed in a high-impedance state (tristated), as inputs. Pins can be reconfigured dynamically, but again, the change applies to all cogs, so synchronizing is important for certain designs. Some protection is available for situations where one core attempts to use a pin as an output while another attempts to use it as an input; this is explained in Parallax's technical reference manual.
Each cog has access to some dedicated counter-timer hardware, and a special timing signal generator intended to simplify the design of video output stages, such as composite PAL or NTSC displays (including modulation for broadcast) and Video Graphics Array (VGA) monitors. Parallax thus makes sample code available which can generate video signals (text and somewhat low-resolution graphics) using a minimum parts count consisting of the Propeller, a crystal oscillator, and a few resistors to form a crude digital-to-analog converter (DAC). The frequency of the oscillator is important, as the correction ability of the video timing hardware is limited to the clock rate. It is possible to use multiple cogs in parallel to generate a single video signal. More generally, the timing hardware can be used to implement various pulse-width modulation (PWM) timing signals.
- a bitmap font is provided, suitable for typical character generation applications (but not customizable);
- a logarithm table (base 2, 2048 entries);
- an antilog table (base 2, 2048 entries); and
- a sine table (16-bit, 2049 entries representing first quadrant, angles from 0 to π/2; other three quadrants are created from the same table).
The math extensions are intended to help compensate for the lack of a floating-point unit, and more primitive missing operations, such as multiplication and division (this is masked in Spin but is a limit for assembly language routines). The Propeller is a 32-bit processor, however, and these tables may have insufficient accuracy for higher-precision uses.
Built in Spin bytecode interpreter
Spin is a multitasking high-level computer programming language created by Parallax's Chip Gracey, who also designed the Propeller microcontroller on which it runs, for their line of Propeller microcontrollers.
Spin code is written on the Propeller Tool, a GUI-oriented software development platform written for Windows XP. This compiler converts the Spin code into bytecodes that can be loaded (with the same tool) into the main 32 KB RAM, and optionally into the I²C boot electrically erasable programmable read-only memory (EEPROM), of the Propeller chip. After booting the propeller, a bytecode interpreter is copied from the built in ROM into the 2 KB RAM of the primary COG. This COG will then start interpreting the bytecodes in the main 32 KB RAM. More than one copy of the bytecode interpreter can run in other COGs, so several Spin code threads can run simultaneously. Within a Spin code program, assembly code program(s) can be inline inserted. These assembler program(s) will then run on their own COGs.
The Propeller's interpreter for its proprietary multi-threaded Spin computer language is a bytecode interpreter. This interpreter decodes strings of instructions, one instruction per byte, from user code which has been edited, compiled, and loaded onto the Propeller from within a purpose-specific integrated development environment (IDE). This IDE, which Parallax names The Propeller tool, is intended for use under a Microsoft Windows operating system.
The Spin language is a high-level programming language. Because it is interpreted in software, it runs slower than pure Propeller assembly, but can be more space-efficient: Propeller assembly opcodes are 32 bits long; Spin directives are 8 bits long, which may be followed by a number of 8-bit bytes to specify how that directive operates. Spin also allows avoiding significant memory segmentation issues that must be considered for assembly code.
At startup, a copy of the bytecode interpreter (less than 2 KB in size), will be copied into the dedicated RAM of a cog and will then start interpreting bytecode in the main 32 KB RAM. Additional cogs can be started from that point, loading a separate copy of the interpreter into the new cog's dedicated RAM (a total of eight interpreter threads can, thus, run simultaneously). Notably, this means that at least a minimal amount of startup code must be Spin code, for all Propeller applications.
Spin's syntax can be divided into blocks, which hold:
- VAR – global variables
- CON – program constants
- PUB – code for a public subroutine
- PRI – code for a private subroutine
- OBJ – code for objects
- DAT – predefined data, memory reservations and assembly code
- reboot: causes the microcontroller to reboot
- waitcnt: wait for the system counter to equal or exceed a specified value
- waitvid: waits for a (video) timing event before outputting (video) data to I/O pins
- coginit: starts a processor on a new task
An example program, (as it would appear in the Propeller Tool editor) which emits the current system counter every 3,000,000 cycles, then is shut down by another cog after 40,000,000 cycles:
The Parallax Propeller is gradually accumulating software libraries which give it similar abilities to Parallax's older BASIC Stamp product; however there is no uniform list of which PBASIC facilities now have Spin equivalents.
It has been jokingly opined that "If two languages were to meet in a bar – Fortran and BASIC – nine months later one would find Spin." This refers to the whitespace formatting of FORTRAN and the keyword-based operation of BASIC.
Package and I/O
The initial version of the chip (called the P8X32A) provides one 32-bit port in a 40-pin 0.6 in dual in-line package (DIP), 44-pin LQFP, or Quad Flat No-leads package (QFN) surface-mount technology package. Of the 40 available pins, 32 are used for I/O, four for power and ground pins, two for an external crystal (if used), one to enable power outage and brownout detection, and one for reset.
All eight cores can access the 32-bit port (designated "A"; there is currently no "B") simultaneously. A special control mechanism is used to avoid I/O conflicts if one core attempts to use an I/O pin as an output while another tries to use it as input. Any of these pins can be used for the timing or pulse-width modulation output techniques described above.
Parallax has stated that it expects later versions of the Propeller to offer more I/O pins and/or more memory.
Virtual I/O devices
The Propeller's designers designed it around the concept of "virtual I/O devices". For example, the HYDRA Game Development Kit, (a computer system designed for hobbyists, to learn to develop retro-style video games) uses the built-in character generator and video support logic to generate a virtual graphics processing unit-generator that outputs VGA color pictures, PAL/NTSC compatible color pictures or broadcast RF video+audio in software.
The screen capture displayed here was made using a software virtual display driver that sends the pixel data over a serial link to a PC.
Software libraries are available to implement several I/O devices ranging from simple UARTs and Serial I/O interfaces such as SPI, I²C and PS/2 compatible serial mouse and keyboard interfaces, motor drivers for robotic systems, MIDI interfaces and LCD controllers.
Dedicated cores instead of interrupts
The design philosophy of the Propeller is that a hard real-time multi-core architecture negates the need for dedicated interrupt hardware and support in assembly. In traditional CPU architecture, external interrupt lines are fed to an on-chip interrupt controller and are serviced by one or more interrupt service routines. When an interrupt occurs, the interrupt controller suspends normal CPU processing and saves internal state (typically on the stack), then vectors to the designated interrupt service routine. After handling the interrupt, the service routine executes a return from interrupt instruction which restores the internal state and resumes CPU processing.
To handle an external signal promptly on the Propeller, any one of the 32 I/O lines is configured as an input. A cog is then configured to wait for a transition (either positive or negative edge) on that input using one of the two counter circuits available to each cog. While waiting for the signal, the cog operates in low-power mode, essentially sleeping. Extending this technique, a Propeller can be set up to respond to eight independent interrupt lines with essentially zero handling delay. Alternately, one line can be used to signal the interrupt, and then additional input lines can be read to determine the nature of the event. The code running in the other cores is not affected by the interrupt handling cog. Unlike a traditional multitasking single-processor interrupt architecture, the signal response timing remains predictable, and indeed using the term interrupt in this context can cause confusion, since this function can be more properly thought of as polling with a zero loop time.
On power up, Brownout detection, software reset, or external hardware reset, the Propeller will load a machine-code booting routine from the internal ROM into the RAM of its first (primary) cog and execute it. This code emulates an I²C interface in software, temporarily using two I/O pins for the needed serial clock and data signals to load user code from an external I2C EEPROM.
Simultaneously, it emulates a serial port, using two other I/O pins that can be used to upload software directly to RAM (and optionally to the external EEPROM). If the Propeller sees no commands from the serial port, it loads the user program (the entry code of which must be written in Spin, as described above) from the serial EEPROM into the main 32 KB RAM. After that, it loads the Spin interpreter from its built-in ROM into the dedicated RAM of its first cog, overwriting most of the bootloader.
Regardless of how the user program is loaded, execution starts by interpreting initial user bytecode with the Spin interpreter running in the primary cog. After this initial Spin code runs, the application can turn on any unused cog to start a new thread, and/or start assembly language routines.
External persistent memory
Other language implementations
Apart from Spin and the Propeller's low-level assembler, a number of other languages have been ported to it.
Parallax supports Propeller-GCC which is a port of the GNU Compiler Collection (GCC) compiler for the programming languages C and C++, for Propeller (branch release_1_0). The C compiler and the C Library are ANSI C compliant. The C++ compiler is ANSI-C99 compliant. Full C++ is supported with external memory. The SimpleIDE program provides users a simple way to write programs without requiring makefiles. In 2013, Parallax incorporated Propeller-GCC and Simple Libraries into the Propeller-C Learn series of tutorials. Propeller-GCC is actively maintained. Propeller-GCC and SimpleIDE are officially supported Parallax software products.
The ImageCraft ICCV7 for Propeller C compiler has been marked to end-of-life state.
PropBASIC is a BASIC programming language for the Parallax Propeller Microcontroller. PropBASIC requires Brad's Spin Tool (BST), a cross-platform set of tools for developing with the Parallax Propeller. As of August 2015, BST runs on i386-linux-gtk2, PowerPC-darwin (Mac OS X 10.4 through 10.6), i386-darwin (Mac OS X 10.4 through 10.6) and i386-Win32 (Windows 95 through Windows 7).
Forth on the Propeller
A free version that enjoys extensive development and community support is PropForth. It is tailored to the prop architecture, and necessarily deviates from any general standard regarding architectural uniqueness, consistent with the concept of Forth.
Beyond the Forth interpreter, PropForth provides many features that exploit the chip's abilities. Linked I/O refers to the method of associating a stream with process, allowing one process to link to the next on the fly, transparent to the application. This can reduce or eliminate the need of a hardware debugging or Joint Test Action Group (JTAG) interface in many cases. Multi-Channel Synchronous Serial (MCS) refers to the synchronous serial communication between prop chips. 96-bit packets are sent continuously between two cogs, the result is that applications see additional resources (+6 cogs for each prop chip added) with little or no impact on throughput for a well constructed application.
LogicAnalyzer refers to an extension package that implements software logic analyzer. EEPROMfilesystem and SDfilesystem are extensions that implement rudimentary storage using EEPROM and SD flash.
PagedAssembler refers to the package of optimizations that allow assembler routines to be swapped in (and out by overwrite) on the fly, allowing virtually unlimited application size. Script execution allows extensions to be loaded on the fly, allowing program source up to the size of storage media.
Propeller and Java
Pascal compiler and runtime
PICo programmable logic controller (PLC, PICoPLC) supports output to Propeller processor. The program is created in a GUI ladder logic editor and resulting code is emitted as Spin source. PICoPLC also supports P8X32 with create-simulate-run feature. No restrictions on target hardware as the oscillator frequency and IO pins are freely configurable in the ladder editor. PICoPLC developer website ().
As of 2014[update], Parallax is building a new Propeller with cogs that each will run at about 200 MIPS, whereas the current Propeller's cogs each run at around 20 MIPS. The improved performance would result from a maximum clock speed increase to 200 MHz (from 80 MHz) and an architecture that pipelines instructions, executing an average of nearly one instruction per clock cycle (approximately a ten-fold increase).
- makezine.com Archived 2008-06-25 at the Wayback Machine
- Gracey, Ken (2014). "Propeller 1 Open Source". Parallax Inc. Parallax Inc. Retrieved 4 February 2017.
The Propeller 1 (P8X32A) is now a 100% open multicore microcontroller, including all of the hardware and tools ... The Propeller 1 may be the most open chip in its class.
- "electronicdesign.com". Archived from the original on 2007-10-14. Retrieved 2008-10-10.
- David A. Scanlan, Martin A. Hebel. "Programming the eight-core propeller chip" Journal of Computing Sciences in Colleges, Volume 23, Issue 1, October 2007.
- Parallax Forums Archived 2010-09-24 at the Wayback Machine
- selmaware.com Archived 2008-12-21 at the Wayback Machine; a dedicated video generator board with a propeller
- screen capture software
- parallax.com; propeller object exchange software library
- propeller wikispaces.com Archived 2010-09-21 at the Wayback Machine
- circuitcellar.com Archived 2008-07-06 at the Wayback Machine
- PropGCC on Google Code
- Propeller C Learning System
- Catalina - a C compiler for the Propeller Archived 2010-09-24 at the Wayback Machine
- google.com; propforth
- Programming Propeller in Java
- Official website, Parallax Inc:
- Wiki with detailed information about the propeller
- Propeller forum at Parallax Inc:
- Propeller GCC Beta Site
- Article at EiED online
- a second article at EiED online
- An article at ferret.com.au
- List of programming languages running on the Propeller
- Download PICoPLC from APStech[permanent dead link]
- FirstSpin, a weekly educational audio program about the Spin programming language and the Propeller, sponsored by Parallax | <urn:uuid:fc2637a1-0805-41de-9c92-4c8094bb715a> | {
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HCPCS and CPT work hand in hand. HCPCS is the abbreviation for Healthcare Common Procedure Coding System.
- HCPCS (Healthcare Common Procedure Coding System) is a standardized coding system for billing medical procedures and services in the United States, including CPT and additional alphanumeric codes.
- CPT (Current Procedural Terminology) is a subset of HCPCS, consisting of numerical codes specifically for billing medical services performed by physicians and other healthcare professionals.
- HCPCS and CPT codes are crucial in medical billing and insurance reimbursement, ensuring accurate and consistent communication between providers, payers, and patients.
HCPCS vs CPT
HCPCS and CPT are codes used in medical billing. HCPCS are used for services and supplies not covered by CPT codes, as basic healthcare services like medical devices, medical supplies, etc. CPT codes are used for standard medical procedures and services, like surgeries, diagnostic tests, etc.
The HCPCS codes consist of three levels, Level 1, Level 2, and Level 3. It needs CPT codes to claim the services by physicians and surgeons to the payers of these services.
The CPT codes are the ones that are used in the HCPCS Level 1 coding. They contain the procedures different medical departments must follow during an operation.
|Parameters of Comparison
|HCPCS codes are used to give a standardized description of delivering healthcare services.
|CPT codes describe the services that medical workers have to be acknowledged.
|The Health Insurance Portability and Accountability Act state that everyone should be free to access HCPCS procedures.
|The American Medical Association has owned CPT codes, and outsiders have to pay to access these.
|HCPCS operates on three levels. Namely, Level 1, Level 2, and Level 3.
|CPT has three categories. They are Category 1, Category 2, and Category 3.
|HCPCS was created by the Centers for Medicare and Medicaid (CMS).
|CPT was developed by the American Medical Association (AMA).
|HCPCS has codes for both direct healthcare workers and non-direct healthcare workers.
|The CPT codes are only for the procedures to be operated upon by a patient.
What is HCPCS?
The Centers for Medicare and Medicaid organizations have developed HCPCS codes. It was designed to identify the insurance policies one is eligible for.
Level 1 contains the codes that the American Medical Association has addressed. These are the CPT codes.
Level 2 of HCPCS consists of codes related to non-physical service providers. Mainly the ambulance services are noted here.
The Level 3 codes are called the local codes. These codes are presently not in use but have a history until December 31, 2003.
What is CPT?
The American Medical Association has produced CPT to address the procedures medical professionals must follow while attending to patients. The CPT editorial panel publishes this in the AMA.
Category 1 contains six main sections. They are Codes for evaluation and management, codes for anaesthesia, codes for surgery and radiology, codes for pathology and laboratory, and codes for medicine.
The second category in CPT defines the codes clinics must follow while evaluating and managing them. The advisory board of CPT – Performance Measures Advisory Group edits and reviews this category.
The third category of CPT is addressed by emerging technology in the medical field. It starts from 0016T – 0207T.
Main Differences Between HCPCS and CPT
- HCPCS is a standardized description of the procedures a medical professional has to follow while attending to a patient. CPT consists of the codes that describe this set of guidelines.
- The HIPAA has made it mandatory that anyone can access HCPCS. AMA copyrights the CPT, and hence it is a paid service.
- HCPCS is divided into three levels, mainly Level 1, Level 2, and Level 3. The CPT is divided into three categories: Category 1, Category, and Category 3.
- The Centers for Medicare and Medicaid developed HCPCS. The American Medical Association is the creator of CPT.
- The codes in HCPCS are applicable to both direct and indirect medical professionals. The CPT is a part of HCPCS, containing the rules to follow while treating a patient.
Last Updated : 11 June, 2023
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Piyush Yadav has spent the past 25 years working as a physicist in the local community. He is a physicist passionate about making science more accessible to our readers. He holds a BSc in Natural Sciences and Post Graduate Diploma in Environmental Science. You can read more about him on his bio page. | <urn:uuid:d6fab5c6-b209-4a96-814d-ef285c35a632> | {
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When you have a child or children with autism, you probably spend more time with doctors and therapists than most other families. First, there’s the search for a diagnosis, then there are potential treatments, not to mention the other conditions—such as ADHD or gastrointestinal issues—sometimes associated with ASD.
All this means you’ve almost certainly come into contact with the ICD-10-CM. What does this string of letters and numbers mean, and how does it connect to autism? In this article, we’ll explore the ICD and how it impacts autism diagnosis.
What is the ICD-10-CM index?
The ICD-10-CM index is a version of the International Classification of Diseases, a tool created by the World Health Organization. It’s essentially a list of diseases, disorders, and other health conditions, all of which are categorized and labeled with a code made up of letters and numbers.
The ICD got its start as the International Statistical Institute’s International List of Causes of Death in 1893. Eventually, the World Health Organization took over its maintenance, and it was expanded to include all conditions, not just fatal ones. Every country that is a member of WHO must use the ICD to compile national death and disease statistics.
Member countries currently use the tenth edition of the ICD, called ICD-10. The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) is a version created for use in the United States. The U.S. uses the ICD-10-CM to diagnose conditions and record patient information, and it uses the standard ICD-10 to classify data from death certificates.
ICD-10 came into effect globally in 1990, but the United States didn’t begin using it for mortality information until 1999 and didn’t fully transition to the ICD-10-CM until 2015. That’s why some websites will list what tenth revision codes are equivalent to those from its predecessor, the ICD-9—although there aren’t exact matches, since the transition to the tenth edition added about 55,000 new codes.
These codes have important purposes in the medical world. On a larger scale, public health officials use the data to conduct research and keep track of trends. For patients and caregivers, codes are usually used in hospital billing and insurance claims.
How is autism classified in the ICD-10-CM Index?
Autism is labeled with the code F84.0. It is a “billable code,” meaning it’s detailed enough to constitute a medical diagnosis. It falls under the section for mental and behavioral disorders (codes F00 through F99), the subsection of pervasive and specific developmental disorders (F80 through F89), and the smaller subsection of pervasive developmental disorders (F84).
The ICD defines a pervasive developmental disorder as “severe distortions in the development of many basic psychological functions that are not normal for any stage in development.” F84 itself is a non-billable code, so it can’t be entered into any system as a diagnosis, but every code that falls under it (F84.0 through F84.9) can.
Click here to find out more
Looking at F84.0 autistic disorder
The description of F84.0 autistic disorder in the ICD is basically the same as other descriptions of autism—children with ASD will have difficulties with social interaction, language and communication skills, and repetitive behavior that become evident in early childhood, particularly before the age of three.
An ICD code may have “inclusion terms,” which are other conditions the code can be used for. Often, the inclusion terms are just synonyms of the primary one. In the case of code F84.0, the inclusion terms are autism spectrum disorder, infantile autism, infantile psychosis, and Kanner’s syndrome.
The ICD also has Type 1 Excludes Notes, which indicate when two codes should never be diagnosed alongside each other. In this case, autism and asperger’s syndrome are considered to be mutually exclusive (a position not taken by all diagnostic authorities, as we’ll see later). Asperger’s syndrome is called code F84.5 instead of code F84.0. The difference, according to the ICD, is that children with asperger’s don’t have the language and cognitive impairments that can be found in other autism spectrum disorders.
ICD coding allows professionals to include an additional code in their diagnosis, so they can further specify the disorder or identify any associated medical condition such as an intellectual disability. In that case, the patient would be coded for F84.0 autistic disorder as well as a code between F70-F79, which represent mild, moderate, severe, and unspecified intellectual disabilities.
Autism in the ICD-9
American children diagnosed with autism before 2015, when the ICD-9 phased out, may have received the code 299.0 or 299.1. Code 299.0 indicated “autistic disorder, current or active state” and 299.1 indicated “autistic disorder, residual state,” meaning the patient used to meet the criteria for an ASD diagnosis but no longer does. People with ASD in a residual state may still have symptoms found in autism, but not enough to maintain the diagnosis. Either way, both codes now fall under F84.0 autistic disorder.
Is the ICD-10-CM Index related to the DSM V?
The DSM V is the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. It has been in effect since 2013. Unlike the ICD, it only covers mental conditions. But they have similar purposes in providing a shared, consistent set of terms and diagnostic criteria for health care professionals.
Because they’re created by two separate organizations, there are some discrepancies between the two manuals. For example, in the ICD-10, childhood disintegrative disorder, asperger’s syndrome, and pervasive developmental disorder-not otherwise specified each has its own code separate from autism. The American Psychiatric Association, however, collapsed each of these diagnoses under autism spectrum disorder.
That said, the indexes have very similar definitions of ASD. Both emphasize repetitive behavior, struggles with social interaction and communication, and the appearance of symptoms in early childhood.
The main difference between the two is that DSM-V codes can not be submitted for insurance claims. They are only useful for identification and diagnosis. If an insurance claim is submitted in the United States without an ICD code, it will be rejected.
Clearly, the ICD-10-CM is important for anyone with long-term medical diagnoses. As research is done and advances are made, the ICD will continue to change how we understand and classify conditions.
In fact, the ICD-11 is already on its way—WHO member countries will be allowed to implement it in 2022, though the United States isn’t expected to fully adopt it until the latter end of the decade.
Autism has a new code in the ICD-11: 6A02, now called “autism spectrum disorder” instead of “autistic disorder”. There is a new range of codes from 6A02.0 to 6A02.5, indicating whether the individual has impaired intellectual development or functional language. ICD-11 has also followed the DSM-V’s lead in including asperger’s syndrome under ASD.
We don’t know when ICD-11 will reach the U.S., or what, if any, modifications will be made to it. Either way, this article has hopefully helped you understand its purpose. Whether ASD is known as code F84.0, 6A02, 299.0, or something else in the future, autistic people and their loved ones represent a vibrant, supportive community.
Autism Speaks. (n.d.). DSM-5 and Autism: Frequently Asked Questions. Autism Speaks. https://www.autismspeaks.org/dsm-5-and-autism-frequently-asked-questions
Bielby, J. (2020, May 4). ICD-10, ICD-10-CM, & ICD-10-PCS. A.R. Dykes. https://guides.library.kumc.edu/icd10
Boyd, N. (n.d.). Diagnostic Codes: DSM-5 vs ICD-10. KASA. https://kasa-solutions.com/diagnostic-codes-dsm-5-vs-icd-10/
Holman, T. (2018, October). ICD-10-CM (Clinical Modification). TechTarget. https://searchhealthit.techtarget.com/definition/ICD-10-CM
World Health Organization. (2021). International Statistical Classification of Diseases and Related Health Problems (ICD). World Health Organization. https://www.who.int/standards/classifications/classification-of-diseases
World Health Organization. (2021). 2021 ICD-10-CM CODE F84.0. ICD List. https://icdlist.com/icd-10/F84.0
World Health Organization. (2021, May). 6A02 Autism spectrum disorder. ICD-11 for Mortality and Morbidity Statistics. https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f437815624 | <urn:uuid:170d356e-2d00-4493-a7d1-c84026c3b761> | {
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Bronchopneumonia - Inflammation of the lung parenchyma that is associated with BRONCHITIS, usually involving lobular areas from TERMINAL BRONCHIOLES to the PULMONARY ALVEOLI. The affected areas become filled with exudate that forms consolidated patches.
Chlamydial Pneumonia - Pneumonia caused by infections with the genus CHLAMYDIA; and CHLAMYDOPHILA, usually with CHLAMYDOPHILA PNEUMONIAE.
Cryptogenic Organizing Pneumonia - An interstitial lung disease of unknown etiology, occurring between 21-80 years of age. It is characterized by a dramatic onset of a "pneumonia-like" illness with cough, fever, malaise, fatigue, and weight loss. Pathological features include prominent interstitial inflammation without collagen fibrosis, diffuse fibroblastic foci, and no microscopic honeycomb change. There is excessive proliferation of granulation tissue within small airways and alveolar ducts.
Eosinophils - Granular leukocytes with a nucleus that usually has two lobes connected by a slender thread of chromatin, and cytoplasm containing coarse, round granules that are uniform in size and stainable by eosin.
Hamman-Rich Syndrome - Acute idiopathic interstitial pneumonitis characterized by diffuse PULMONARY ALVEOLI damage with uniform edematous connective tissue proliferation. It is often associated with extensive fibroblastic distortion of the lung parenchyma and leads to ADULT RESPIRATORY DISTRESS SYNDROME in later stages.
Healthcare-Associated Pneumonia - Infection of the lung often accompanied by inflammation that is acquired through an interaction within a healthcare institution often through a therapeutic experience (e.g., use of catheters or ventilators).
Idiopathic Interstitial Pneumonias - A group of interstitial lung diseases with no known etiology. There are several entities with varying patterns of inflammation and fibrosis. They are classified by their distinct clinical-radiological-pathological features and prognosis. They include IDIOPATHIC PULMONARY FIBROSIS; CRYPTOGENIC ORGANIZING PNEUMONIA; and others.
Lung Diseases, Interstitial - A diverse group of lung diseases that affect the lung parenchyma. They are characterized by an initial inflammation of PULMONARY ALVEOLI that extends to the interstitium and beyond leading to diffuse PULMONARY FIBROSIS. Interstitial lung diseases are classified by their etiology (known or unknown causes), and radiological-pathological features.
Murine pneumonia virus - A species of the genus PNEUMOVIRUS causing pneumonia in mice.
Organizing Pneumonia - Any obstructive lung disease characterized by consolidated formation of GRANULATION TISSUE polyps within ALVEOLAR DUCTS AND ALVEOLI. It is classified as either primary (cryptogenic organizing pneumonia) or secondary organizing pneumonia. Secondary organizing pneumonia after transplantation is called bronchiolitis obliterans syndrome.
Pneumonia - Infection of the lung often accompanied by inflammation.
Pneumonia of Calves, Enzootic - Chronic endemic respiratory disease of dairy calves and an important component of bovine respiratory disease complex. It primarily affects calves up to six months of age and the etiology is multifactorial. Stress plus a primary viral infection is followed by a secondary bacterial infection. The latter is most commonly associated with PASTEURELLA MULTOCIDA producing a purulent BRONCHOPNEUMONIA. Sometimes present are MANNHEIMIA HAEMOLYTICA; HAEMOPHILUS SOMNUS and mycoplasma species.
Pneumonia of Swine, Mycoplasmal - A chronic, clinically mild, infectious pneumonia of PIGS caused by MYCOPLASMA HYOPNEUMONIAE. Ninety percent of swine herds worldwide are infected with this economically costly disease that primarily affects animals aged two to six months old. The disease can be associated with porcine respiratory disease complex. PASTEURELLA MULTOCIDA is often found as a secondary infection.
Pneumonia, Aspiration - A type of lung inflammation resulting from the aspiration of food, liquid, or gastric contents into the upper RESPIRATORY TRACT.
Pneumonia, Atypical Interstitial, of Cattle - A cattle disease of uncertain cause, probably an allergic reaction.
Pneumonia, Bacterial - Inflammation of the lung parenchyma that is caused by bacterial infections.
Pneumonia, Lipid - Pneumonia due to aspiration or inhalation of various oily or fatty substances or otherwise accumulation of endogenous lipid substances in the PULMONARY ALVEOLI.
Pneumonia, Mycoplasma - Interstitial pneumonia caused by extensive infection of the lungs (LUNG) and BRONCHI, particularly the lower lobes of the lungs, by MYCOPLASMA PNEUMONIAE in humans. In SHEEP, it is caused by MYCOPLASMA OVIPNEUMONIAE. In CATTLE, it may be caused by MYCOPLASMA DISPAR.
Pneumonia, Necrotizing - Severe complication of pneumonia characterized by liquefaction of lung tissue.
Pneumonia, Pneumococcal - A febrile disease caused by STREPTOCOCCUS PNEUMONIAE.
Pneumonia, Pneumocystis - A pulmonary disease in humans occurring in immunodeficient or malnourished patients or infants, characterized by DYSPNEA, tachypnea, and HYPOXEMIA. Pneumocystis pneumonia is a frequently seen opportunistic infection in AIDS. It is caused by the fungus PNEUMOCYSTIS JIROVECII. The disease is also found in other MAMMALS where it is caused by related species of Pneumocystis.
Pneumonia, Progressive Interstitial, of Sheep - Chronic respiratory disease caused by the VISNA-MAEDI VIRUS. It was formerly believed to be identical with jaagsiekte (PULMONARY ADENOMATOSIS, OVINE) but is now recognized as a separate entity.
Pneumonia, Rickettsial - Pneumonia caused by infection with bacteria of the family RICKETTSIACEAE.
Pneumonia, Staphylococcal - Pneumonia caused by infections with bacteria of the genus STAPHYLOCOCCUS, usually with STAPHYLOCOCCUS AUREUS.
Pneumonia, Ventilator-Associated - Serious INFLAMMATION of the LUNG in patients who required the use of PULMONARY VENTILATOR. It is usually caused by bacterial CROSS INFECTION in hospitals.
Pneumonia, Viral - Inflammation of the lung parenchyma that is caused by a viral infection.
Pneumovirus - A genus of the family PARAMYXOVIRIDAE (subfamily PNEUMOVIRINAE) where the human and bovine virions have neither hemagglutinin nor neuraminidase activity. RESPIRATORY SYNCYTIAL VIRUS, HUMAN is the type species.
Pulmonary Alveoli - Small polyhedral outpouchings along the walls of the alveolar sacs, alveolar ducts and terminal bronchioles through the walls of which gas exchange between alveolar air and pulmonary capillary blood takes place.
Pulmonary Eosinophilia - A condition characterized by infiltration of the lung with EOSINOPHILS due to inflammation or other disease processes. Major eosinophilic lung diseases are the eosinophilic pneumonias caused by infections, allergens, or toxic agents.
Radiation Pneumonitis - Inflammation of the lung due to harmful effects of ionizing or non-ionizing radiation.
Rickettsiaceae - A family of gram-negative bacteria belonging to the order Rickettsiales.
Streptococcus pneumoniae - A gram-positive organism found in the upper respiratory tract, inflammatory exudates, and various body fluids of normal and/or diseased humans and, rarely, domestic animals.
Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. Wherever such a combination exists, there is a "use additional code" note at the etiology code, and a "code first" note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.
Type 1 Excludes
A type 1 excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.
- abscess of lung with pneumonia J85.1
- aspiration pneumonia due to anesthesia during labor and delivery O74.0
- aspiration pneumonia due to anesthesia during pregnancy O29
- aspiration pneumonia due to anesthesia during puerperium O89.0
- aspiration pneumonia due to solids and liquids J69
- aspiration pneumonia NOS J69.0
- congenital pneumonia P23.0
- drug-induced interstitial lung disorder J70.2 J70.4
- interstitial pneumonia NOS J84.9
- lipid pneumonia J69.1
- neonatal aspiration pneumonia P24
- pneumonitis due to external agents J67 J70
- pneumonitis due to fumes and vapors J68.0
- usual interstitial pneumonia J84.178 | <urn:uuid:70b751f4-0c28-4234-9a2a-e63583e353ac> | {
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Battery Charge Time Calculator
Use our battery charge time calculator to easily estimate how long it’ll take to fully charge your battery.
Battery Charge Time Calculator
Tip: If you’re solar charging your battery, you can estimate its charge time much more accurately with our solar battery charge time calculator.
How to Use This Calculator
Enter your battery capacity and select its units from the list. The unit options are milliamp hours (mAh), amp hours (Ah), watt hours (Wh), and kilowatt hours (kWh).
Enter your battery charger’s charge current and select its units from the list. The unit options are milliamps (mA), amps (A), and watts (W).
If the calculator asks for it, enter your battery voltage or charge voltage. Depending on the combination of units you selected for your battery capacity and charge current, the calculator may ask you to input a voltage.
Select your battery type from the list.
Optional: Enter your battery state of charge as a percentage. For instance, if your battery is 20% charged, you’d enter the number 20. If your battery is dead, you’d enter 0.
Click Calculate Charge Time to get your results.
Battery Charging Time Calculation Formulas
For those interested in the underlying math, here are 3 formulas to for calculating battery charging time. I start with the simplest and least accurate formula and end with the most complex but most accurate.
Formula: charge time = battery capacity ÷ charge current
The easiest but least accurate way to estimate charge time is to divide battery capacity by charge current.
Most often, your battery’s capacity will be given in amp hours (Ah), and your charger’s charge current will be given in amps (A). So you’ll often see this formula written with these units:
charge time = battery capacity (Ah) ÷ charge current (A)
However, battery capacity can also be expressed in milliamp hours (mAh), watt hours (Wh) and kilowatt hours (kWh). And your battery charger may tell you its power output in milliamps (mA) or watts (W) rather than amps. So you may also see the formula written with different unit combinations.
charge time = battery capacity (mAh) ÷ charge current (mA) charge time = battery capacity (Wh) ÷ charge rate (W)
And sometimes, your units are mismatched. Your battery capacity may be given in watt hours and your charge rate in amps. Or they may be given in milliamp hours and watts.
In these cases, you need to convert the units until you have a ‘matching’ pair.- such as amp hours and amps, watt hours and watts, or milliamp hours and milliamps.
For reference, here are the formulas you need to convert between the most common units for battery capacity and charge rate. Most of them link to our relevant conversion calculator.
Battery capacity unit conversions:
- watt hours = amp hours × volts
- amp hours = watt hours ÷ volts
- milliamp hours = amp hours × 1000
- amp hours = milliamp hours ÷ 1000
- watt hours = milliamp hours × volts ÷ 1000
- milliamp hours = watt hours ÷ volts × 1000
- kilowatt hours = amp hours × volts ÷ 1000
- amp hours = kilowatt hours ÷ volts × 1000
- watt hours = kilowatt hours × 1000
- kilowatt hours = watt hours ÷ 1000
Charge rate unit conversions:
The formula itself is simple, but taking into account all the possible conversions can get a little overwhelming. So let’s run through a few examples.
Example 1: Battery Capacity in Amp Hours, Charging Current in Amps
Let’s say you have the following setup:
- Battery capacity: 100 amp hours
- Charging current: 10 amps
To calculate charging time using this formula, you simply divide battery capacity by charging current.
In this scenario, your estimated charge time is 10 hours.
Example 2: Battery Capacity in Watt Hours, Charging Rate in Watts
Let’s now consider this scenario:
Because your units are again ‘matching’, to calculate charging time you again simply divide battery capacity by charging rate.
In this scenario, your estimated charge time is 8 hours.
Example 3: Battery Capacity in Milliamp Hours, Charging Rate in Watts
Let’s consider the following scenario where the units are mismatched.
First, you need to decide which set of matching units you want to convert to. You consider watt hours for battery capacity and watts for charge rate. But you’re unable to find the battery’s voltage, which you need to convert milliamp hours to watt hours.
You know the charger’s output voltage is 5 volts, so you settle on amp hours for battery capacity and amps for charge rate.
With that decided, you first divide watts by volts to get your charging current in amps.
Next, you convert battery capacity from milliamp hours to amp hours by dividing milliamp hours by 1000.
Now you have your battery capacity and charging current in ‘matching’ units. Finally, you divide battery capacity by charging current to get charge time.
In this example, your estimated battery charging time is 1.5 hours.
Formula: charge time = battery capacity ÷ (charge current × charge efficiency)
No battery charges and discharges with 100% efficiency. Some of the energy will be lost due to inefficiencies during the charging process.
This formula builds on the previous one by factoring in charge/discharge efficiency, which differs based on battery type.
Here are efficiency ranges of the main types of rechargeable batteries (source):
Note: Real-world charge efficiency is not fixed and varies throughout the charging process based on a number of factors, including charge rate and battery state of charge. The faster the charge, typically the less efficient it is.
Example 1: Lead Acid Battery
Let’s assume you have the following setup:
To calculate charging time using Formula 2, first you must pick a charge efficiency value for your battery. Lead acid batteries typically have energy efficiencies of around 80-85%. You’re charging your battery at 0.1C rate, which isn’t that fast, so you assume the efficiency will be around 85%.
With an efficiency percentage picked, you just need to plug the values in to the formula.
100Ah ÷ (10A × 85%) = 100Ah ÷ 8.5A = 11.76 hrs
In this example, your estimated charge time is 11.76 hours.
Recall, that, using Formula 1, we estimated the charge time for this setup to be 10 hours. Just by taking into account charge efficiency our time estimate increased by nearly 2 hours.
Example 2: LiFePO4 Battery
Let’s assume you again have the following setup:
Based on your battery being a lithium battery and the charge rate being relatively slow, you assume a charge efficiency of 95%. With that, you can plug your values into Formula 2.
1200Wh ÷ (150W × 95%) = 1200Wh ÷ 142.5W = 8.42 hrs
In this example, your estimated charge time is 8.42 hours.
Using Formula 1, we estimated this same setup to have a charge time of 8 hours. Because lithium batteries are more efficient, factoring in charge efficiency doesn’t affect our estimate as much as it did with a lead acid battery.
Example 3: Lithium Ion Battery
Again, let’s revisit the same setup as before:
First, you need to assume a charge efficiency. Based on the battery being a lithium battery and the charge rate being relatively fast, you assume the charge efficiency is 90%.
As before, you need to ‘match’ units, so you first convert the charging current to amps.
Then you convert the battery’s capacity from milliamp hours to amp hours.
With similar units, you can now plug everything into the formula to calculate charge time.
3Ah ÷ (2A × 90%) = 3Ah ÷ 1.8A = 1.67 hours
In this example, your estimated charge time is 1.67 hours.
Formula: charge time = (battery capacity × depth of discharge) ÷ (charge current × charge efficiency)
The 2 formulas above assume that your battery is completely dead. In technical terms, this is expressed by saying the battery is at 100% depth of discharge (DoD). You can also describe it as 0% state of charge (SoC).
Formula 3 incorporates DoD to let you estimate charging time regardless of how charged your battery is.
Example 1: 50% DoD
Let’s revisit this setup, but this time assume our lead acid battery has a 50% DoD. (Most lead acid batteries should only be discharged to 50% at most to preserve battery life.)
As before, let’s assume a charging efficiency of 85%.
We have all the info we need, so we just plug the numbers into Formula 3.
(100Ah × 50%) ÷ (10A × 85%) = 50Ah ÷ 8.5A = 5.88 hrs
In this example, your battery’s estimated charge time is 5.88 hours.
Example 2: 80% DoD
For this example, imagine you have the following setup:
As before, we’ll assume that the charging efficiency is 95%.
With that in mind, here’s the calculation you’d do to calculate charge time.
(1200Wh × 80%) ÷ (150W × 95%) = 960Wh ÷ 142.5W = 6.74 hrs
In this example, it will take about 6.7 hours to fully charge your battery from 80% DoD.
Example 3: 95% DoD
Let’s say your phone battery is at 5%, meaning it’s at a 95% depth of discharge. And your phone battery and charger have the following specs:
As before, we need to convert capacity and charge rate to similar units. Let’s first convert battery capacity to amp hours.
Next, let’s convert charge current to amps.
Because the charge C-rate is relatively high, we’ll again assume a charging efficiency of 90% and then plug everything into Formula 3.
(3Ah × 95%) ÷ (2A × 90%) = 2.85Ah ÷ 1.8A = 1.58 hrs
Your phone battery will take about 1.6 hours to charge from 5% to full.
Why None of These Formulas Is Perfectly Accurate
None of these battery charge time formulas captures the real-life complexity of battery charging. Here are some more factors that affect charging time:
- Your battery may be powering something. If it is, some of the charge current will be siphoned off to continue powering that device. The more power the device is using, the longer it will take for your battery to charge fully.
- Battery chargers aren’t always outputting their max charge rate. Many battery chargers employ charging algorithms that adjust the charging current and voltage based on how charged the battery is. For example, some battery chargers slow the charge rate down drastically once the battery reaches around 70-80% charged. These charging algorithms vary based on charger and battery type.
- Batteries lose capacity as they age. An older battery will have less capacity than an identical new battery. Your 100Ah LiFePO4 battery may have only have around 85Ah capacity after 1000 cycles. And the rates at which batteries age depend on a number of factors.
- Lithium batteries have a Battery Management System (BMS). Besides consuming a modest amount of power, the BMS can adjust the charging current to protect the battery and optimize its lifespan. iPhones have a feature called Optimized Battery Charging that delays charging the phone’s battery past 80% until you need to use it.
- Lead acid battery chargers usually have a timed absorption stage. After being charged to around 70-80%, many lead acid battery chargers (and solar charge controllers) enter a timed absorption stage for the remainder of the charge cycle that is necessary for the health of the battery. It’s usually a fixed 2-3 hours, regardless of how big your battery is, or how fast your charger.
In short, batteries are wildly complex, and accurately calculating battery charge time is no easy task. It goes without saying that any charge time you calculate using the above formulas.- or our battery charge time calculator.- should be viewed as an estimate.
EBL INR 26650 Li-ion Rechargeable Batteries 3.7V 5000mAh
WHAT ARE EBL’S SHIPPING OPTIONS?
Each order from EBL is shipped from the United States and will be delivered by standard shipping with an estimated delivery time of 7-14 business days.
When will my order be shipped?
We usually take 2 to 5 business days to schedule shipments, except for pre-sales items. A notification will be sent to the customer via email after shipment.
Which countries do you ship to?
We can ship to the United States, Canada and Mexico.
Do you ship internationally on your website? Can you ship to my country?
Our website is still testing shipping products worldwide. Therefore, the shipping cost charged at checkout is an estimate and will be based on the actual postage cost incurred when the product is sent by courier (generally based on the weight and volume of the products).Please Note: We will refund the excess if the postage charged is more than the actual shipping charge. Meanwhile, if the postage charged is less than the actual shipping cost, we will also charge the customer for the additional shipping cost.
Orders over 25
Orders under 25
Standard shipping charge of 5
Weight Between 1-4oz
Weight Between 5-15oz
Weight Between 16-25oz
Weight Between 26-49oz
Weight Between 50-80oz
Delivery areas within the U.S.
EBL official website supports delivery to most areas of the United States. We cannot deliver to the following areas:
- American Samoa
- Marshall Islands
- Northern Mariana Islands
- U.S. Virgin Islands
- Armed Forces Americas
- Armed Forces Europe
- Armed Forces Pacific
Please note: Power stations and solar panels cannot be shipped to Hawaii, Puerto Rico or Alaska.
Thank you for your understanding.
We also offer international shipping to the following countries: Canada and Mexico.
And we can ship to other countries, but only for wholesale orders. Please contact us at firstname.lastname@example.org for more details.
As we are still testing shipping of EBL products to all parts of the world. Therefore, the shipping charges charged at checkout are an estimate and the actual shipping charges will be based on the actual postage costs incurred when the product is sent by the courier (generally based on the weight and volume of the product).
- Batteries cannot be shipped to other countries.
- If the postage charged is more than the actual postage cost, we will refund the excess. Also, if the postage charged is less than the actual shipping cost, we will charge the customer for the additional shipping cost.
1) Standard Shipping is not available for P.O. Boxes and APO/FPO addresses.
2) After the order has been paid, the warehouse needs 2-5 business days to process your order. You will receive a notification once your order has been shipped.
3) If you place more than one order, you may get multiple deliveries. We’ll send you a shipping confirmation email for each order, so you’ll know exactly what to expect and when to expect it.
4) In most cases, the package will be delivered within the estimated time of arrival. However, the actual delivery date may be affected by weather conditions and other external factors. Please refer to the tracking information for the most accurate delivery date.
5) If there is any shipping issue with your package, you must contact Customer Support within 30 days of placing your order.
How would EBL Official ship my order?
USPS and UPS are our logistics partners to ship out EBL products. we will choose the carrier that we think works best for our customers.
How do I check the status of my order?
Once your order is picked up by the carrier at our warehouse, we will send you a shipment tracking update email with the estimated delivery date and tracking number. If you do not receive this email, please check your spam or junk mail folder or contact us by email at email@example.com.
I ordered more than one item. Will they all be delivered at the same time?
We try to make sure all your items reach you at the same time. Sometimes our products are not always sent together since different shipping options can be used,depending on the product. Once an item has been shipped,you will receive a shipment notification email.
Why is there no tracking update?
If your order is still under the estimated delivery time frame, kindly wait patiently. Once this process has been completed, you will see tracking updates.
If your order has not been updated for a long time and is overdue, you may contact the shipping courier or contact us for help.
Can I change the delivery address of my package after it has been shipped out?
Unfortunately, we cannot change the shipping address once the product is in transit.
What do I need to do when the product I received is different from the one I ordered?
Please provide some details about the issue and contact customer support at firstname.lastname@example.org.
Delivered but Not Received
If the tracking information shows that your package has been delivered, but you cannot find it, please wait two business days for it to arrive. In the meantime, we recommend that you check your home and ask your neighbors if they may have received it for you.2. If after that you still haven’t received it, please contact us via email@example.com and we will be happy to help you.
Welcome to EBL’s Warranty and Refund Policy page, where you can email us directly if you encounter any quality-related problems after purchasing EBL products. We apologize in advance for any inconvenience your purchase of EBL products may cause.
If your product is defective during the warranty period, please contact us by mail or via live chat and let us know what we can do to help you.
We will take care of all quality-related issues and offer a REPLACEMENT or FULL REFUND, including the return shipping costs.
Please note that this page is for products purchased through eblofficial.com. For products purchased through the EBL store on sites such as eBay and Amazon or from EBL’s authorized distributors, please contact them directly.
All products purchased from EBL are guaranteed with a 12-month hassle-free warranty. In each case, the warranty period is measured starting on the date of purchase by the original consumer purchaser.
Valid Proof of Purchase
A sales receipt from the consumer’s first purchase, or other reasonable proof, is required in order to confirm the start date of the warranty period. Please provide both of the following vouchers when processing warranty claims:
- Provided order number from eblofficial.com.
- The email or phone number or name used to place the order.
Limited to Original Consumer Buyer
The warranty on EBL’s product is limited to the original consumer purchaser and is not transferable to any subsequent owner.
Warranty excludes :
- Products without sufficient proof of purchase.
- Damage caused by misuse the faulty parts.(including static discharge).
- Improper installation.
- Damaged by yourself.
- Purchase the product by mistake.
- Neglect, accident or modification, which have been soldered or altered during assembly.
- Complimentary products.
How to claim warranty?
To obtain warranty service, please contact our customer service team at firstname.lastname@example.org.
EBL will replace any EBL product that fails to operate within the applicable warranty period due to defect in workmanship or material. The replacement product assumes the remaining warranty period of the original product.
We offer a 30 day hassle-free money back guarantee on items purchased directly from eblofficial.com. ( We only provide prepaid return label for quality problem products. Other than that, customers need to pay for the return shipping fee. ) If for any reason you are not satisfied and would like to return an item, please let us know within 30 days.
Refunds can only be issued to the original payment method and cannot be issued to other cards or bank accounts. Refunds will be processed within 3-5 business days, and refunds generally take 10-15 business days to be returned to the original payment method.
Note: Once the package is shipped, any shipping costs paid at the time of the order, if applicable, are non-refundable.
There are certain situations where only partial refunds are granted:
- Products with missing parts that do not affect normal use.
- Products that cannot be replaced and have quality problems in part.
Return shipping costs should be paid by the customer in the following situations:
- Purchase the product by mistake.
- Usage of product contrary to its stated instructions.
- Returning products without any proven defect.
- Removal of identification labels such as, but not limited to, the original label, patent, serial number, or trade dress.
- Damage caused by improper storage, abuse or user error.
- Neglect, accident or modification, which have been soldered or altered during assembly.
Late or Missing Refunds
If you haven’t received your refund, first check your bank account again. If payment was made by credit card, we will refund the money to your account once we receive the product. Please allow 10-15 business days for the credit to be applied to your credit card or original payment method.Then contact your credit card company, it may take some time for your refund to be officially posted. Next contact your bank. There is usually some processing time before the refund is credited. If you have done all of this and you still have not received your refund, please contact us at email@example.com.
How do I return an item?
- Get in touch with us and start the return process within 30 days of the original shipping date.
- Provide proof of purchase from eblofficial.com (either the email address, phone number used to register, or order number).
- The product should be returned in its original packaging, unused, and in the same condition as the item you received.
- Refunds will be processed within 3-5 business days after we confirm receipt of your returned items at our warehouse.
⚡ 26650 Rechargeable Battery ⚡
【26650 Battery Specifications】
≤70mQ2(AC Impedance, 1000 Hz)
26650 cell dimensions/26650 battery diameter
【 Ultra Long Lasting 】
EBL high-performance Li-ion 26650 batteries have been manufactured with premium raw materials and high-density cell technology, they will give your devices enough power and last longer, so you can rest assured to use your various devices.
【 High Quality Competitive price 】
100% Brand New and High quality. 3.7v 26650 With a high capacity of 5000mAh, it can last a long time. Superior performance under low-temperature conditions. EBL 26650 li-ion rechargeable batteries for high power LED flashlights, electronic devices and other equipment 26650 size(please carefully confirm whether your equipment needs 26650 size before your order)
Quality Steel Shell, very sturdy and durable. Effectively prevent the 26650 rechargeable battery from leakage and short circuit.
【S torage 】
The rechargeale 26650 cells stored in the RT (room temperature), the 26650 battery’s cell should be charge once per 6 months to avoid the cell over-discharge. The customer should charge the cell for I hour by 0.5C for long-term storage.
The 26650 li-ion battery working principle is to release energy by electrochemistry to provide the power; actually, it is a chemistry product so that it should be re-charged to active the battery energy after a storage period because its performance will be attenuated after long term storage. If you cant to knwo more information about battery storage, related battery storage article here: Battery Storage Guidelines!
【 What You Get 】
2/4/8/16 Pack lithium rechargeable 26650 batteries 3.7V 5000mAh
All ebl 26650 batteries are protected by plastic battery case. Reliable Li-ion packing.(Provided with every pair of 26650 rechargeable batteries purchased )
We also sell 26650 rechargeable batteries with charger/ 26650 battery charger As reputable battery wholesaler, you can bulk buy batteries in our Eblofficial store at very affordable price, but high quality household batteries and rechargeable battery chargers.
Further helpful information about 26650 batteries:
【What is the size of 26650 battery?】
A 26650 battery is a type of cylindrical rechargeable lithium-ion battery, 26650 battery size: 26mm 65mm(DL). It is one of the larger rechargeable battery sizes and is commonly used in high-drain devices such as flashlights, power tools, and electric bicycles. The 26650 battery has a high capacity and can provide a substantial amount of power, making it a popular choice for high-powered devices that require long-lasting energy.
【Are 18650 and 26650 interchangeable?】
No, 18650 and 26650 batteries are not interchangeable because they have different battery sizes. Since the 26650 battery size.26mm 65mm(DL) has a substantially bigger diameter than the 18650 battery size.18mm 65mm(DL), it cannot be used in accessories made for that smaller battery.
Everything You Need to Know About the 18650 Battery
This article tells you everything you need to know about 18650 batteries. We’ll talk about different types, features, charging, lifespans, and our recommendations for batteries and chargers.
- What is an 18650?
- Recommended 18650 Batteries
- Various Battery Sizes
- Comparing 18650s to Other Common Batteries
- 18650 Terminology
- Protected vs Unprotected 18650 Batteries?
- How much power does an 18650 have?
- How many times can you recharge an 18650 or other battery?
- How frequently should I recharge my 18650?
- How do I know my 18650 is Dying?
- How can I measure the quality of an 18650 if I am unsure of the age of a battery?
- 18650 Battery Chemistry
- What are 18650 batteries used for?
- What is the best travel 18650 battery?
- What 18650 Brands are Best?
What is an 18650?
An 18650 is a lithium ion rechargeable battery. Their proper name is “18650 cell”. The 18650 cell has voltage of 3.7v and has between 1800mAh and 3500mAh (mili-amp-hours).
18650s may have a voltage range between 2.5 volts and 4.2 volts, or a charging voltage of 4.2 volts, but the nominal voltage of a standard 18650 is 3.7 volts.
There are two types; protected and unprotected. We absolutely recommend protected cell 18650 batteries. Protected cells include a protection circuit that stops the cell from being overcharged.
Unprotected cells can be overcharged and burst and potentially cause a fire unless there are specific electronics to protect the battery. The popular LG HG2 and INR and Samsung 25r and 35e are UNPROTECTED batteries, only use them in a device designed to use unprotected 18650s.
We also recommend you stick with high quality brand name 18650s. Knock offs may lie about high mAh (capacity).
The average 18650 battery charge time is about 4 hours. Charge time can vary with amperage and voltage of the charger and the battery type.
Recommended 18650 Batteries
|Battery Make and TypeAll are 3.7v Lithium Ion (Li-ion)
|Max Milliamp hours
|NotesShop around for best price
|Orbtronic 18650 Protected #ORB3500P
|Only available direct from vendorgood price
|Olight ORB-186C35 Protected #ORB-186C35
|Nitecore 18650 NL1835RProtected #NL1835R
|Good for travel, expensive.Has micro-USB charger port so it can charge itself with a cable/USB port
|Panasonic NCR18650BD ButtonProtected#NCR18650-BD
|Less expensive PROTECTED and good for high drain devices.
|Panasonic NCR 18650 3400mAh NOT PROTECTED#NCR18650B-3400
|Less expensive but is NOT PROTECTED. Use carefully.
|Panasonic NCR18650BE NOT PROTECTED#NCR18650BE-3200
|Less expensive but isNOT PROTECTED. Use carefully.
Various Battery Sizes
The following is a picture showing various battery sizes. The 18650 is 1170 cubic mm, the 14500 and AA are 700 cubic mm, the AAA is 467 cubic mm.
Note the 14500’s cannot be used in all AA devices unless they support both 3.7 and 1.5 volt batteries. The 21700 at 1550 cubic mm, is larger than the 18650 battery – the 21700 and 18650 is not interchangeable.
A battery might say protected mode 3.7v 18650 3000 mAh low self discharge for high drain devices. What does that all these features mean?
- “protected mode” means it has an overcharge and overdraw circuit protection built in (more info below).
- “3.7v” – is the optimal or peak voltage. It will drop as you use the battery.
- “3000 mAh” measures the amp hours the battery can provide. A higher number is better. The highest realistically available on an 18650 today is about 4000 mAh, anything higher than that is marketing hype.
- “Low self discharge” is a good thing. That means it will hold a charge in storage. The less it loses in storage the more charge will be left for you to run your flashlight or other device.
- “for high drain devices” – the battery is optimized for high drain devices. These are devices that use a lot of power very fast, such as RC toy car.
Protected vs Unprotected 18650 Batteries?
Protected 18650 batteries have an electronic circuit. The circuit is embedded in the cell packaging (battery casing) that protects the cell from “over charge”, heat or “over discharge”, over current and short circuit. A 18650 protected battery is safer than an 18650 unprotected battery (less likely to overheat, burst or start on fire).
Unprotected 18650 batteries are cheaper, but we do not recommend their use. Unprotected batteries should only be used where the load/draw and charging is externally monitored and controlled. The protected batteries normally have a “button top”, but check the specifications to make sure. Generally 18650 flat top batteries do not include the protection circuit.
If any 18650 battery is damaged or looks corroded or appears to be leaking, get rid of it at a battery recycling center. Be safe.
How much power does an 18650 have?
A 3.7v a 3400mAh 18650 stores about 2 aH to max of 3.5 aH. It can store about 10 to 13 watt hours. A small air conditioning unit that can cool about 9000 BTU uses about 1100 watts per hour. So it would take more than 110 of the 18650 batteries to run the air conditioner for 1 hour.
In comparison you would need three 12v 40 amp car batteries. But 110 18650s are smaller than three car batteries.
How many times can you recharge an 18650 or other battery?
Recharge cycles vary and are limited. Think of it like a bucket. The trick is that the bucket also gets filled with a tiny bit of other junk over time, so there is less room. As the battery is reused (recharged), the battery degrades due to oxidation and electro-chemical degradation.
This happens to any rechargeable battery such as an 18650, 21700, 26650, 14500, AA, AAA or even a car battery. They can only be recharged a limited number of times.
You want to select rechargeable batteries that can be recharged many times. We specifically recommend 18650‘s because they have the ability to be recharged 300 to as many as 2000 times.
How frequently should I recharge my 18650?
The way you recharge your battery impacts the life of the battery. If you can measure it, you want to deplete from 3.7v down it to about 3v before you recharge. If you are not sure, use the device until it indicates a battery needs to be replaced. For a flashlight, run it till the light is dim or goes out.
A good charger will tell you the voltage of the battery so you can eventually get a sense of the life of the battery in various devices. If you recharge too frequently you “use up” the life without a return.
Some people don’t let it dip below 3.3v (or even higher). Each brand and model of 18650 has different maximum cycles. So this is really a process of matching your device and usage to the life cycle of the battery.
Be aware that an 18650 battery that drops below 2.5v may “lock” the device so it can’t be used. The “lock” function happens in devices such as vaping devices.
How do I know my 18650 is Dying?
Here is a list of 7 ways you can tell if you need to get rid of an 18650 (or other rechargeable battery). Look through these to determine if your 18560 is nearing the end of its life and needs to be retired:
- The battery will lose a charge on the shelf must faster than normal. It loses it’s charge after a couple of days or even worse overnight.
- The battery gets hot when charging or discharging, warmer than normal.
- You have used the battery frequently over 2 to 3 years.
- The battery can hold less than 80% of its original capacity.
- Recharge time gets abnormally long.
- If there is ANY cracking or deformation in the battery.
These are the 6 signs your 18650 is dead and it is time to get a new one. If you ignore these warning signs you risk fire or even having the battery explode while being recharged.
How can I measure the quality of an 18650 if I am unsure of the age of a battery?
A trick is to buy one or two similar 18650s and mark them “new” with a Sharpe (or label them A, B, C, etc). Then use them and compare their voltage and discharge rates with the questionable 18650s.
Basically you are comparing good vs unknown this way.
You can also gauge temperature this way. Charge both the new and unknown one to see how hot the new one is compared to the one you are unsure of.
18650 Battery Chemistry
There are a number of different chemical combinations for 18650 batteries. We recommend that you FOCUS on protected mode, the chemistry can change and isn’t always reported. Many simply say Li-ION (meaning Lithium Ion).
There are actually a number of Li-Ion batteries. Here are some of the current “types”. Depending on your device type one might be better than the others.
- LiFePO4 which is Lithium iron phosphate
- also known as IFR or LFP or Li-phosphate
- LiMn2O4 which is Lithium manganese oxide
- also known as IMR or LMO or Li-manganese (high amp draw)
- LiNiMnCoO2 which is Lithium manganese nickel
- also known as INR or NMC (high amp draw)
- LiNiCoAlO2 which is Lithium nickel cobalt aluminum oxide
- also known as NCA or Li-aluminum
- LiNiCoO2 which is Lithium nickel cobalt oxide
- also known as NCO
- LiCoO2 which is Lithium cobalt oxide
- also known as ICR LCO Li-cobalt
What are 18650 batteries used for?
Flashlights, electronics, laptops, vaping and even some electric vehicles use 18650s. The Tesla uses 7180 of these batteries. Many high lumen flashlights such as the Thrunite TC15 v3 (best buy) or Fenix PD36 TAC (mo43 durable) use the 18650 or the even larger 21700 flashlights like the Nitecore P20iX a 4000 lumen flashlight.
Laptops and other electronic devices use one or more 18650’s and have recharging electronics built in. 18650’s are also used in vaping (smoking) devices.
18650s are are generally Lithium Ion batteries. If you are familiar with electronics you can change out some battery packs manually, but be careful – using the wrong type of 18650 or using it incorrectly can cause a fire.
Which is the Best 18650 Battery?
Overall best 18650 battery – The Orbtronic 18650 battery. This is an 18650 3.7v 3500mAh Protected cell. This is a high drain battery. We like it but it is expensive.
Best low cost 18650 battery – The Olight ORB-186P26 18650 2600mAh 3. The Panasonic 18650 is an 18650 3.7v 2600mAh Protected cell. This battery is less expensive and slightly lower amp hours than the Orbtronic. Also, this lower cost protected 18650 battery is still more expensive than the unprotected ones.
What is the best travel 18650 battery?
Nitecore NL1834R (currently not available on Amazon but available directly from Nitecore). This is an 18650 3.7v 3400mAh protected cells with a built-in micro-USB charger. It is a few dollars more, but it allows you to charge it on the go and not have to carry a dedicated charger. The unit we have has slightly different packaging.
The cheapest decent one is the Titanium Innovations 18650 at 2600mAh. It won’t last as long as the 3400 mAh Nitecore but is 1/2 the price.
What 18650 Brands are Best?
The Orbtronic, Olight, Samsung, LG, Panasonic, Surefire, ThruNite and Nitecore are good reliable 18650 rechargeable cells. Be sure to buy them from a reputable source such as BatteryJunction or direct from the manufacturer. Note: Amazon stopped selling 18650s.
We don’t use the lower voltage and amperage 18650s, because they have lower amp hours and low peak wattage and lower sustained wattage.
We are willing to pay a few more dollars for the longer life, higher capacity and better quality.
650 Battery Charger
18650 batteries are rechargeable, so you will need a good charger. We use two different 18650 chargers.
The best 18650 battery charger is the Nitecore Ci4 because it can charge pretty much anything.
Specifically, it supports: lithium ion 26650, 22650, 21700, 18650, 17670, 18490, 17500, 18350, 16340 (the 16340 is also known as RCR123), 14500, 10440 and Ni-MH and Ni-Cd AA, AAA, AAAA, C rechargeable batteries. This is our favorite charger for the 18650s.
Our runner up and “best buy” is the XTAR X4 Charger. It is a USB powered 18650 charger. It charges the batteries with any USB power source. This unit is dependent on the power source, and is a bit more expensive.
It has an LCD display for charging status. A 2amp interface yields slower charge speeds. Even the 5amp is slow because it charges at.5 amps. We have used the XTAR and Nitecore with a Nektek solar panel that has a 2amp USB interface and it has consistently worked.
The best mid priced 18650 flashlight is the Thrunite TC15 2403 lumen flashlight. It is about 1/2 the price of the PD36 and but a bit less bright. It is a GREAT buy (we have the older TN12 in emergency kits). We suggest two of these instead of one of the Fenix.
It has the following modes: Strobe (975 lumens for 226 minutes), Turbo (975 lumens for 126 minutes), High (652 lumens for 199minutes), Medium (266 lumens for 9.7 hrs), Low (19 lumens/177 hrs) and Firefly(0.29 lumens for 62 days) and it can charge itself with a USB power source. It is waterproof (IPX8) and has a max throw of 223m (764ft).
The toughest 18650 flashlight is the Fenix PD36 TAC. It is not cheap but it is durable and very bright, and has a clip. The light level is 1000 lumens, and it is water resistant to IPX8. This is a “duty” quality flashlight.
The PD36 TAC offers five different brightness levels and strobe:
- Turbo: 3000 lumen – 1 hr 30 min
- High: 1000 lumen – 3 hr 15 min
- Medium: 350 Lumen (8hr 24min)
- Low 150 lumen – 18 hr 45 min
- Eco: 30 lumen – 160 hr
- STROBE (about 3hrs 2000 lumen)
It has a 300 yard or 274 meter throw.
Both the Fenix PD36 or TN15 are great LED Flashlights that use the powerful 18650 battery.
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1 Комментарии и мнения владельцев
August, can you kind of put this in ‘plain English’ for us less tech savvy folks? Are these better than say, nicad batteries? longer life usage wise as well as recharge times wise? Are they more cost effective than other rechargeables? I don’t mind a larger up front cost if it is going to save me more money in the long run. DH uses rechargeable batteries for his work equipment (cheaper stuff, but company reimburses him) and if we can find something more cost effective, that would be great.
Good questions and thank you for the kind words. 1st off I would not switch devices that use AA or AAA to 18650 unless it was an EVERY DAY use. I might use up the old AA or AAA batteries first before considering switching. Remember these are completely different sizes, and weights. But if you have a need for a very bright flashlight or a device that uses the 18650 go for it. They can be recharged and are readily available from dozens of manufacturers and are likely to only get better over time. As an example I would recommend the ThruNite TN12 or Fenix PD35 to a police officer hands down. It has more power so will last longer in use. Nicad (NiCD), Lithium ion, Nickel-Metal Hydride (NiMH),lithium polymer, alkaline and lead/sulfuric acid in a 12volt car battery — are all ways to store energy. Alkaline and straight lithium (like Energizer Ultimate) are NOT rechargeable. We like the non-rechargeable Energizer Ultimate (lithium) over the other alkaline batteries because they are much less likely to leak/corrode. Also the Energizer Ultimate has a 20 year shelf life, so is great for emergencies. Some of the rechargables have longer shelf life too. Again you need to compare the battery to your use. 18650’s are designed for use – not shelf storage. Are these better than say, nicad batteries? longer life usage wise as well as recharge times wise? Not Necessarily, you have to read the specs to confirm. Some of the extreme drain rechargeable batteries will only recharge 100 to 500 times where a more normal high drain could be recharged 2000 times. This matters if you use a device every single day. The AA will last longer for the same amount of light than AAA, and an 18650 will last even longer (see the table). The 18650 has 10x the wattage capacity as the lower end AAA and the 18650 is 3x to 4x the capacity of the AA. Are they more cost effective than other rechargeables? Again unless you have a need stick with AA or AAA rechargeable batteries. The Eneloop AA is a better buy if you don’t have a direct need. It can be recharged 2100 recharge cycles (2100 times). So it would last 4 to 5 years of recharging with every day recharging. Amazon has good rechargeables also, but they are almost the exact same price as the name brand Eneloop. Here is more info on our AA, AAA and chargers- https://commonsensehome.com/best-battery-chargers/ Overall, we recommend any rechargeable including: car batteries, NiMH, NiCD and LiPo. The 18650 is rechargeable Lithium Ion. The only thing we recommend the Alkaline for are gifts or devices that are likely to get lost. Whether you are using AA, AAA, 9v, button or a car battery – match the battery to your needs. But note the Energizer Ultimate has more “capacity” than the normal 14500, but it cannot be recharged. We don’t recommend the alkaline AA/AAA batteries they are cheap. BUT an alkaline battery is way more expensive compared to rechargeable after only 2 to 5 recharges. They can be used in high-drain devices (high lumen LED flashlights, digital cameras etc) BUT their life expectancy will be sharply reduced. They also suffer from more temperature sensitivity. And in day to day experience they tend to corrode and fail more frequently.
Hi August, I enjoy your articles and the great information they contain very much and those of your wife also. I just have one small complaint. Your articles can be shared on social media everywhere for people all over the world but you don’t have a print function. Many times I want to print an article to reference later without trying to remember which website it was on. For everyday living commonsensehome would be one of the first places I would look, but for a certain battery I might have to check seventy different sites and no telling how many articles. Please think about adding the print button.
I totally understand your dilemma and we wanted to provide that feature. Laurie and I researched (and regularly check) for a printing plugin. None of the ones we found so far work on all platforms (Windows, unix, Android, iPhone, Apple mac etc). Here are a couple options: (1) In many browsers you can right click and select print (2) cut the entire post and paste it into your favorite editor and print (3) use the specific browser print function.
Hi August, thank you for putting this article together! I bit the bullet and bought a 2018 Lupine Blika headlamp to use on week long ski trips here in Alaska. Really only use the 3 watt output setting, the larger bulbs give an unnecessary amount of light and drain a battery VERY quickly. The battery pack that came with the head lamp is small and I need more capacity but the larger OEM battery packs are prohibitively expensive. Owner’s manual says the OEM battery packs have 18650 batteries in them so I figured I’d just buy 18650 batteries and make up my own battery packs. Discovered when I went shopping for batteries that there are apparently dozens of 18650 battery types/outputs and I have no idea which one to use. The battery voltage in the owner’s manual says 7.2 volts and it has a visual battery level meter built right into the the battery pack. I’m afraid of 2 things: I assume the OEM battery pack has circuitry to give a consistent power output so the light stays near the same brightness for the duration of the battery discharge cycle. If I make up my own battery pack, I’ll lose that circuitry and may toast my very expensive headlamp due to too high or too low power input. Is there a stand alone voltage, wattage unit I can buy to put in line to properly regulate my home made battery pack output? And, which 18650 battery will be the best for my usage? Because I’m carrying them, low weight and high capacity is necessary. Thank you for any answers you have for my above questions and thank you for putting out this great site! Matt Obermiller
Thanks for the positive feedback. In response to your comment, the output must match the unit you are using. The 1860 I note in the article is protected mode, so it will not burn up or draw outside spec (that is the battery side). The headlamp battery pack may have a voltage regulator built in. The only suggestion I have is to tinker; but only if you can afford frying one. A lot of the LED emitters circuits will take any 18650 – but some may damage the circuit without protection on the LED side OR they may accept any voltage and work fine. The little AA flashlight we reviewed, will use either an AA or 14500 which are dramatically different, so the only way to find out is test it. Watch out for overheating and be prepared to fry your electronics. If you succeed (or fail), would you mind writing a guest post on this? I am sure the community would appreciate the information. Regarding weight, all 18650s are all fairly heavy. I have not seen a LIPO 18650 yet, but they might be available somewhere. If you are going for lightweight the Energizer Ultimate Lithium AA are super light but one-time use. You would need an AA based headlamp such as the Fenix HP15 – and then you could pick AA rechargeables such as Eneloop Pro or Tenergy are both good depending on use profile – in your case I think the higher mAh would be better from the Eneloop Pro. It really depends on what you are doing. If you are out for long periods the solar panel and rechargeable AA or 18650 would potentially cut your load (and allow you to charge a cellphone or any other USB device) but only if you carried more batteries than the weight of the solar panel. The nektek is 1.3lbs though so unless you need to charge a lot of stuff and are out for a long time this probably isnt an option. (ounces are pounds) All the best.
This is the 1st time I’ve ever heard of these and boy am I confused! I’m guessing that you don’t replace your regular rechargeable AA or AAA batteries with these? I’m going to read up and educate myself. This must be something that preppers are into. Love the preppers but the “prepping” is too overwhelming for me being average 65 year old female. Just had to share. I love reading all of the interesting things that preppers are doing. Thanks for letting me share. Debbie
No worries, Debbie. If a device needs an 18650 battery, it’ll be labeled somewhere that it needs one. No swapping out your current batteries required. It’s just a way to cram more power in a relatively small package. Some preppers use them, I’m sure, but they’re mainly for electronic gadgets that suck a lot of power – like our small LED flashlight that’s bright enough to light up the back of the ten acres from the front of the 10 acres.
Hi August. My question is how do I know if my 18650 batteries are not discharging cocorrectly? I bought some Samsung 25R and was notified by the seller not to use them as they were from a bad batch that were not discharging correctly after I had already been using them. They seemed to be working just fine, but I stopped using them anyway. But I have a lot of other 18650 batteris that I use for vaping and would like to know what I need to be on the lookout for. Thanks for your time.
Good question. A bad 18650 can burst or damage the electronics using it. Some electronics have overload protection which greatly reduce the likelihood of damage. Your device may have that protection so the battery is protected once by the in battery “protection” (which might be failing) and again by the device. Regardless, if the manufacturer/seller is recommending not using them, I would stick with that. A burst 18650 is a mess. Get them to give you replacements and move on.
im trying to change dead 18650 batteries in a triple drill battery pack they have the code SE US 18650VT but i cant work out which battery i need, i know they are only 1.5 a/hr…(can i upgrade to bigger) 12v drill the other line under that code is.T C112VSG19R. this is the line i cant interperit or find any info on.thanks for any feedback…cheers
It’s probably safest to contact the tool manufacturer directly. If it’s a battery pack (versus individual batteries), they probably have proprietary battery packs and using anything else is likely to void the warranty.
You’re welcome. Sorry I don’t have more specific info, but there are a LOT of different tools out there, and many companies are bundling the 18650s for specific applications, even solar electric systems. If you’re past your warranty period on the tool, are handy, and the company is no help, you could try swapping out the batteries in the pack with well rated 18650s. I just snagged August and he’s going to comment more on this option.
We cant recommend any tinkering… but we have done it successfully on a laptop and a simple battery pack (both out of warranty). The risk is that you will damage electronics or even start a fire. Many of the devices are built in a way that you cannot easily access the battery packs. Also some are be designed for a specific voltage and/or amperage. The fact that tons of devices use 18650’s in series or parallel make them a tempting self repair project. All we can say is stay safe and if you choose to tinker and are successful, please leave a comment so others will know too. There are YouTube DIY rebuild videos for various brands of battery packs. All the best.
I have seen 18650 battery’s advertised with capacities up to 9900 mAh. Are these real? Is that a maximum a 18650 can be in mAh?
The highest current stable 18650 battery is 3500 mAh. I fully expect the research to improve over time. 9900 is not real. Also watch out for batteries without overcharge protection. Check reviews carefully. Best of luck.
After quick research, I believe it is a different form factor of battery. Not an 18650. The “S1 S2 S3 S4 S5” battery, is a brick design for cellphones, specifically a code that matches the form factor for the specific Samsung model. In my mind those are not 18650’s even if they are described as one. They are square or rectangular and thin and unique to a specific device. They use similar technology to an 18650 and fit inside a cellphone, tablet or other thinner portable computing device.
1s, 2s, is gow many cells in series. series connection will increase voltage, parallel will increase capacity. 1s would be 1 cell @3.7v 2s would be 2 cells connected positive to negative (think old flashlight stacking batteries in handle) @ 7.4, 3 s being 3 cell- @ 12.1v and so forth.
hello, I am a dentist and use my led surgical light powered by battery pack of two pack 18650 2200mah, I just replaced my battery pack with a fresh battery pack. question: how can I make my battery pack last longer? use it till it drains and then recharge? or keep it connected to my charger intermittently through out the day as I use is daily. thanks Drlopez
Good question. We added a couple sections in the post to answer this. A quick answer is you want to balance recharges with “using up” the battery. Check your specific battery specifications for lifecycle and charging recommendations. In general though, if you recharge before the battery is at least partly depleted you “lose” a recharge – and batteries only have 300 to 2000 total recharges before they should be replaced. Generally you want the battery to drop from 3.7v to about 3v. In other words don’t top off a 3400mAh battery at 3300mAh instead charge it at 2500mAh or even 2000 (where you choose depends on the number of recharges you expect and the devices sensitivity to low voltage/amperage). I hope this helps.
Hi August. I do not agree with you regarding the charging of batteries. If you look at the datasheets of these batteries, you will see that the lesser the drain on the battery the longer the battery will last. It is the same with cellphone batteries, also Li-ion. My cellphone battery get charged every night. Mostly my battery still have 35% to 45% charge left. I have no problem getting 2-3 years life out of my cellphone battery. Years ago people was told to fully discharge the battery before charging. That might have been correct for old battery types like Nickel Metal Hydrate batteries, but Li-Ion batteries give you the best life performance if you can keep them between 40% to 80% charge. I viewed the datasheet of a 100Ah Li-FePo4 battery pack, used for solar systems, the other day. It is rated at 2000 charge cycles, but they gave a graph showing expected life time at different discharge depths between charges. If you don’t discharge it more than 50% you can get almost 20 years life out of the battery, based on every day recharging via solar.
You are correct. It is why I like larger packs where possible (higher wattage at same voltage to allow lower overall drain). And as you noted, this is recommended by the manufacturers and has to do with the design of the 18650 batteries. I don’t follow all the rules, I leave mine in flashlights and other devices until they don’t light up the way I want. So I am not staying in the 40% to 80% range. I don’t worry about the cycle rates because 2000 is awesome but 500 to 1000 is just great too and I don’t have to monitor them all in detail, but if you do you can drastically extend their life. Thanks for the feedback.
I’m trying to use 18650 in a trail camera as directed by the owners manual. The 18650 I bought are Nurie18650-1A. 3.6 v. 2600mAh, it call for 2 batteries in the camera. How do I know if these are the correct battery ? It mentions something about PR200 when discussing the battery ?
I believe you are asking about the PR200 Trail Camera – it looks like that model requires any two 18650s. Although the Nuon NURE18650 will work, it lists that it is a high self discharge battery (it loses charge just sitting around). Also, the Nuon is only 2600mAh. Instead I recommend a 3000mAh to 3400mAh protected mode low self discharge 18650, such as the: Samsung, Panasonic, Orbtronic, LG or Nitecore. Finally, you need to confirm with the camera manufacturer manual for exact information and battery types.
Hi. What a useful website! I am in the process of changing the Samsung 1500mAh18650 batteries on my AEG vacuum cleaner. it is 5 1/2 years old and they have gone already! (joke). Am I best to replace with the 18650 3500mAh units. Same physical size etc. Also, the manufacturer’s instructions are to leave the cleaner permanently on charge. Is that a good idea? Thanks
High mAh will in general be safe- it will just run longer (more capacity) – the wattage is 3.7v x 1500 = 5500m-watts vs the 3.7v x 3500 = 12,950 m-watts. The “charge all the time” part is more tricky. It depends on the device, electronics and charger. If you get lower self discharge batteries i suspect you would only want to charge it before use (or after its dead). You really need to confirm with the manufacturer to confirm – if they have another small battery in the electronics the trickle charge could be to keep the unit powered. I cant be sure, so use your best judgement.
Hi August, I am one of those species that are naturally inquisitive and will forever “tinker” with everything. the latest being replacing my NiCD batteries in my cordless drill with LI-ion batteries. I have matched the voltage and the drill 18V works fine. I have not yet recharged the batteries.,Can I use my NiCD charger to charge the replaced LI-ion batteries? A friend of mine bought me Rekieta 18650 12000ma/h3.7v batteries from a china shop which I have tried in a similar way on my 14.4v drill, also matching the voltage. Sadly the drill does not work although the voltage is correct. the lettering on these batteries are very foreign and I cannot determine whether they are indeed rechargeable or not. HELP.
August is up to his eyeballs in alligators at work at the moment, so not much time for the site. From what I was able to find online at this QA on Quora “Can I use a NiCad battery charger for lithium?“, the most likely answer seems to be “No. voltage profile, current profile, and current tapering profile are all different.” Batteries can explode or have a meltdown under conditions that they were not designed for, so be careful.
I just received a flashlight that uses a 18650 battery. The flashlight says “shustar”, “Albinaly”, and “CE RoHS” in different places. The battery says “shustar”. The wall charger has a light on the plug-in part that glows yellow when plugged in; don’t know if it changes color when the battery is fully charged because I just started charging the battery. Did I get anything worthwhile? I assume the battery is not a protected type.
The best I can say is track back the manufacturer and try to find the specifications and documentation. I do not know which make/model devices you are using. We recommend the better reviewed, name brand flashlights and chargers. The name brand are a few more dollars but you can call for support and they have wider reviews. Regarding the battery, we recommend that you use a protected mode 18650 regardless of the device unless it specifies an unprotected 18650.
Hello. I have a question that I think will be more common this year with the popularity of outdoor Wi-Fi security cameras, and the solar charging panels to keep the cameras running day night. I have purchased a few of the solar chargers dedicated for Amazon Blink cameras. The Blink cameras run on a pair AA Li-Ion internal batteries, that are advertised to “run for up to two years”. Obviously, replacing the internal pair of AA batteries with a pair of 18650 rechargeable batteries, running from inside a solar panel, to the USB port on the cameras, should do better. The Blink cameras’ Chinese aftermarket dedicated solar panels have two 18650 flat top 3.6V 2600 mAh of various branded batteries mounted in the back of the panels; where there is also a bit of circuitry on a small board. The solar panel specs says it outputs 6.0 V, 0.4 A. I am curious about what type of 18650 batteries will work best in this variable load/trickle charge situation. The cameras are awake full time 24/7, but not recording and/or sending Wi-Fi radio signals much of that time. The battery usage is a situation where there is a tiny draw full time, and larger draw occasionally when they are motion tripped, and also being recharged maybe 12 – 14 hours a day at various levels of solar power. Most of what I’ve seen for the small solar power panels are using lower capacity batteries (2,200 to 2,600 mAh). Aside from price, is that because the charging current from the solar panel is so low (Max 0.4A)? I’m concerned about the the “flat top” battery style (not protected?), supplied in the panels, but I used those for years in E-Vape service. Just lucky? I think the high end chargers used, along with the vape devices’ circuitry maybe provided protection? Well that’s just one concern. The bigger question is what style/type of 18650 will work best (most durable) for the daily variable solar charging, along with simultaneous variable draw from the batteries. I see a plethora of brands, and models out there, and don’t relish frequently changing out batteries whilst balancing on a ladder. Like some other commentators, price has a lower priority/concern than ladder climbing frequency.
The solar panel USB feed is a good idea. To confirm runtime etc I would need specs on the panel. Two 18650s provide up to 25ah where the two AA provide 9ah. So the panels (if they charge even with lower quality batteries should do far better than the internal AAs and last for years. Solar Panel. The wattage (output) of the solar panel and amount of sun it gets is key. If the panel can’t get enough sun the batteries will eventually die. Solar Panel 18650. Nearly all manufacturers use the cheapest battery that will perform in the device. Unprotected are cheaper so they build the “protection” into the electronics instead of the battery. If you replace the unprotected battery with a better protected battery it will likely give you better life but I cannot be sure. If the panel gets enough sun it is probably unnecessary to replace the batteries right away. One way to confirm them is remove them and put them in a protected charger to check their max wattage. Alternate solution. The 6 MinPak waterproof 6×18650 pack could use your old vaping batteries and still have more than 10x the watt hours. If it works, you could just change them out every 3 to 5 years, recharge and replace. This might be a better pick for wooded areas. As I don’t have specs, any “creative solutions” would need to be tested.
Hello August: I have a cordless vacuum (Type AE – 14.4V DC) hat uses 4 batteries LGDAHB31865. I searched and find that this refers to a 18650 BATTERY. I want to replace it for equal or ideally better ones. I live in Canada and I do not find the reference above mentioned anywhere other than China. Could you please help me with some brand name, reference o place where I could buy it. I’m older and the vacuum is like new and been working well for me (light and handy), but the batteries are almost dead after 2 years and the manufacturer offers no help even know it is a big Company. Thanks in advance Jaime R.
Yes the LGDAHB31865 is a High Discharge LG 18650. They appear to be available on eBay. I can’t suggest using any other battery. The risk is that the electronics might be tweaked to match that specific battery (charge/draw). First, idea is to charge the LGDAHB31865 batteries outside the unit to see if they truly are dead (if they dont charge then you know its not your unit). Second idea… I suspect you could use two 2 packs Orbtronic 18650 batteries (I have these). There is a risk that this could damage the vacuum or the new batteries. I suspect the Orbtronic might allow the unit to run longer also. Although I cannot recommend it, if you test it out please keep us posted. Best of Luck Jaime R, sorry I could not provide a definitive answer.
August, thank you for your prompt answer. I’ll check on eBay to see if they have it. The solution of the Orbtronic 18650 batteries, will be more expensive than buying a new vacuum. Nowadays, it is difficult to find and appliance that last more than 2 years.
Yup that is why they use cheap batteries, everything is about cutting unit costs. BatteryJunction.com might have cheaper one unprotected 18650s (which I suspect that your vacuum is using). We buy the expensive batteries and they last much longer. Again be careful, the electronics could smoke if they had a tight match to the battery specs (and remember unprotected 18650s can burst).
August, this is the type of batteries that this machine uses (http://www.cylxpower.com/previewimg.jsp?fileID=ABUIABACGAAgseS5xQUo7rLI8wYw6Ac46Ac); I guess they are unprotected. I did find on eBay from a Canadian seller this (https://www.ebay.ca/itm/2X-18650-9900mAh-Li-ion-Battery-3-7V-Rechargeable-Canadian-seller/333462620310). Do you think that will work? Thanks again for all your help.
Hi Jaime. August is having an extra crazy week at work (they dumped a big project that would normally take months in his lap and want it done this week), so I decided to chime in. For better or worse, the only way to know for sure it to try and see if it works. The odds look good, but you can’t tell for sure until you try.
Please let me be BLUNT! There is no such thing as an 18650 Cell that can deliver over 4000 MAH! NONE Any advert saying that their battery provides this is a Lie False Adverts! and from testing they are usually less than 2400 Mah. Additionally they have a high “internal” resistance, which means that there is a higher voltage drop at higher current levels. My personal guide line would be : Buy Japan or South Korea mfg 18650’s ALL China branded are inferior and/or falsely labeled. Many of the Adverts are just LIES! Amazon and Ebay should stop listing them.
Hi, I just recently started buying LED flashlights powered by 18650’s. I understand the higher mAh batteries give longer runtime, but now I just ordered a “high power” flashlight that says to use “high discharge” rate batteries of 10A or more, so my question is, can you tell if a 18650 cell is “high discharge” just from the numbers/ letters printed on the side of the battery? Thanks, Ed
Some battery types are designed for high discharge, some are “LSD” low self discharge. The high discharge ones generally don’t hold a charge in storage, but do a good job of providing power fast. The low self discharge ones don’t provide power fast but also don’t “leak” power over time. If you have an 18650 battery you will need to research the type of battery to find out if it is normal, low self discharge or high discharge.
Ok, August, so if I understand you correctly, most high discharge batteries will say on the casing “High discharge” or similar- These are the batteries I got; https://edisonbright.myshopify.com/collections/batteries/products/3-pack-edisonbright-ebr34-3400mah-18650-rechargeable-li-ion-protected-batteries. and I am ordering this flashlight; https://lumintoplighting.com/lumintop-gt-mini-pro-3500-lumens-xhp502-led-high-intensity-outdoor-flashlight-p0068.html. which is 3500 lumens- I don’t want to smoke the battery…. Seem like they might work? Thanks, Ed
Ed, It would be best to check with the people selling that specific flashlight. We haven’t used that particular product before, and they should know the items they’re selling.
There are far too many general statements here. The author states his opinion of the best batteries and flashlights. Some of my flashlights are definitely better to use unprotected cells for the same reason some of my vape devices do. The protection circuits are sometimes built into the lights now, and protected batteries will not allow the amp draw needed because they are capped at 10 to 12 amps. Also the best light is often based on the intended use…do you need a long throw, more flood, or combination. Some lights now even have proprietary batteries and chargers. That is the case with Olight Seeker 2, but you can actually use an externally charged 21700 orbtronics protected battery with the buttontop closest to the cap. You can’t however charge that battery in the light. The Olight special modified battery re-routs a negative contact to the positive side for the magnetic charging. The negative terminal on the light is at the head.
Hi August, Is it safe for 18650 batteries to be “plugged in” all the time, for example in applications like emergency back up lights, where they come on only during power outages? Regards, Paul
August is up to his eyeballs at work, so I’ll chime in. While it might not be ideal from a battery life perspective, if that’s what the device requires to function, that’s what it requires to function. It should not be safety concern (no risk of explosion, etc).
I’m buying a protected 18650 battery for a solar charging light in my garage. I only need one, but the SH is the same as the price of one battery. If I order 2 or 3 and don’t need them for 2-4 years, will they still be good or am I better off just buying the one now and deal with it.
After doing some digging, it looks like most people are not having any issues with 18650 batteries that have been stored a few years. The article “Proper 18650 Battery Storage” suggests a charge of roughly 40% for best storage life.
How to Know a Fake 18650 Battery
About: Tech nerd like web technologies and gadgets. Kitesurf on weekends and recently got involved in 3D printing technology. About danleow »
An average genuine 18650 batteries will weigh about 45g and no nothing less than 42g. You can see I have a fake 18650 battery in the pic weigh 32g only and the genuine 18650 battery weight 45g. Some genuine 18650 battery can weigh more than 50g. Good brands will tell you the weight of the battery.
You can use a digital kitchen scale.
Why fake 18650 battery weigh less? That is because inside is a smaller battery with step up circuit which wrap in layers of paper and stuffed inside a 18650 battery size case then heat shrink in a tight plastic label sheet to make it look real.
Genuine sellers will specify battery weight in their product description/sheet.
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Комментарии и мнения владельцев
There is a lot of great info here both in the video and in Комментарии и мнения владельцев too. I am learning from everyone I can about using these 18650 batteries but I dont see much info about their C ratings only mAh’s/fake or not. I use them for very high discharge applications (custom r/c vehicles) and now using an awesome little spotwelder to help create them. No more trying to solder/fail batteries. If i can figure out how to create (instructables) i will. https://youtu.be/TJq31wVMOuw
Fake is the wrong word. A fake battery would be one that is not a battery at all. In fact, there are empty cells made that are not fake, they are simply sold as empty to fill a mechanical void for battery packs with odd numbers of cells, and are used to fill a space mechanically for the structure of tha pack, without unbalancing the individual strings of cells. This is common in higher density packs that have staggered string sizes, or a pack with a specific shape, but wanting to maintain the fullness of the pack within that shape.
There are a lot of different capacity cells sold, and each weigh a different amount. There are a lot of reasons for using smaller cell sizes, ranging from reducing the cost of the cell for marketing or cost reasons, to safety regulations for a particular regulated application. There are safety standards for appliances used in critical or hazardous environments that might limit how much lithium is present, or have containment requirements that reduce how much you can put in a cell and still meet the safety spec. A cell that is integrated as a backup of short duration might be made for one application, and find it’s way to the surplus market where it is sold on ebay. Nothing fake going on there, as long as no lies are being told.
If the battery has a rating that matches it’s actual capacity, any capacity or weight is valid. That is a big IF as exaggerations and rip-offs are common. Anyone can cut the shrink wrap off a cell, and replace it with a new wrap, with whatever markings they want. These repackaged cells can simply be remarketed cells, or actual forgeries of popular brands. Some flashlight makers rebrand all batteries they sell. Some are honest and some are not.
And besides capacity specifications, there are safety features, and the absence or presence of cell protection circuitry that has an impact as well.
When evaluating a cell from a new vendor, you should perform a capacity test where you drain a cell to the rated cutoff voltage, then test the charge cycle to see how much charge it takes, then perform a discharge at both slow and fast rates to see the results from thos tests. Discharge rates matter! The slower you discharge a storage cell, the more power in total you get from it. And that affects the cell rating for a given application. So the same cell can have a different capacity depending on what it is used for.
And a sand filled cell sounds fishy, and probably is. Unless there are weight requirements that need to be met coupled with a lower capacity requirement. The buyer of a manufacturer’s production run is responsible for the specifications of that run, and their reasons and final product markings could be honest or dishonest. While I would agree in principle that dishonestly market batteries are somewhat fake in nature, the word fake is not an accurate word in most cases. A buyer will always do capacity spot checks as part of the qa of the incoming parts, as most parts have a certain percentage of bad units, and for a product build there will need to be some way to accommodate for the occasional bad part, especially from a new manufacturer or from a surplus supplier. Even new chips might be remanufactured pulls from scrap electronics, so the incoming QA team is there to keep suppliers honest.
So you are right that there is more to a battery than the claims printed on the shrink wrap cover. But the QA process is so much more than just weighing the cell.
UltraFire 5000mAH 18650 Review: A Case Against This Battery
Today we are going to be conducting an UltraFire 5000mAh 18650 Battery review. While it might be one of the most economical options for energizing a vape pen, the battery’s capacity is just not up to snuff compared to one of the best batteries.
The price point for UltraFire is perhaps what entices vapers the most. The batteries can be found on eBay for under two dollars. However, when tested, the TR 18650 UltraFire has a fraction of its advertised battery life.
Some UltraFire 18650 battery reviews have blamed the poor battery life on bad cells. But the majority of users suggest that these particular batteries are merely cheap and poorly manufactured.
The one benefit of purchasing on eBay is that most of the sellers will offer free returns if you are not satisfied with your batteries. Therefore, you can be guaranteed your money back if the battery does not perform as advertised.
UltraFire 5000mAH 18650 Review
The TR 18650 batteries received this rating because, as the majority of users claim, the cell life just doesn’t meet the officially designated capacity.
In fact, the batteries only reach about 1000mAH on average. They also cannot reach high currents.
In the course of conducting an UltraFire 5000mAH 18650 review, one of the central plus sides was that the batteries are extremely cheap and readily available. Some users also claim that their batteries functioned properly, and held their recharging capabilities.
There are reports of users recharging their UltraFire 5000mAH 18650 batteries for several months and not seeing any compromised battery power. This kind of feedback occurs for about every one out of fifteen users.
The upside here is that the batteries are so cheap you could very feasibly buy a set to try out and then return them if they don’t end up functioning properly. You’d have to do this on either eBay or Amazon, though. Otherwise you’d run the risk of not be guaranteed a full refund. There are so many available on both websites that you will have no trouble finding competitive pricing.
It is also widely known that mAH on almost all batteries are going to be overstated. So, some users consider the fact that, for the price, the TR 18650 batteries only reaching 1000mAH is not such a bad thing. Furthermore, during all my tests with the batteries, they charged up properly without becoming overheated.
Unfortunately for these batteries, the downsides still outweigh any of the benefits. Being that the official specifications are way higher than the actual performance of the batteries, most users feel that they were duped into buying a cheap and falsely advertised product, rightfully so. The batteries claim to be capable of recharging up to 1000 cycles, when they barely held their charge after just two.
Most users share a similar experience. If you were going to be taking your vape on a trip for business or a long car ride, these batteries will most likely leave you high and dry.
I read that one user made sure the batteries were fully charged, put one in and couldn’t even get his vape to turn on. The UltraFire TR 18650 5000mAH is also an unprotected battery, even though it is advertised as being protected on the cell itself.
The small electronic protection circuit protects against common hazards like overcharging, short-circuiting, high temperatures, and over-discharging. In addition to being a much safer bet all around, the protected cells are also generally last much longer than unprotected, and hold their recharge life much better. Most users like to spring for the protected options as it provides them a little more peace of mind; I know I’m one of them.
UltraFire battery reviews also seem to make a note that the batteries were constructed in China, and vapers are weary of Chinese mAH ratings being way off. Unless of course it is a more trusted brand. In almost all the tests that we performed for the UltraFire battery review, the levels were dramatically below the official specifications.
The discharge begins to lose capacity around 2 amps. Discharge time slowly diminishes down to under an hour after a few charges. Maximum discharge power and energy output also beings to crash at around thirty minutes once the batteries have been taken off the charger. Not to mention the button on the top is missing those critically important vent holes to avoid eventual overheating.
The UltraFire brand does offer some other useful products and services. Perhaps not too much for vapers, though. One of the great advantages for buying products on the official UltraFire website is that they offer a 180-day warranty. (Unfortunately, the UltraFire TR 18650 5000mAH are not sold on the website.)
The shop also has a number of competitively priced recharging stations and quick-charge stations for reusable batteries. But the most innovative and useful tool on the UltraFire docket is their portable solar panel with its own USB output, priced at thirty-five dollars.
As you can probably tell by the UltraFire review above, I am not the biggest fan of this product. I’m perfectly ok with spending a little extra to make sure that the quality of the battery I’m receiving will be dependable, safe, and, perhaps most importantly, not compromise my vape.
However, there are plenty of options available to show those in doubt about the superior rechargeable battery for vape pens. The Sony VTC 4 18650 is popularly considered to be the most powerful and longest lasting rechargeable battery, and great for vape pens.
There is also the LG HG2 3000mAh and Samsung 25R 2500mAh which are industry favorites and have accurate mAH ratings that you can depend on.
This video compares a few different batteries: | <urn:uuid:f80742cb-88b1-4d22-b2a9-62e904fd267b> | {
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June is Alzheimer’s & Brain Awareness Month!
What is Alzheimer’s disease?
Alzheimer’s is a progressive neurodegenerative disease that causes multifaceted changes in the brain following cell damage which destroys memory, mental function, cognitive skills, and motor skills and affects the daily living and activities of those plagued with the disease. Per the Alzheimer’s Association, more than six million Americans are living with Alzheimer’s. The disease is noted to be more deadly than such cancers as breast and prostate combined.
In the disease process of Alzheimer’s, the brain cells degenerate and die, leading to dementia and a decline in memory and mental function. Patients become suspicious and aggressive with their family, caregivers and friends. It is the most common cause of dementia and accounts for over 60-80% of the cases, Per the Alzheimer’s Association. The progressive disease typically begins in patients 65 years and older, but it can affect people under 65 with “early onset of Alzheimer’s disease”.
This blog post will discuss Alzheimer’s, the role dementia places, and documenting and coding the disease for physicians.
Alzheimer’s Disease and Dementia coding
Per ICD-10, certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-10-CM has a coding convention that requires the underlying condition to be sequenced first, if applicable, followed by the manifestation. Wherever such a combination exists, there is a “use additional code” note at the etiology code and a “code first” note at the manifestation code.
These instructional notes indicate the proper sequencing order of the codes and etiology followed by manifestation. When “diseases classified elsewhere” is not listed as part of your manifestation code, you will follow the “use additional code” note at the bottom of the etiology code and the “code first” note at the bottom of the manifestation code.
Dementia is an integral part of the diagnosis of Alzheimer’s disease. The physician does not have to give both a diagnosis of Alzheimer’s disease and dementia to report both codes; coding guidelines and sequencing of the codes should be followed when assigning the diagnosis codes. In addition to the sequencing of diagnosis codes, it is also vital to code the diagnosis codes to the highest level of specificity. Reviewing documentation is imperative for selecting the correct code, ex: G30.0 Alzheimer’s disease with “early onset” vs G30.1 Alzheimer’s disease with “late onset”. The physician or APP should be queried for clarification if documentation is unclear or ambiguous.
ICD-10-CM Alphabetic Index:
- G30.9 would be reported first, followed by F02.811 or F02.80 to show dementia with or without behavioral disturbances.
- Since the codes F02.80 and F02.811 are in brackets, these are considered a manifestation of the disease and would be sequenced second
Parent Code Notes: G30
Includes: Alzheimer’s dementia senile and presenile forms
Excludes1: senile degeneration of brain NEC (G31.1)
senile dementia NOS (F03)
senility NOS (R41.81)
Use additional code, if applicable, to identify:
delirium, if applicable (F05)
dementia with anxiety (F02.84, F02.A4, F02.B4, F02.C4)
dementia with behavioral disturbance (F02.81-, F02.A1-, F02.B1-, F02.C1-)
dementia with mood disturbance (F02.83, F02.A3, F02.B3, F02.C3)
dementia with psychotic disturbance (F02.82, F02.A2, F02.B2, F02.C2)
dementia without behavioral disturbance (F02.80, F02.A0, F02.B0, F02.C0)
mild neurocognitive disorder due to known physiological condition (F06.7-)
Advanced Care Planning
Providers will often discuss end-of-life decisions with the patients and family members, as the disease tends to become progressive and aggressive over time, not allowing the patient to make decisions regarding their care to providers and family members. In our prior blog post on “Documenting & Coding ACP”, I discuss the uncomfortable and challenging situation of having the ACP conversation. Still, providers need to have the family sign the required documentation.
How SDOH affects Alzheimer’s
Per the Alzheimer’s Association, older Black Americans are about twice as likely to have Alzheimer’s or other dementias as older Whites. Older Hispanics are about one and one-half times as likely to have Alzheimer’s or other dementias as older Whites. This is often due to poor access to proper healthcare, resources and early testing, factors of social determinants of health. SDOHs are defined as economic and social conditions that influence the health of people and communities. Examples may include food, housing insecurity, education and employment. These conditions tend to have the most critical impact on people’s health, well-being, and quality of life.
Documentation of other social and economic factors (Social Determinants of Health) is also vital for code assignment and the medical necessity and continued treatment of the patient’s condition.
Documentation continues to play a crucial role in identifying and combating SDOH needs that affect their patient population. Providers should report the conditions by utilizing the ICD-10-CM codes Z55-Z65 (“Z codes”) found in Chapter 21 (Z00-Z99, Factors influencing health status and contact with health services). These codes help identify the insurance companies’ nonmedical factors that may affect a patient’s health status.
Alzheimer’s disease is not only hard on the patient but also hard on the family and caregivers. Many tend to mourn the loss of what “used to be”. Caregivers work around the clock caring for the patients. But they must collaborate with the care team of physicians, social workers, caseworkers, and others involved in the patient’s care.
There are support groups for families and caregivers. The Alzheimer’s Foundation of America (AFA) have a great online resource page for caregivers, and there is also an AFA helpline available seven days a week.
- Webchat @ ALZFDN.ORG
To schedule training for your organization or private practice providers or schedule a chart review email us today at email@example.com or visit the website and fill out the “contact us” form. | <urn:uuid:fc273d3f-321e-449e-897e-2c701ce36d88> | {
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From Wikipedia, the free encyclopedia - View original article
|Health care in the United States|
|Government Health Programs|
|Private health coverage|
|Health care reform law|
|State level reform|
|Municipal health coverage|
In the United States, Medicare is a national social insurance program, administered by the U.S. federal government since 1966, currently using about 30 private insurance companies across the United States. Medicare provides health insurance for Americans aged 65 and older who have worked and paid into the system. It also provides health insurance to younger people with disabilities, end stage renal disease and amyotrophic lateral sclerosis.
In 2010, Medicare provided health insurance to 48 million Americans—40 million people age 65 and older and eight million younger people with disabilities. It was the primary payer for an estimated 15.3 million inpatient stays in 2011, representing 47.2 percent ($182.7 billion) of total aggregate inpatient hospital costs in the United States. Medicare serves a large population of elderly and disabled individuals. On average, Medicare covers about half (48 percent) of the health care charges for those enrolled in Medicare. The enrollees must then cover the remaining approved charges either with supplemental insurance or with another form of out-of-pocket coverage. Out-of-pocket costs can vary depending on the amount of health care a Medicare enrollee needs. They might include uncovered services—such as long-term, dental, hearing, and vision care—and the supplemental insurance.
In 1965, under the leadership of President Johnson, Congress created Medicare under Title XVIII of the Social Security Act to provide health insurance to people age 65 and older, regardless of income or medical history. Before Medicare's creation, approximately 65% of those over 65 had health insurance, with coverage often unavailable or unaffordable to the rest, because older adults paid more than three times as much for health insurance as younger people. Medicare spurred the racial integration of thousands of waiting rooms, hospital floors, and physician practices by making payments to health care providers conditional on desegregation.
Medicare has been in operation for well over forty-five years and, during that time, has undergone several changes. Since 1965, the provisions of Medicare have expanded to include benefits for speech, physical, and chiropractic therapy in 1972 (Medicare.gov, 2012). Medicare added the option of payments to health maintenance organizations (Medicare.gov, 2012) in the 1980s. Over the years, Congress expanded Medicare eligibility to younger people who have permanent disabilities and receive Social Security Disability Insurance (SSDI) payments and those who have end-stage renal disease (ESRD). The association with HMOs begun in the 1980s was formalized under President Clinton in 1997. In 2003, under President George W. Bush, a Medicare program for covering almost all drugs was passed (and went into effect in 2006).
Since the creation of Medicare, science and medicine have advanced, and life expectancy has increased as well. The fact that people are living longer necessitates more services for later stages in life. Thus in 1982, the government added hospice benefits to aid the elderly on a temporary basis (Medicare.gov, 2012). Two years later in 1984, hospice became a permanent benefit. Congress further expanded Medicare in 2001 to cover younger people with amyotrophic lateral sclerosis (ALS, or Lou Gehrig’s disease).
|Health care in the United States|
|Government Health Programs|
|Private health coverage|
|Health care reform law|
|State level reform|
|Municipal health coverage|
The Centers for Medicare and Medicaid Services (CMS), a component of the Department of Health and Human Services (HHS), administers Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), and the Clinical Laboratory Improvement Amendments (CLIA). Along with the Departments of Labor and Treasury, CMS also implements the insurance reform provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and most aspects of the Patient Protection and Affordable Care Act (PPACA) of 2010 as amended. The Social Security Administration is responsible for determining Medicare eligibility, eligibility for and payment of Extra Help/Low Income Subsidy payments related to Part D Medicare, and collecting some premium payments for the Medicare program.
The Chief Actuary of CMS is responsible for providing accounting information and cost-projections to the Medicare Board of Trustees to assist them in assessing the financial health of the program. The Board is required by law to issue annual reports on the financial status of the Medicare Trust Funds, and those reports are required to contain a statement of actuarial opinion by the Chief Actuary.
Since the beginning of the Medicare program, CMS has contracted with private insurance companies to operate as intermediaries between the government and medical providers. Contracted processes include claims and payment processing, call center services, clinician enrollment, and fraud investigation.
Medicare has several sources of financing.
Part A is largely funded by revenue from a 2.9 percent payroll tax levied on employers and workers (each pay 1.45 percent). Until December 31, 1993, the law provided a maximum amount of compensation on which the Medicare tax could be imposed each year, in the same way that the Social Security tax works in the United States. Beginning January 1, 1994, the compensation limit was removed. A self-employed individual must pay the entire 2.9% tax on self-employed net earnings (because they are both employee and employer), but may deduct half of the tax from the income in calculating income tax. Beginning in 2013, the 2.9% Part A tax continues to apply to the first US $200,000 of income for individuals or $250,000 for couples filing jointly and rose to 3.8% on income in excess of those amounts to help partially fund the subsidies included in PPACA.
Parts B and D are partially funded by premiums paid by Medicare enrollees and general fund revenue. In 2006 a surtax was added to Part B premium for higher-income seniors to partially fund Part D. In the PPACA legislation of 2010, a surtax was added to the Part D premium for higher income seniors to partially fund PPACA and the number of Part B beneficiaries subject to the 2006 surtax was doubled, also partially to fund PPACA.
In 2011, Medicare spending accounted for about 15 percent of the federal budget, and this share is projected to increase to over 17 percent by 2020.
The retirement of the Baby Boom generation—which by 2030 is projected to increase enrollment from 48 million to more than 80 million as the number of workers per enrollee declines from 3.7 to 2.4—and rising overall health care costs pose substantial financial challenges to the program. Medicare spending is projected to increase from $560 billion in 2010 to just over $1 trillion by 2022. Baby-boomers health is also an important factor: twenty percent have five or more chronic conditions which will further add to the future cost of health care (www.cms.gov, 2012). In response, policymakers have recently offered a number of competing proposals to reduce Medicare costs.
In general, all persons 65 years of age or older who have been legal residents of the United States for at least 5 years are eligible for Medicare. People with disabilities under 65 may also be eligible if they receive Social Security Disability Insurance (SSDI) benefits. Specific medical conditions may also help people become eligible to enroll in Medicare.
People qualify for Medicare coverage, and Medicare Part A premiums are entirely waived, if the following circumstances apply:
Those who are 65 and older who choose to enroll in Part A Medicare must pay a monthly premium to remain enrolled in Medicare Part A if they or their spouse have not paid the qualifying Medicare payroll taxes.
People with disabilities who receive SSDI are eligible for Medicare while they continue to receive SSDI payments; they lose eligibility for Medicare based on disability if they stop receiving SSDI. The 24-month exclusion means that people who become disabled must wait 2 years before receiving government medical insurance, unless they have one of the listed diseases. The 24-month period is measured from the date that an individual is determined to be eligible for SSDI payments, not necessarily when the first payment is actually received. Many new SSDI recipients receive "back" disability pay, covering a period that usually begins 6 months from the start of disability and ending with the first monthly SSDI payment.
Some beneficiaries are dual-eligible. This means they qualify for both Medicare and Medicaid. In some states for those making below a certain income, Medicaid will pay the beneficiaries' Part B premium for them (most beneficiaries have worked long enough and have no Part A premium), as well as some of their out of pocket medical and hospital expenses.
Medicare has four parts: Part A is Hospital Insurance. Part B is Medical Insurance. Medicare Part D covers many prescription drugs, although some are covered by Part B. Part C health plans, the most popular of which are branded Medicare Advantage, are another way for Original Medicare beneficiaries to receive their Part A, B and D benefits (basically Part C is a public supplement option that can be compared with supplemental Medicare coverage from a former employer or private so-called Medigap insurance). All Medicare benefits are subject to medical necessity.
The original program included Parts A and B. Part-C-like plans have existed as demonstration projects in Medicare since the early 1980s but the Part was formalized by 1997 legislation. (Simplistically, Part C is a voucher program similar to the insurance reform included in the Patient Protection and Affordable Care Act of 2010 as amended). Part D was introduced January 1, 2006.
The maximum length of stay that Medicare Part A will cover in a hospital inpatient stay or series of stays is typically 90 days. The first 60 days would be paid by Medicare in full, except one copay at the beginning of the 60 days of $1,216. Days 61–90 require a co-payment (as of 2014, $304 per day). The beneficiary is also allocated "lifetime reserve days" that can be used after 90 days. These lifetime reserve days require a copayment (as of 2013, $592 per day), and the beneficiary can only use a total of 60 of these days throughout their lifetime.
A new pool of 90 hospital days, with new copays of $1,216 and $304, only starts after the beneficiary has 60 days continuously with no payment from Medicare for hospital or nursing home.
Some services can be done as inpatient services, which would be reimbursed under Part A, or as outpatient services, which would not be reimbursed under Part A. The "Two-Midnight Rule" decides which is which. In August 2013, the Centers for Medicare and Medicaid Services announced a final rule concerning eligibility for hospital inpatient services effective October 1, 2013. Under the new rule, if a physician admits a Medicare beneficiary as an inpatient with an expectation that the patient will require hospital care that “crosses two midnights,” Medicare Part A payment is “generally appropriate.” However, if it is anticipated that the patient will require hospital care for less than two midnights, Medicare Part A payment is generally not appropriate. The time a patient spends in the hospital before an inpatient admission is formally ordered is considered outpatient time. But, hospitals and physicians can take into consideration the pre-inpatient admission time when determining if a patient’s care will reasonably be expected to cross two midnights to be covered under Part A.
Medicare penalizes hospitals for readmissions. After making initial payments for hospital stays, Medicare will take back from the hospital these payments, plus a penalty of 4 to 18 times the initial payment, if an above-average number of patients from the hospital are readmitted within 30 days. These readmission penalties apply after some of the most common treatments: pneumonia, heart failure, heart attack, COPD, knee replacement, hip replacement. A study conducted by the Agency for Healthcare Research and Quality (AHRQ) of 18 States found that 1.8 million Medicare patients aged 65 and older were readmitted within 30 days of an initial hospital stay in 2011; the conditions with the highest readmission rates were congestive heart failure, septicemia, pneumonia, and chronic obstructive pulmonary disease and bronchiectasis.
The highest penalties on hospitals are charged after knee or hip replacements, $265,000 per excess readmission. The goals are to encourage better post-hospital care and more referrals to hospice and end-of-life care in lieu of treatment, while the effect is also to reduce coverage in hospitals which treat poor and frail patients. The total penalties for above-average readmissions in 2013 are $280 million, for 7,000 excess readmissions, or $40,000 for each readmission above the US average rate.
Part A also covers brief stays for rehabilitation or convalescence in a skilled nursing facility if certain criteria are met:
The maximum length of stay that Medicare Part A will cover in a skilled nursing facility per ailment is 100 days. The first 20 days would be paid for in full by Medicare with the remaining 80 days requiring a co-payment (as of 2014, $152 per day). Many insurance companies have a provision for skilled nursing care in the policies they sell.
If a beneficiary uses some portion of their Part A benefit and then goes at least 60 days without receiving facility-based skilled services, the 90-day hospital clock and 100-day nursing home clock are reset and the person qualifies for new benefit periods.
Hospice benefits are also provided under Part A of Medicare for terminally ill persons with less than six months to live, as determined by the patient's physician. The terminally ill person must sign a statement that hospice care has been chosen over other Medicare-covered benefits, (e.g. assisted living or hospital care). Treatment provided includes pharmaceutical products for symptom control and pain relief as well as other services not otherwise covered by Medicare such as grief counseling. Hospice is covered 100% with no co-pay or deductible by Medicare Part A except that patients are responsible for a copay for outpatient drugs and respite care, if needed.
Part B medical insurance helps pay for some services and products not covered by Part A, generally on an outpatient basis. Part B is optional and may be deferred if the beneficiary or his/her spouse is still working and has group health coverage through that employer. There is a lifetime penalty (10% per year) imposed for not enrolling in Part B unless actively working and receiving group health coverage from that employer.
Part B coverage begins once a patient meets his or her deductible ($147 in 2013), then typically Medicare covers 80% of approved services, while the remaining 20% is paid by the patient, either directly or indirectly by private Medigap insurance.
Part B coverage includes physician and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation, immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments such as Lupron, and other outpatient medical treatments administered in a doctor's office. Medication administration is covered under Part B if it is administered by the physician during an office visit.
Part B also helps with durable medical equipment (DME), including canes, walkers, wheelchairs, and mobility scooters for those with mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy, as well as one pair of eyeglasses following cataract surgery, and oxygen for home use is also covered.
Complex rules are used to manage the benefit, and advisories are periodically issued which describe coverage criteria. On the national level these advisories are issued by CMS, and are known as National Coverage Determinations (NCD). Local Coverage Determinations (LCD) apply within the multi-state area managed by a specific regional Medicare Part B contractor, and Local Medical Review Policies (LMRP) were superseded by LCDs in 2003. Coverage information is also located in the CMS Internet-Only Manuals (IOM), the Code of Federal Regulations (CFR), the Social Security Act, and the Federal Register.
With the passage of the Balanced Budget Act of 1997, Medicare beneficiaries were formally given the option to receive their Original Medicare benefits through capitated health insurance Part C plans, instead of through the Original fee for service Medicare payment system. They had been previously doing so via a series of demonstration projects that dated back to the early 1980s. These Part C plans were initially known as "Medicare+Choice". As of the Medicare Modernization Act of 2003, most "Medicare+Choice" plans were rebranded as "Medicare Advantage" (MA) plans.
Original "fee-for-service" Medicare has a standard benefit package that covers medically necessary care that members can receive from nearly any hospital or doctor in the country (if that doctor or hospital accepts Medicare). Original Medicare beneficiaries who choose to enroll in a capitated Part C Medicare Advantage health plan instead give up none of their rights as an Original Medicare beneficiary, receive the same standard benefits—as a minimum—as provided in Original Medicare, and they get an annual out of pocket (OOP) limit not included in Original Medicare. However they must typically use only a select network of providers except in emergencies, typically restricted to the area surrounding their legal residence. Most Part C plans are traditional health maintenance organizations (HMOs) although a few are preferred provider organizations (which typically means the provider restrictions are not as confining as with an HMO). For almost all Part C plans, the beneficiary is required to have a primary care physician; that is not a requirement of Original Medicare.
The difference between using Original Medicare plus—for example—a private Medigap supplement versus sticking totally with Medicare through a public Part C Medicare Advantage health plan is the standard HMO vs. non-HMO decision faced by almost all U.S. residents that get their healthcare insurance through an employer. It has nothing directly to do with Medicare.
Public Part C Medicare Advantage health plan members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare (Parts A & B), such as the OOP limit, prescription drugs, dental care, vision care, annual physicals, coverage outside the United States, and even gym or health club memberships as well as—and probably most importantly—reduce the 20% co-pays and high deductibles associated with Original Medicare. But in some situations the benefits are more limited (but they can never be more limited than Original Medicare and must always include an OOP limit) and there is no premium. In some cases, the insurer even rebates part or all of the Part B premium although these types of Part C plans are becoming rare.
Public Part C Medicare Advantage and other Part C health plans are required to offer coverage that meets or exceeds the standards set by Original Medicare, but they do not have to cover every benefit in the same way. After approval by the Centers for Medicare and Medicaid Services, if a Part C plan chooses to pay less than Original Medicare for some benefits, such as SNF care, the savings may be passed along to consumers by offering even lower co-payments for doctor visits.
The 2003-law payment formulas purposely overcompensated Part C plans by 12 percent or more on average compared to what Original Medicare beneficiaries received in the same county on average, in order to increase the availability of Part C plans in rural and inner-city geographies. Before 2003 Part C plans tended to be suburban HMOs tied to major nearby teaching hospitals that cost the government the same as or even 5% less on average than it cost to cover the medical needs of a comparable beneficiary on Original Medicare. The 2003 law even began an incongruous capitated fee for service option within Part C.
Although the 2003 payment formulas succeeded in increasing the percentage of rural and inner city poor that could take advantage of the OOP limit and lower co-pays and deductibles—as well as the coordinated medical care—associated with Part C plans, in practice one set of Medicare beneficiaries received more benefits than others. These payment formulas were almost completely eliminated by PPACA and have been almost totally phased out according to the 2013 MedPAC annual report, March 2013.
Enrollment in public Part C health plans, including Medicare Advantage plans, grew from 5.4 million in 2005 to over 13 million in 2013. This represents 28% of Medicare beneficiaries. Almost all Medicare beneficiaries have access to at least two Medicare Advantage plans; most have access to three or more.
Medicare Part D went into effect on January 1, 2006. Anyone with Part A or B is eligible for Part D. It was made possible by the passage of the Medicare Modernization Act. In order to receive this benefit, a person with Medicare must enroll in a stand-alone Prescription Drug Plan (PDP) or Medicare Advantage plan with prescription drug coverage (MA-PD). These plans are approved and regulated by the Medicare program, but are actually designed and administered by private health insurance companies and pharmacy benefit managers. Unlike Original Medicare (Part A and B), Part D coverage is not standardized (although it is highly regulated by the Centers for Medicare and Medicaid Services). Plans choose which drugs (or even classes of drugs) they wish to cover, at what level (or tier) they wish to cover it, and are free to choose not to cover some drugs at all. Plans that cover excluded drugs are not allowed to pass those costs on to Medicare, and plans are required to repay CMS if they are found to have billed Medicare in these cases.
Under the 2003 law that created Medicare Part D, the Social Security Administration provides extensive Extra Help to lower income seniors such that they have almost no drug costs. In addition approximately 25 states offer additional assistance on top of Part D. It should be noted again for beneficiaries who are dual-eligible (Medicare and Medicaid eligible) Medicaid may pay for drugs not covered by part D of Medicare.
One often-confusing aspect of Part D is a deductible structure that sometimes (but not usually) includes a deductible due from the patient before any payments are made by the insurer, and always includes another deductible in the middle of spending, sometimes referred to as "the donut hole." Because of the Social Security Extra Help and the state pharmacy assistance programs mentioned above, and due to the design of the insurance plans themselves, the "donut hole" only affects roughly 5% of Medicare beneficiaries. With the implementation of the PPACA, the "donut hole" has been largely eliminated. After 2020, those beneficiaries still affected by it will pay the same co-pay for their covered drugs when in the "donut hole" as they were before entering it. After about $6000[vague] in out-of-pocket prescription-drug spending, a spending level reached by about 1% of Medicare beneficiaries, the beneficiary will be responsible for 5% of the price of his or her drugs.
No part of Medicare pays for all of a beneficiary's covered medical costs and many costs are not covered at all. The program contains premiums, deductibles and coinsurance, which the covered individual must pay out-of-pocket. A study published by the Kaiser Family Foundation in 2008 found the Fee-for-Service Medicare benefit package was less generous than either the typical large employer Preferred provider organization plan or the Federal Employees Health Benefits Program Standard Option. Some people may qualify to have other governmental programs (such as Medicaid) pay premiums and some or all of the costs associated with Medicare.
Most Medicare enrollees do not pay a monthly Part A premium, because they (or a spouse) have had 40 or more 3-month quarters in which they paid Federal Insurance Contributions Act taxes.The benefit is the same no matter how much or how little the beneficiary paid as long as the minimum number of quarters is reached. Medicare-eligible persons who do not have 40 or more quarters of Medicare-covered employment may buy into Part A for a monthly premium of:
Most Medicare Part B enrollees pay an insurance premium for this coverage; the standard Part B premium for 2013 and 2014 is $104.90 per month. A new income-based premium surtax schema has been in effect since 2007, wherein Part B premiums are higher for beneficiaries with incomes exceeding $85,000 for individuals or $170,000 for married couples. Depending on the extent to which beneficiary earnings exceed the base income, these higher Part B premiums are $139.90, $199.80, $259.70, or $319.70 for 2012, with the highest premium paid by individuals earning more than $214,000, or married couples earning more than $428,000.
Medicare Part B premiums are commonly deducted automatically from beneficiaries' monthly Social Security checks. They can also be paid quarterly via bill sent directly to beneficiaries. This alternative is becoming more common because whereas the eligibility age for Medicare has remained at 65 as per the 1965 legislation the so-called Full Retirement Age for Social Security has been increased to 66 and will go even higher over time. Therefore many people delay collecting Social Security and have to pay their Part B premium directly.
Part C and D plans may or may not charge premiums, depending on the plans' designs as approved by the Centers for Medicare and Medicaid Services.
Part A — For each benefit period, a beneficiary will pay:
Part B — After a beneficiary meets the yearly deductible of $140.00 (in 2012), they will be required to pay a co-insurance of 20% of the Medicare-approved amount for all services covered by Part B with the exception of most lab services which are covered at 100%, and outpatient mental health which is currently (2010–2011) covered at 55% (45% copay). The copay for outpatient mental health which started at 50% is gradually being stepped down over several years until it matches the 20% required for other services. They are also required to pay an excess charge of 15% for services rendered by non-participating Medicare providers.
The deductibles, co-pays, and coinsurance charges for Part C and D plans vary from plan to plan. All Part C plans include an annual out of pocket limit. Original Medicare does not include an OOP limit.
Of the Medicare beneficiaries that do not receive supplemental insurance via a former employer (40%) or a public Part C Medicare Advantage health plan (about 30%), almost all elect to purchase a type of private supplemental insurance coverage, called a Medigap plan, to help fill in the financial holes in Original Medicare (Part A and B). These Medigap insurance policies are standardized by CMS, but are sold and administered by private companies. Some Medigap policies sold before 2006 may include coverage for prescription drugs. Medigap policies sold after the introduction of Medicare Part D on January 1, 2006 are prohibited from covering drugs. Medicare regulations prohibit a Medicare beneficiary from having both a public Part C Medicare Advantage health plan and a Medigap Policy. Medigap policies may be purchased by beneficiaries who are receiving benefits from Original Medicare (Part A & Part B). They are regulated by state insurance departments rather than the federal government although CMS outlines what the various Medigap plans must cover at a minimum.
Medicare contracts with regional insurance companies process over one billion fee-for-service claims per year. In 2008, Medicare accounted for 13% ($386 billion) of the federal budget. In 2010 it is projected to account for 12.5% ($452 billion) of the total expenditures. For the decade 2010–2019 medicare is projected to cost 6.4 trillion dollars or 14.8% of the federal budget for the period.
For institutional care, such as hospital and nursing home care, Medicare uses prospective payment systems. A prospective payment system is one in which the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care used. The actual allotment of funds is based on a list of diagnosis-related groups (DRG). The actual amount depends on the primary diagnosis that is actually made at the hospital. There are some issues surrounding Medicare's use of DRGs because if the patient uses less care, the hospital gets to keep the remainder. This, in theory, should balance the costs for the hospital. However, if the patient uses more care, then the hospital has to cover its own losses. This results in the issue of "upcoding," when a physician makes a more severe diagnosis to hedge against accidental costs.
Payment for physician services under Medicare has evolved since the program was created in 1965. Initially, Medicare compensated physicians based on the physician's charges, and allowed physicians to bill Medicare beneficiaries the amount in excess of Medicare's reimbursement. In 1975, annual increases in physician fees were limited by the Medicare Economic Index (MEI). The MEI was designed to measure changes in costs of physician's time and operating expenses, adjusted for changes in physician productivity. From 1984 to 1991, the yearly change in fees was determined by legislation. This was done because physician fees were rising faster than projected.
The Omnibus Budget Reconciliation Act of 1989 made several changes to physician payments under Medicare. Firstly, it introduced the Medicare Fee Schedule, which took effect in 1992. Secondly, it limited the amount Medicare non-providers could balance bill Medicare beneficiaries. Thirdly, it introduced the Medicare Volume Performance Standards (MVPS) as a way to control costs.
On January 1, 1992, Medicare introduced the Medicare Fee Schedule (MFS), a list of about 7,000 services that can be billed for. Each service is priced within the Resource-Based Relative Value Scale (RBRVS) with three Relative Value Units (RVUs) values largely determining the price. The three RVUs for a procedure are each geographically weighted and the weighted RVU value is multiplied by a global Conversion Factor (CF), yielding a price in dollars. The RVUs themselves are largely decided by a private group of 29 (mostly specialist) physicians—the American Medical Association's Specialty Society Relative Value Scale Update Committee (RUC).
From 1992 to 1997, adjustments to physician payments were adjusted using the MEI and the MVPS, which essentially tried to compensate for the increasing volume of services provided by physicians by decreasing their reimbursement per service.
In 1998, Congress replaced the VPS with the Sustainable Growth Rate (SGR). This was done because of highly variable payment rates under the MVPS. The SGR attempts to control spending by setting yearly and cumulative spending targets. If actual spending for a given year exceeds the spending target for that year, reimbursement rates are adjusted downward by decreasing the Conversion Factor (CF) for RBRVS RVUs.
Since 2002, actual Medicare Part B expenditures have exceeded projections.
In 2002, payment rates were cut by 4.8%. In 2003, payment rates were scheduled to be reduced by 4.4%. However, Congress boosted the cumulative SGR target in the Consolidated Appropriation Resolution of 2003 (P.L. 108-7), allowing payments for physician services to rise 1.6%. In 2004 and 2005, payment rates were again scheduled to be reduced. The Medicare Modernization Act (P.L. 108-173) increased payments 1.5% for those two years.
In 2006, the SGR mechanism was scheduled to decrease physician payments by 4.4%. (This number results from a 7% decrease in physician payments times a 2.8% inflation adjustment increase.) Congress overrode this decrease in the Deficit Reduction Act (P.L. 109-362), and held physician payments in 2006 at their 2005 levels. Similarly, another congressional act held 2007 payments at their 2006 levels, and HR 6331 held 2008 physician payments to their 2007 levels, and provided for a 1.1% increase in physician payments in 2009. Without further continuing congressional intervention, the SGR is expected to decrease physician payments from 25% to 35% over the next several years.
MFS has been criticized for not paying doctors enough because of the low conversion factor. By adjustments to the MFS conversion factor, it is possible to make global adjustments in payments to all doctors.
The SGR was the subject of possible reform legislation again in 2014. On March 14, 2014, the United States House of Representatives passed the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015; 113th Congress), a bill that would have replaced the (SGR) formula with new systems for establishing those payment rates. However, the bill would pay for these changes by delaying the Affordable Care Act's individual mandate requirement, a proposal that was very unpopular with Democrats. The SGR was expected to cause Medicare reimbursement cuts of 24 percent on April 1, 2014, if a solution to reform or delay the SGR was not found. This led to another bill, the Protecting Access to Medicare Act of 2014 (H.R. 4302; 113th Congress), which would delay those cuts until March 2015. This bill was also controversial. The American Medical Association and other medical groups opposed it, asking Congress to provide a permanent solution instead of just another delay.
There are three ways for providers to participate in Medicare. “Participating” providers take "assignment," which means that they accept Medicare’s approved rate for their services as payment in full. Some doctors do not take assignment or “participate”, but they also treat Medicare enrollees and are authorized to charge no more than a small fixed amount above Medicare’s approved rate. A minority of doctors are "private contractors," which means they opt out of Medicare and refuse to accept Medicare payments altogether. These doctors are required to inform patients will be liable for the full cost of their services out-of-pocket in advance of treatment.
While the majority of providers accept Medicare assignments, (97 percent for some specialties), and most physicians still accept at least some new Medicare patients, that number is in decline. While 80% of physicians in the Texas Medical Association accepted new Medicare patients in 2000, only 60% were doing so by 2012. A study published in 2012 concluded that the Centers for Medicare and Medicaid Services (CMS) relies on the recommendations of an American Medical Association advisory panel. The study lead by Dr. Miriam J. Laugesen, of Columbia Mailman School of Public Health, and colleagues at UCLA and the University of Illinois, shows that for services provided between 1994 and 2010, CMS agreed with 87.4% of the recommendations of the committee, known as RUC or the Relative Value Update Committee.
Chemotherapy and other medications dispensed in a physician's office are reimbursed according to the Average Sales Price, a number computed by taking the total dollar sales of a drug as the numerator and the number of units sold nationwide as the denominator. The current reimbursement formula is known as "ASP+6" since it reimburses physicians at 106% of the ASP of drugs. Pharmaceutical company discounts and rebates are included in the calculation of ASP, and tend to reduce it. In addition, Medicare pays 80% of ASP+6 which is the equivalent of 84.8% of the actual average cost of the drug. Some patients have supplemental insurance or can afford the co-pay. Large numbers do not. This leaves the payment to physicians for most of the drugs in an "underwater" state. ASP+6 superseded Average Wholesale Price in 2005, after a 2003 front-page New York Times article drew attention to the inaccuracies of Average Wholesale Price calculations.
"Physicians in geographic Health Professional Shortage Areas (HPSAs) and Physician Scarcity Areas (PSAs) can receive incentive payments from Medicare. Payments are made on a quarterly basis, rather than claim-by-claim, and are handled by each area's Medicare carrier."
Generally, if you are already receiving Social Security payments, at age 65 you will be automatically enrolled in Medicare Part A (Hospital Insurance). In addition, you will generally also be automatically enrolled in Medicare Part B (Medical Insurance). If you choose to accept Part B you will need to pay a monthly premium to keep it. However, you may delay enrollment with no penalty under some circumstances, or with penalty under other circumstances.
Part A & B
Part A Late Enrollment Penalty If you are not eligible for premium-free Part A, and you don’t buy a premium-based Part A when you’re first eligible, your monthly premium may go up 10%. You will have to pay the higher premium for twice the number of years you could have had Part A, but didn’t sign-up. For example, if you were eligible for Part A for 2 years but didn’t sign-up, you will have to pay the higher premium for 4 years. Usually, you don’t have to pay a penalty if you meet certain conditions that allow you to sign up for Part A during a Special Enrollment Period.
Part B Late Enrollment Penalty If you don’t sign up for Part B when you’re first eligible, you may have to pay a late enrollment penalty for as long as you have Medicare. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn’t sign up for it. Usually, you don’t pay a late enrollment penalty if you meet certain conditions that allow you to sign up for Part B during a special enrollment period.
Medicare differs from private insurance available to working Americans in that it is a social insurance program. Social insurance programs provide statutorily guaranteed benefits to the entire population (under certain circumstances, such as old age or unemployment), benefits which are financed in significant part through universal taxes. In effect, Medicare is a mechanism by which the state takes a portion of its citizens' resources to guarantee health and financial security to its citizens in old age or in case of disability, helping them cope with the enormous, unpredictable cost of health care. In its universality, Medicare differs substantially from private insurers, which must make decisions about whom to cover and what benefits to offer in order to manage their risk pools and guarantee that costs do not exceed premiums.
Because the federal government is legally obligated to provide Medicare benefits to older and disabled Americans, it cannot cut costs by restricting eligibility or benefits, except by going through a difficult legislative process. Although cutting costs by cutting benefits is difficult, the program can also achieve substantial economies of scale in terms of the prices it pays for health care and administrative expenses and, as a result, private insurers’ costs have grown almost 60% more than Medicare’s since 1970.[Original research?] Medicare’s cost growth is now the same as GDP growth and expected to stay well below private insurance’s for the next decade.
Because Medicare offers statutorily determined benefits, its coverage policies and payment rates are publicly known, and all enrollees are entitled to the same coverage. In the private insurance market, plans can be tailored to offer different benefits to different customers, enabling individuals to reduce coverage costs while assuming risks that they will not need care that is not covered. But insurers have far fewer disclosure requirements than Medicare, and studies show that customers in the private sector can face major difficulties determining what care is covered and at what cost. Moreover, since Medicare collects data about utilization and costs for its enrollees – data which private insurers treat as trade secrets – it provides researchers with key information about the performance of the health care system.
Medicare also has an important role driving changes in the entire health care system. Because Medicare pays for a huge share of health care in every region of the country, it has a great deal of power to set delivery and payment policies. For example, Medicare promoted the adaptation of prospective payments based on DRG’s, which prevents unscrupulous providers from setting their own exorbitant prices. Meanwhile, the Patient Protection and Affordable Care Act has given Medicare the mandate to promote cost-containment throughout the health care system, for example, by promoting the creation of accountable care organizations or by replacing fee-for-service payments with bundled payments.
Over the long-term, Medicare faces significant financial challenges because of rising overall health care costs, increasing enrollment as the population ages, and a decreasing ratio of workers to enrollees. Total Medicare spending is projected to increase from $523 billion in 2010 to $932 billion by 2020. From 2010 to 2030, Medicare enrollment is projected to increase from 47 million to 79 million, and the ratio of workers to enrollees is expected to decrease from 3.7 to 2.4. However, the ratio of workers to retirees has declined steadily for decades, and social insurance systems have remained sustainable due to rising worker productivity. There is some evidence that productivity gains will continue to offset demographic trends in the near future.
Paul Krugman, Nobel laureate in economics and New York Times columnist, wrote in 2014 that despite the earlier projections of Medicare insolvency, the increase in Medicare costs have slowed, postponing the crisis "perhaps indefinitely." The long-term outlook for Medicare, "while not great, actually isn’t all that bad," wrote Krugman. "For years, many people — myself included — have warned that Medicare is a much bigger problem than Social Security, and the latest report from the program’s trustees still shows spending rising from 3.6 percent of G.D.P. now to 5.6 percent in 2035. But that’s a smaller rise than in previous projections." The long-term upward trend has flattened significantly, he wrote.
The Congressional Budget Office (CBO) wrote in 2008 that "future growth in spending per beneficiary for Medicare and Medicaid—the federal government’s major health care programs—will be the most important determinant of long-term trends in federal spending. Changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation’s central long-term challenge in setting federal fiscal policy."
Overall health care costs were projected in 2011 to increase by 5.8 percent annually from 2010 to 2020, in part because of increased utilization of medical services, higher prices for services, and new technologies. Health care costs are rising across the board, but the cost of insurance has risen dramatically for families and employers as well as the federal government. In fact, since 1970 the per-capita cost of private coverage has grown roughly one percentage point faster each year than the per-capita cost of Medicare. Since the late 1990s, Medicare has performed especially well relative to private insurers. Over the next decade, Medicare’s per capita spending is projected to grow at a rate of 2.5 percent each year, compared to private insurance’s 4.8 percent. Nonetheless, most experts and policymakers agree containing health care costs is essential to the nation’s fiscal outlook. Much of the debate over the future of Medicare revolves around whether per capita costs should be reduced by limiting payments to providers or by shifting more costs to Medicare enrollees.
Several measures serve as indicators of the long-term financial status of Medicare. These include total Medicare spending as a share of gross domestic product (GDP), the solvency of the Medicare HI trust fund, Medicare per-capita spending growth relative to inflation and per-capita GDP growth; and general fund revenue as a share of total Medicare spending.
This measure, which examines Medicare spending in the context of the U.S. economy as a whole, is expected to increase from 3.6 percent in 2010 to 5.6 percent in 2035 and to 6.2 percent by 2080.
This measure involves only Part A. The trust fund is considered insolvent when available revenue plus any existing balances will not cover 100 percent of annual projected costs. According to the latest estimate by the Medicare trustees (2011), the trust fund is expected to become insolvent in 13 years (2024), at which time available revenue will cover 90 percent of annual projected costs. Since Medicare began, this solvency projection has ranged from two to 28 years, with an average of 11.3 years.
The Independent Payment Advisory Board (IPAB), which the Affordable Care Act or "ACA" created, will use this measure to determine whether it must recommend to Congress proposals to reduce Medicare costs. Under the ACA, Congress established maximum targets, or thresholds, for per-capita Medicare spending growth. For the five-year periods ending in 2015 through 2019, these targets are based on the average of CPI-U and CPI-M. For the five-year periods ending in 2020 and subsequent years, these targets are based on per-capita GDP growth plus one percentage point. Each year, the CMS Office of the Actuary must compare those two values, and if the spending measure is larger than the economic measure, IPAB must propose cost-savings recommendations for consideration in Congress on an expedited basis. The Congressional Budget Office projects that Medicare per-capita spending growth will not exceed the economic target at any time between 2015 and 2021.
This measure, established under the Medicare Modernization Act (MMA), examines Medicare spending in the context of the federal budget. Each year, MMA requires the Medicare trustees to make a determination about whether general fund revenue is projected to exceed 45 percent of total program spending within a seven-year period. If the Medicare trustees make this determination in two consecutive years, a “funding warning” is issued. In response, the president must submit cost-saving legislation to Congress, which must consider this legislation on an expedited basis. In 2009, for the fourth consecutive year, the Medicare trustees determined that general fund revenue would exceed the threshold. However, in January 2009, the House passed a resolution to suspend congressional consideration of any legislation related to a Medicare funding warning.
Medicare’s unfunded obligation is the total amount of money that would have to be set aside today such that the principal and interest would cover the gap between projected Part A revenues and spending over a given timeframe. As of 2009, Medicare’s unfunded obligation over an infinite timeframe was $36 trillion. Due to the passage of health reform, Medicare’s unfunded obligation over the next 75 years declined from $13.5 trillion to $3 trillion.
Popular opinion surveys show that the public views Medicare’s problems as serious, but not as urgent as other concerns. In January 2006, the Pew Research Center found 62 percent of the public said addressing Medicare’s financial problems should be a high priority for the government, but that still put it behind other priorities. Surveys suggest that there’s no public consensus behind any specific strategy to keep the program solvent.
The Government Accountability Office lists Medicare as a "high-risk" government program in need of reform, in part because of its vulnerability to fraud and partly because of its long-term financial problems. Fewer than 5% of Medicare claims are audited.
Yaron Brook of the Ayn Rand Institute has argued that the birth of Medicare represented a shift away from personal responsibility and towards a view that health care is an unearned "entitlement" to be provided at others' expense.
Robert M. Ball, a former commissioner of Social Security under President Kennedy in 1961 (and later under Johnson, and Nixon) defined the major obstacle to financing health insurance for the elderly: the high cost of care for the aged combined with the generally low incomes of retired people. Because retired older people use much more medical care than younger employed people, an insurance premium related to the risk for older people needed to be high, but if the high premium had to be paid after retirement, when incomes are low, it was an almost impossible burden for the average person. The only feasible approach, he said, was to finance health insurance in the same way as cash benefits for retirement, by contributions paid while at work, when the payments are least burdensome, with the protection furnished in retirement without further payment. In the early 1960s relatively few of the elderly had health insurance, and what they had was usually inadequate. Insurers such as Blue Cross, which had originally applied the principle of community rating, faced competition from other commercial insurers that did not community rate, and so were forced to raise their rates for the elderly.
Also, Medicare is not generally an unearned entitlement. Entitlement is most commonly based on a record of contributions to the Medicare fund. As such it is a form of social insurance making it feasible for people to pay for insurance for sickness in old age when they are young and able to work and be assured of getting back benefits when they are older and no longer working. Some people will pay in more than they receive back and others will get back more than they paid in, but this is the practice with any form of insurance, public or private.
A 2001 study by the Government Accountability Office evaluated the quality of responses given by Medicare contractor customer service representatives to provider (physician) questions. The evaluators assembled a list of questions, which they asked during a random sampling of calls to Medicare contractors. The rate of complete, accurate information provided by Medicare customer service representatives was 15%. Since then, steps have been taken to improve the quality of customer service given by Medicare contractors, specifically the 1-800-MEDICARE contractor. As a result, 1-800-MEDICARE customer service representatives (CSR) have seen an increase in training, quality assurance monitoring has significantly increased, and a customer satisfaction survey is offered to random callers.
In most states the Joint Commission, a private, non-profit organization for accrediting hospitals, decides whether or not a hospital is able to participate in Medicare, as currently there are no competitor organizations recognized by CMS.
Other organizations can also accredit hospitals for Medicare. These include the Community Health Accreditation Program, the Accreditation Commission for Health Care, the Compliance Team and the Healthcare Quality Association on Accreditation.
Accreditation is voluntary and an organization may choose to be evaluated by their State Survey Agency or by CMS directly.
Medicare funds the vast majority of residency training in the US. This tax-based financing covers resident salaries and benefits through payments called Direct Medical Education payments. Medicare also uses taxes for Indirect Medical Education, a subsidy paid to teaching hospitals in exchange for training resident physicians. For the 2008 fiscal year these payments were $2.7 and $5.7 billion respectively. Overall funding levels have remained at the same level over the last ten years, so that the same number or fewer residents have been trained under this program. Meanwhile, the US population continues to grow older, which has led to greater demand for physicians. At the same time the cost of medical services continue rising rapidly and many geographic areas face physician shortages, both trends suggesting the supply of physicians remains too low.
Medicare finds itself in the odd position of having assumed control of graduate medical education, currently facing major budget constraints, and as a result, freezing funding for graduate medical education, as well as for physician reimbursement rates. This halt in funding in turn exacerbates the exact problem Medicare sought to solve in the first place: improving the availability of medical care. However, some healthcare administration experts believe that the shortage of physicians may be an opportunity for providers to reorganize their delivery systems to become less costly and more efficient. Physicians' assistants and Advanced Registered Nurse Practitioners may begin assuming more responsibilities that traditionally fell to doctors, but do not necessarily require the advanced training and skill of a physician.
Of the 38,377 medical school graduates who applied for The National Resident Matching Program in 2012, 73.1%, 22,934, of US Medical School Graduates were able to find PGY-1 matches. In contrast, only 42.4% of graduates from Foreign Medical Schools who applied were successful. 3,909, or 10.2%, withdrew altogether from the match process, with the remaining 8,421, or 16.2%, who were unsuccessful in obtaining a residency slot in the PGY-1 match, left to attempt to rematch at a later time. The NRMR acknowledges that those who did not match in the previous years, and who reapplied for the match, were not included in the figures.
|This section requires expansion with: with separate more detailed descriptions of legislation and reforms. (January 2012)|
In 1977, the Health Care Financing Administration (HCFA) was established as a federal agency responsible for the administration of Medicare and Medicaid. This would be renamed to Centers for Medicare and Medicaid Services (CMS) in 2001. By 1983, the diagnosis-related group (DRG) replaced pay for service reimbursements to hospitals for Medicare patients.
In 2003 Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which President George W. Bush signed into law on December 8, 2003. Part of this legislation included filling gaps in prescription-drug coverage left by the Medicare Secondary Payer Act that was enacted in 1980. The 2003 bill strengthened the Workers' Compensation Medicare Set-Aside Program (WCMSA) that is monitored and administered by CMS.
On August 1, 2007, the U.S. House United States Congress voted to reduce payments to Medicare Advantage providers in order to pay for expanded coverage of children's health under the SCHIP program. As of 2008, Medicare Advantage plans cost, on average, 13 percent more per person insured than direct payment plans. Many health economists have concluded that payments to Medicare Advantage providers have been excessive. The Senate, after heavy lobbying from the insurance industry, declined to agree to the cuts in Medicare Advantage proposed by the House. President Bush subsequently vetoed the SCHIP extension.
The Patient Protection and Affordable Care Act ("PPACA") of 2010 made a number of changes to the Medicare program. Several provisions of the law were designed to reduce the cost of Medicare. Congress reduced payments to privately managed Medicare Advantage plans to align more closely with rates paid for comparable care under traditional Medicare. Congress also slightly reduced annual increases in payments to physicians and to hospitals that serve a disproportionate share of low-income patients. Along with other minor adjustments, these changes reduced Medicare’s projected cost over the next decade by $455 billion.
Additionally, the PPACA created the Independent Payment Advisory Board (“IPAB”), which will be empowered to submit legislative proposals to reduce the cost of Medicare if the program’s per-capita spending grows faster than per-capita GDP plus one percent. While the IPAB would be barred from rationing care, raising revenue, changing benefits or eligibility, increasing cost sharing, or cutting payments to hospitals, its creation has been one of the more controversial aspects of health reform.
The PPACA also made some changes to Medicare enrollee’s’ benefits. By 2020, it will close the so-called “donut hole” between Part D plans’ coverage limits and the catastrophic cap on out-of-pocket spending, reducing a Part D enrollee’s’ exposure to the cost of prescription drugs by an average of $2,000 a year. Limits were also placed on out-of-pocket costs for in-network care for Medicare Advantage enrollees. Meanwhile, Medicare Part B and D premiums were restructured in ways that reduced costs for most people while raising contributions from the wealthiest people with Medicare. The law also expanded coverage of preventive services.
The PPACA instituted a number of measures to control Medicare fraud and abuse, such as longer oversight periods, provider screenings, stronger standards for certain providers, the creation of databases to share data between federal and state agencies, and stiffer penalties for violators. The law also created mechanisms, such as the Center for Medicare and Medicaid Innovation to fund experiments to identify new payment and delivery models that could conceivably be expanded to reduce the cost of health care while improving quality.
As legislators continue to seek new ways to control the cost of Medicare, a number of new proposals to reform Medicare have been introduced in recent years.
Since the mid-1990s, there have been a number of proposals to change Medicare from a publicly run social insurance program with a defined benefit, for which there is no limit to the government’s expenses, into a program that offers "premium support" for enrollees. The basic concept behind the proposals is that the government would make a defined contribution, that is a premium support, to the health plan of a Medicare enrollee's choice. Insurers would compete to provide Medicare benefits and this competition would set the level of fixed contribution. Additionally, enrollees would be able to purchase greater coverage by paying more in addition to the fixed government contribution. Conversely, enrollees could choose lower cost coverage and keep the difference between their coverage costs and the fixed government contribution. The goal of premium Medicare plans is for greater cost-effectiveness; if such a proposal worked as planned, the financial incentive would be greatest for Medicare plans that offer the best care at the lowest cost.
There have been a number of criticisms of the premium support model. Some have raised concern about risk selection, where insurers find ways to avoid covering people expected to have high health care costs. Premium support proposals, such as the 2011 plan proposed by Rep. Paul Ryan (R–Wis.), have aimed to avoid risk selection by including protection language mandating that plans participating in such coverage must provide insurance to all beneficiaries and are not able to avoid covering higher risk beneficiaries. Some critics are concerned that the Medicare population, which has particularly high rates of cognitive impairment and dementia, would have a hard time choosing between competing health plans. Robert Moffit, a senior fellow of The Heritage Foundation responded to this concern, stating that while there may be research indicating that individuals have difficulty making the correct choice of health care plan, there is no evidence to show that government officials can make better choices. Henry Aaron, one of the original proponents of premium supports, has recently argued that the idea should not be implemented, given that Medicare Advantage plans have not successfully contained costs more effectively than traditional Medicare and because the political climate is hostile to the kinds of regulations that would be needed to make the idea workable.
Two distinct premium support systems have recently been proposed in Congress in order to control the cost of Medicare. The House Republicans’ 2012 budget would have abolished traditional Medicare and required the eligible population to purchase private insurance with a newly created premium support program. This plan would have cut the cost of Medicare by capping the value of the voucher and tying its growth to inflation, which is expected to be lower than rising health costs, saving roughly 155 billion over ten years. Paul Ryan, the plan’s author, claimed that competition would drive down costs, but the Congressional Budget Office (CBO) found that the plan would dramatically raise the cost of health care, with all of the additional costs falling on enrollees. The CBO found that under the plan, typical 65-year olds would go from paying 35 percent of their health care costs to paying 68 percent by 2030.
In December 2011, Ryan and Sen. Ron Wyden (D–Oreg.) jointly proposed a new premium support system. Unlike Ryan’s original plan, this new system would maintain traditional Medicare as an option, and the premium support would not be tied to inflation. The spending targets in the Ryan-Wyden plan are the same as the targets included in the Affordable Care Act; it is unclear whether the plan would reduce Medicare expenditure relative to current law.
Raising the age of eligibility
A number of different plans have been introduced that would raise the age of Medicare eligibility. Some have argued that, as the population ages and the ratio of workers to retirees increases, programs for the elderly need to be reduced. Since the age at which Americans can retire with full Social Security benefits is rising to 67, it is argued that the age of eligibility for Medicare should rise with it (although people can begin receiving reduced Social Security benefits as early as age 62).
The CBO projected that raising the age of Medicare eligibility would save $113 billion over 10 years after accounting for the necessary expansion of Medicaid and state health insurance exchange subsidies under health care reform, which are needed to help those who could not afford insurance purchase it. The Kaiser Family Foundation found that raising the age of eligibility would save the federal government $5.7 billion a year, while raising costs for other payers. According to Kaiser, raising the age would cost $3.7 billion to 65- and 66-year olds, $2.8 billion to other consumers whose premiums would rise as insurance pools absorbed more risk, $4.5 billion to employers offering insurance, and $0.7 billion to states expanding their Medicaid rolls. Ultimately Kaiser found that the plan would raise total social costs by more than twice the savings to the federal government.
Negotiating the prices of prescription drugs
Currently, people with Medicare can get prescription drug coverage through a Medicare Advantage plan or through the standalone private prescription drug plans (PDPs) established under Medicare Part D. Each plan established its own coverage policies and independently negotiates the prices it pays to drug manufacturers. But because each plan has a much smaller coverage pool than the entire Medicare program, many argue that this system of paying for prescription drugs undermines the government’s bargaining power and artificially raises the cost of drug coverage.
Many look to the Veterans Health Administration as a model of lower cost prescription drug coverage. Since the VHA provides healthcare directly, it maintains its owns formulary and negotiates prices with manufacturers. Studies show that the VHA pays dramatically less for drugs than the PDP plans Medicare Part D subsidizes. One analysis found that adopting a formulary similar to the VHA’s would save Medicare $14 billion a year (over 10 years the savings would be around $140 billion).
There are other proposals for savings on prescription drugs that do not require such fundamental changes to Medicare Part D’s payment and coverage policies. Manufacturers who supply drugs to Medicaid are required to offer a 15 percent rebate on the average manufacturer’s price. Low-income elderly individuals who qualify for both Medicare and Medicaid receive drug coverage through Medicare Part D, and no reimbursement is paid for the drugs the government purchases for them. Reinstating that rebate would yield savings of $112 billion, according to a recent CBO estimate.
Some have questioned the ability of the federal government to achieve greater savings than the largest PDPs, since some of the larger plans have coverage pools comparable to Medicare’s, although the evidence from the VHA is promising. Some also worry that controlling the prices of prescription drugs would reduce incentives for manufacturers to invest in R&D, although the same could be said of anything that would reduce costs.
Reforming care for the “dual-eligibles”
Roughly 9 million Americans – mostly older adults with low incomes – are eligible for both Medicare and Medicaid. These men and women tend to have particularly poor health – more than half are being treated for five or more chronic conditions – and high costs. Average annual per-capita spending for “dual-eligibles” is $20,000, compared to $10,900 for the Medicare population as a whole all enrollees.
The dual-eligible population comprises roughly 20 percent of Medicare’s enrollees but accounts for 36 percent of its costs. There is substantial evidence that these individuals receive highly inefficient care because responsibility for their care is split between the Medicare and Medicaid programs – most see a number of different providers without any kind of mechanism to coordinate their care, and they face high rates of potentially preventable hospitalizations. Because Medicaid and Medicare cover different aspects of health care, both have a financial incentive to shunt patients into care the other program will pay for.
Many experts have suggested that establishing mechanisms to coordinate care for the dual-eligibles could yield substantial savings in the Medicare program, mostly by reducing hospitalizations. Such programs would connect patients with primary care, create an individualized health plan, assist enrollees in receiving social and human services as well as medical care, reconcile medications prescribed by different doctors to ensure they do not undermine one another, and oversee behavior to improve health. The general ethos of these proposals is to “treat the patient, not the condition,” and maintain health while avoiding costly treatments.
There is some controversy over who exactly should take responsibility for coordinating the care of the dual eligibles. There have been some proposals to transfer dual eligibles into existing Medicaid managed care plans, which are controlled by individual states. But many states facing severe budget shortfalls might have some incentive to stint on necessary care or otherwise shift costs to enrollees and their families in order to capture some Medicaid savings. Medicare has more experience managing the care of older adults and will already be expanding coordinated care programs under the ACA, although there are some questions about private Medicare plans’ capacity to manage care and achieve meaningful cost savings.
Income-relating Medicare premiums
Both House Republicans and President Obama proposed increasing the additional premiums paid by the wealthiest people with Medicare, compounding several reforms in the ACA that would increase the number of wealthier individuals paying higher, income-related Part B and Part D premiums. Such proposals are projected to save $20 billion over the course of a decade, and would ultimately result in more than a quarter of Medicare enrollees paying between 35 and 90 percent of their Part B costs by 2035, rather than the typical 25 percent. If the brackets mandated for 2035 were implemented today,[when?] it would mean that anyone earning more than $47,000 (as an individual) or $94,000 (as a couple) would be affected. Under the Republican proposals, affected individuals would pay 40 percent of the total Part B and Part D premiums, which would be equivalent of $2,500 today.
More limited income-relation of premiums only raises limited revenue. Currently, only 5 percent of Medicare enrollees pay an income-related premium, and most only pay 35 percent of their total premium, compared to the 25 percent most people pay. Only a negligible number of enrollees fall into the higher income brackets required to bear a more substantial share of their costs – roughly half a percent of individuals and less than three percent of married couples currently pay more than 35 percent of their total Part B costs.
There is some concern that tying premiums to income would weaken Medicare politically over the long run, since people tend to be more supportive of universal social programs than of means-tested ones.
Some Medicare supplemental insurance (or “Medigap”) plans cover all of an enrollee's cost-sharing, insulating them from any out-of-pocket costs and guaranteeing financial security to individuals with significant health care needs. Many policymakers believe that such plans raise the cost of Medicare by creating a perverse incentive that leads patients to seek unnecessary, costly treatments. Many argue that unnecessary treatments are a major cause of rising costs and propose that people with Medicare should feel more of the cost of their care to create incentives to seek the most efficient alternatives. Various restrictions and surcharges on Medigap coverage have appeared in recent deficit reduction proposals. One of the furthest-reaching reforms proposed, which would prevent Medigap from covering any of the first $500 of coinsurance charges and limit it to covering 50 percent of all costs beyond that, could save $50 billion over ten years. But it would also increase health care costs substantially for people with costly health care needs.
There is some evidence that claims of Medigap’s tendency to cause over-treatment may be exaggerated and that potential savings from restricting it might be smaller than expected. Meanwhile, there are some concerns about the potential effects on enrollees. Individuals who face high charges with every episode of care have been shown to delay or forgo needed care, jeopardizing their health and possibly increasing their health care costs down the line. Given their lack of medical training, most patients tend to have difficulty distinguishing between necessary and unnecessary treatments. The problem could be exaggerated among the Medicare population, which has low levels of health literacy.[full citation needed]
[...] The concern is that private plans will find ways to attract relatively healthier and cheaper-to-cover beneficiaries (the "good" risks), leaving the sicker and more costly ones (the "bad" risks) in TM. Attracting good risks is known as "favorable selection" and attracting "bad" ones is "adverse selection." [...]
[...] Medicare is already very complex, some say too complex. There is research that suggests beneficiaries have difficulty making good choices among the myriad of available plans. [...]
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Akira Muto, Michael B. Orger ¤a, Ann M. Wehman, Matthew C. Smear, Jeremy N. Kay¤a, Patrick S. Page-McCaw¤b, Ethan Gahtan¤c, Tong Xiao, Linda M. Nevin, Nathan J. Gosse, Wendy Staub, Karin Finger-Baier, Herwig Baier*
* To whom correspondence should be addressed. E-mail: firstname.lastname@example.org
The visual system converts the distribution and wavelengths of photons entering the eye into patterns of neuronal activity, which then drive motor and endocrine behavioral responses. The gene products important for visual processing by a living and behaving vertebrate animal have not been identified in an unbiased fashion. Likewise, the genes that affect development of the nervous system to shape visual function later in life are largely unknown. Here we have set out to close this gap in our understanding by using a forward genetic approach in zebrafish. Moving stimuli evoke two innate reflexes in zebrafish larvae, the optomotor and the optokinetic response, providing two rapid and quantitative tests to assess visual function in wild-type (WT) and mutant animals. These behavioral assays were used in a high-throughput screen, encompassing over half a million fish. In almost 2,000 F2 families mutagenized with ethylnitrosourea, we discovered 53 recessive mutations in 41 genes. These new mutations have generated a broad spectrum of phenotypes, which vary in specificity and severity, but can be placed into only a handful of classes. Developmental phenotypes include complete absence or abnormal morphogenesis of photoreceptors, and deficits in ganglion cell differentiation or axon targeting. Other mutations evidently leave neuronal circuits intact, but disrupt phototransduction, light adaptation, or behavior-specific responses. Almost all of the mutants are morphologically indistinguishable from WT, and many survive to adulthood. Genetic linkage mapping and initial molecular analyses show that our approach was effective in identifying genes with functions specific to the visual system. This collection of zebrafish behavioral mutants provides a novel resource for the study of normal vision and its genetic disorders.
Abbreviations: AF, arborization field; [number] dpf, day [number] postfertilization; DiD, 1,1′-dioctadecyl-3,3,3′,3′- tetramethylindodicarbocyanine; DiI, 1,1′-dioctadecyl-3,3,3′,3′-tetramethylindocarbocyanine; DiO, 3,3′-dioctadecyloxacarbocyanine; ENU, ethylnitrosourea; OKR, optokinetic response; OMR, optomotor response; PhR, photoreceptor cell; RGC, retinal ganglion cell; SSA, spontaneous swimming activity; VBA, visually mediated background adaptation; WT, wild-type
While many genes have previously been implicated in the development and function of the vertebrate central nervous system, no systematic attempt has been made to build a comprehensive catalog of genes important for its behavioral output. Motion evokes two visual reflexes in zebrafish larvae, the optomotor and the optokinetic response. After mutagenesis with ethylnitrosourea and inbreeding over two generations, the authors of this study searched for point mutations disrupting either, or both, of these innate responses. In almost 2,000 F2 families, they discovered 53 recessive mutations in 41 genetic loci. Developmental phenotypes included abnormal differentiation or absence of photoreceptors, and deficits in retinal ganglion cell differentiation or axon targeting. Physiological phenotypes include disruptions of phototransduction, light adaptation, and behavior-specific responses. Most of the mutants are morphologically indistinguishable from wild type, and many survive to adulthood. Genetic linkage mapping and initial molecular analyses revealed that the authors' approach identified genes with functions specific to the visual system. This collection of zebrafish behavioral mutants provides a novel resource for studying the genetic architecture of the vertebrate central nervous system.
An animal's behavioral repertoire is deeply rooted in its genome. Mutations of behaviorally important genes may alter or disrupt either the physiology of neuronal circuits or their development. The first task of a research program aimed at identifying the genetic underpinnings of perception and behavior is to build a comprehensive catalog of genes with specific, non-lethal phenotypes, initially with no regard of when and where in the organism they are acting. Forward genetic screens are the method of choice to identify those genes in an unbiased fashion. This approach was pioneered over 30 years ago by Benzer in Drosophila melanogaster and was quickly extended to Caenorhabditis elegans . In these invertebrate species, the forward genetic strategy was particularly productive for the analysis of sensory systems, such as vision, mechanosensation, and olfaction, where these screens helped to discover many genes important for the patterning of sensory epithelia and for sensory transduction [3–7].
Very few behavioral screens have been attempted in vertebrates to date. In mice, Takahashi and colleagues carried out a screen for dominant mutations disrupting circadian behavior . Other groups have carried out behavioral “shelf screens” of previously discovered mutants in both zebrafish and mice [9–11] or collected mutants in motility and locomotor coordination [12,13]. Here we report on the results of the first large-scale behavioral screen focused on a vertebrate sensory system. Following chemical mutagenesis, we searched for recessive mutations that disrupt visually evoked behaviors in zebrafish. Brockerhoff et al. first showed the utility of optokinetic behavior as a powerful screening tool to find visual mutants . Here we used both the optokinetic response (OKR) and the optomotor response (OMR) as screening assays [9,14–16]. These two behaviors employ different motor outputs (swimming and eye movements, respectively), but they are both elicited by large-field motion and are dependent on the retina as the light-sensing organ [15,17]. In a high-throughput screen of almost 2,000 mutagenized genomes, we discovered 41 loci whose mutations lead to a broad spectrum of specific visual (or visuomotor) impairments. Some of the more striking phenotypes include new mutants in retinal axon targeting and in the adaptive dynamics of light responses. This first survey reveals the extent to which single-gene mutations can perturb visual behavior without affecting gross development or vital organ functions. The identities of the corresponding genes are beginning to provide novel insights into how the visual system is assembled and how cellular and molecular interactions shape sensory processing in the vertebrate brain.
We carried out a large-scale screen for mutants with defects in visually elicited behavior. Forty-one founder males (F0) treated with ethylnitrosourea (ENU; see Materials and Methods) were mated with wild-type (WT) females to generate more than 5,000 F1 fish. Adult F1 fish were mated with other F1 fish, or with WT fish, to generate more than 2,000 F2 families. In total, 3,171 F1 fish were used to generate the 1,896 F2 families (2,550 F1 fish for F1 × F1 crosses, and 621 F1 fish for F1 × WT) that gave at least one healthy clutch of F3 embryos in the subsequent generation. F3 embryos and larvae were obtained by random crosses between siblings from F2 families (6,468 F3 clutches in total, or 3.4 clutches per each F2 family on average). From each F3 clutch, typically 12 larvae were tested for OKR and 25 larvae for the OMR (see below). Fish were routinely scored on the seventh day postfertilization (7 dpf). Including retests, over 500,000 individual fish were screened in the course of three years. Calculations based on binomial statistics , taking into account the number of F1 fish used to generate the F2 families, the number of F2 families, the number of crosses for each F2 family, and the number of F3 larval fish tested, show that our screen encompassed 1,688 ENU-mutagenized genomes.
The efficiency of mutagenesis in the founder male germlines was determined by a specific-locus test, using sandy (sdy), a zebrafish tyrosinase mutant . In this test, ENU-treated founder males mated with sdy heterozygous females produced six new sdy mutations in about 2,000 genomes screened. In the actual screen of F2 families, however, two new sdy mutant alleles were identified. The allele distribution of all loci, which was determined after completion of the screen and following extensive complementation tests, shows that our screen was not saturated (see Discussion). We nevertheless successfully identified new alleles of previously reported visual mutants, such as bel and nof (Table 1). Although we did not attempt to characterize mutations falling outside our screening criteria, i.e., those causing embryonic or larval lethality, we noticed (and most of the time discarded) new alleles of chk , bru/eby [21,22], ome, and nok (unpublished data).
We screened for mutations disrupting behavioral responses to visual motion. A coarse grating that drifts across the fishes' visual field elicits either of two distinct responses, an OKR or an OMR. In the OMR, WT animals vigorously swim in the direction of the perceived motion (Video S1). When restrained from swimming and presented with a rotating whole-field motion stimulus, the fish show an OKR to cancel retinal slip: WT animals move their eyes to track the motion. These pursuit phases are interrupted at regular intervals by reset movements, or saccades (Video S2) . To achieve high throughput, we automated both visual stimulation and analysis, as described elsewhere . We found that the two screening assays were complementary: The OKR assay is slower and more labor-intensive, but has single-fish resolution; the OMR assay, on the other hand, is fast, but measures only population responses. For each assay, a behavioral index ranging from 0 (no response) to 1.0 (WT) was calculated (see Materials and Methods). Typical OMR and OKR mutant phenotypes are shown in Figure 1A and 1B.
Mutants detected by at least one of the two assays in the primary screen were kept. To select against phenotypes with general defects, we discarded mutants with overt developmental problems, as well as those that were poor swimmers, with a few exceptions. Putative F2 carriers were mated at least twice more for confirmation of the phenotype in their progeny before they were outcrossed. The OKR screen initially picked up 241 putative mutants, or “putants.” Following two retests, 46 lines (23%) were outcrossed. The OMR screen picked up 361 putants, 34 (9%) of which were confirmed and successfully propagated. In addition to high-contrast stimuli, we also routinely used a lower-contrast grating to detect subtle and/or contrast-specific visual defects. The high percentage of false positives is mostly attributable to the use of these weak test stimuli. The OKR and OMR assays were used independently within the primary screen. A considerable number of OKR mutants were later found to be OMR-deficient, and vice versa, as discussed below (Table 1).
The initial false positive rate of this behavioral screen greatly exceeded that of a morphological screen for small-eye mutants carried out in parallel . However, almost all behavioral mutants were recovered in the following generation. Our strategy of extensive retesting as part of the primary screen therefore dramatically decreased the number of false positives and made this screen practical. Mutants or putative mutants with low penetrance were not kept or are not reported here. The mutants presented in this paper, therefore, were found in about 25% of the population in a clutch. To establish potential complementation groups, we systematically crossed heterozygous carriers of mutants with similar phenotypes. Noncomplementing mutations (in which the transheterozygous progeny showed a mutant phenotype) were considered to be allelic (Table 1).
In addition to OMR and OKR, we also assessed the larvae's visually mediated background adaptation (VBA) at 5 dpf, as a complementary strategy to enrich for visual mutants. The VBA is a neuroendocrine response that is controlled by ambient light levels and appears to depend on the function of retinal ganglion cells (RGCs) . Melanophores in the skin contract their melanin granules in a bright environment, while a dark environment induces melanin dispersal . We tested the VBA only in response to long (over 20 min) exposure to bright light, i.e., the mutants' ability to become pale. Figure 1C shows gradations of the VBA defect in three representative mutants. We found that, of the 89 VBA mutants discovered in the screen, 19 (21%) also had specific OMR or OKR defects. The remaining 70 “dark” mutants were either behaviorally normal or had externally visible, morphological phenotypes and were not always maintained.
To identify defects in motor functions, we systematically tested spontaneous swimming activity (SSA) (Figure 1D) in all our mutants. We also made sure that all mutants listed in Table 1, except s513, showed spontaneous, conjugate eye movements similar to WT when presented with a stationary stimulus. Finally, to identify mutants with developmental defects, we systematically examined their retinal and tectal histology and their retinotectal projections (Table 1).
Because OKR and OMR are both evoked by motion of a large field grating, but differ in their motor output, our collection of mutants presented us with an opportunity to ask how well single-gene mutations can dissociate these two related behaviors. Are there mutations that impair OMR and OKR in a differential manner (weak dissociation) or even disrupt only one of the behaviors, while leaving the other unaffected (strong dissociation)? Table 1 shows that none of our mutants showed a complete absence of either OMR or OKR together with no defect at all in the other behavior. However, the two behaviors were often affected to different degrees. To reveal potential correlations, we plotted the behavioral profiles of our mutant set (Figure 2). Each data point in Figure 2 corresponds to one mutant, measured repeatedly (n > 3 clutches), and was also shaded to represent that mutant's light-exposed VBA score. Although many mutants lacked any visual responses, for those with partial OMR and OKR phenotypes, there was no clear relationship between the magnitudes of the deficit in the two behaviors (correlation coefficient r = 0.4, when mutants with OKR = 0 and OMR = 0 were excluded). Perhaps surprisingly, the severity of the VBA phenotype was not positively related to either OMR (r = −0.5) or OKR (r = −0.4) defects. The overall correlation of all OMR and OKR indices (r = 0.75) and the absence of exclusively OMR- or OKR-specific mutants suggest that these behaviors are weakly dissociable by single-gene mutation. This indicates that OMR and OKR share a major portion of the underlying neural circuitry. In contrast, the VBA appears to employ a dedicated neural pathway largely segregated, and therefore genetically separable, from motion vision.
We discovered seven genes essential for photoreceptor differentiation and/or maintenance (Figures 3 and 4; Table 1). No other phenotypes could be discovered in these mutants, and at least four of them are adult viable. In two mutants (five alleles of wud and yois121), cone photoreceptors are present, but their shapes are shorter and thicker than in WT (see Figure 3). This “stumpy” morphology is not restricted to one particular cone type, as shown by labeling with zpr1, a double-cone-specific marker (Figure 3C and 3D). In five mutants (five alleles of mti, as well as goshs341, pdays351, lims382, and ssds386), all photoreceptors are lost before 6 dpf, except for a small population in the margins of the eye (Figure 4A–4J), where proliferation and differentiation of neuronal precursors continue throughout the life of the fish . This suggests that some of the newborn cells select the photoreceptor fate, but die shortly after beginning differentiation. In mti mutants, degeneration spreads to the outer part of the inner nuclear layers (Figure 4F and 4H). This mutant is also the only one in this class with defective VBA (Figure 4K), as examined further below.
Six of the seven photoreceptor-defective mutants appear normal in their VBA response to light (Figure 4K). This is a curious finding, as it may suggest that classical cone/rod-mediated photoreception is not strictly required for this neuroendocrine response. It is conceivable that the pineal gland, a light-sensing organ in the dorsal forebrain, may control the VBA instead of, or together with, the retina. We therefore asked if presence of the VBA correlated with an intact pineal in our photoreceptor-degeneration mutants. Both VBA-normal and VBA-defective mutants showed a normal pineal, based on expression of shared marker zpr1 (Figure S1). This suggests that none of the mutated genes found here are necessary for the maintenance of the pineal photoreceptors. Moreover, it implies that pineal photoreceptors are not sufficient to control the VBA. This is consistent with the observation that lakritz mutants, which completely lack all RGCs due to mutation in the atonal homolog atoh7 (ath5), but which apparently have a normal pineal gland, show an extreme VBA defect (VBA = 0) . Based on these combined genetic data, we propose that classical cone/rod photoreception is dispensable for this behavior and that other photosensitive cells, situated in the inner retina, signal ambient light levels to the VBA circuitry via the optic nerve.
We identified 11 mutant alleles of nine genes (blds394, dadas503, dlns518, dlns393, edpos371, lajs304, mzrs130, nofs377, snevs102, zats125, and zats376) without detectable anatomical defects (unpublished data), but with complete absence of OKR and OMR (both indices 0.1 or less) (Figure 5; Table 1). The nofs377 mutation is a new allele of the alpha subunit of cone transducin , and the zat gene was shown by positional cloning to encode cone-specific guanylyl cyclase, Gc3 (unpublished data) . Based on these findings, it is likely that some of the other seven genes in this category also encode components of the phototransduction cascade.
Other mutants were found to have variable visual impairments. We speculated that some of these mutants were unable to adjust the gain of their visual responses due to defective light adaptation. We therefore rescreened mutants with partial impairments and normal histology, using a behavioral paradigm previously developed by us to test this process in zebrafish larvae . In brief, initially light-adapted fish were placed in a dark environment for a period of 45 min and then tested for OKR after return to light. The recovery of visual responsiveness following the sudden transition from dark to light served as a convenient surrogate measurement for light adaptation, although we do not know how closely this paradigm mimics adaptation. We identified five mutants (nkis136, utas301, ututs357, ymjs392, and mdrs527) in which the measured light adaptation was severely delayed (example in Figure 6). In addition, another mutant, nbks342, had a chronic impairment of both OKR and OMR, which varied with genetic background and occasionally improved with repeated stimulus presentation (unpublished data). The mutated genes may be components of light-adaptation pathways, either in photoreceptors or in the retinal network.
In WT animals, RGCs project to the contralateral brain and terminate in ten different arborization fields (AFs), of which AF-10, the tectum, is the largest . In our collection of behavioral mutants, we found eight new mutants with specific retinofugal projection deficits (Figure 7): bojs307, darls327, walks536, exas174, misss522, michs314, drgs510, and drgs530, as well as a new allele of bel. In bels385 mutants, RGCs develop normally, but project, in variable proportions, to the ipsilateral side of the brain. The new allele was discovered in the OKR screen, because mutants showed reversed eye movements in response to a drifting grating, as is expected from a predominantly ipsilateral projection [9,27]. The reversed response is seen only when the grating rotates around the mutant, as in the OKR assay, because in this situation the direction of motion is opposite between the two eyes (e.g., temporal-to-nasal for the right eye and nasal-to-temporal for the left eye). In the OMR assay, both eyes are exposed to motion flowing in the same direction. Consequently, the OMR of bel mutants is intact.
The RGC layer of bojs307 mutants is dramatically reduced to about a third of that in WT (Figure 7A and 7B). The optic nerve is thinner, and a variable fraction (up to 50%) of the remaining RGC axons project ipsilaterally (Figure 7C and 7D). Although the axons make this abnormal choice at the midline, they nevertheless show appropriate targeting on the ipsilateral side, innervating the optic tectum as well as the other major AFs. The boj mutation complements mutations in both lakritz (encoding Atoh7/Ath5) and daredevil (encoding an unknown protein) , two previously described genes important for RGC genesis or differentiation. The boj mutants are visually impaired to variable degrees, but most severely in the OMR. Based on our finding that the OMR is normal in bel, the OMR deficit in boj is likely due to the reduced number of RGCs, rather than the ipsilateral projection. Another possible cause could be an as-yet unknown patterning defect in the brain, which is often found in ipsilateral RGC projection mutants .
In darls327 mutants, the ventral branch of the optic tract is completely missing, and with it AF-2, AF-3, and AF-6; the dorsal optic tract (with AF-4, AF-5, AF-7, AF-8, and AF-9) appears intact (Figures 7F and 8). The tectum has normal size and histology, but only its dorsal half is innervated at 7 dpf; the ventral half is devoid of retinal input. We asked if the dorsal RGCs, which project their axons to the ventral branch of the optic tact in WT fish (Figure 8A), are missing in darls327 mutants. We detected differentiated RGCs throughout the retina, including the dorsal part (Figure S2). Axon tracing, following injection of 3,3′-dioctadecyloxacarbocyanine (DiO) and 1,1′-dioctadecyl-3,3,3′,3′- tetramethylindodicarbocyanine (DiD) into the nasal-dorsal and temporal-ventral quadrants of the eye, respectively, revealed that the dorsally located RGCs project into the dorsal, instead of the ventral, branch of the optic tract, sharing the same route as the ventral RGCs (Figure 8B). The absence of both the ventral optic tract and the ventral innervation of the tectum (Figure 8B and 8D) suggests that the darl gene is required for specifying dorsal RGC fate. Positional information along the temporal-nasal axis of the retina seems unaltered in the mutant. Despite the severity of the anatomical defect, this mutant's OMR and OKR scores are not substantially reduced. The VBA, however, is severely disrupted, suggesting that this neuroendocrine behavior requires input from dorsally specified RGCs.
The mutants walks536, exas174, and misss522 show specific axon targeting defects, best seen in, but not restricted to, AF-4. AF-4 is associated with the dorsal branch of the optic tract and normally has a well-ordered, compact structure (see Figure 7E). In walks536 and exas174, AF-4 is overelaborated and located at a greater distance from the optic tract (see Figure 7G and 7H). The tectum in the exas174 mutant shows an abnormal shape, particularly in the ventral-posterior region (Figure S3), and AF-9 is often missing or reduced (unpublished data). In misss522 mutants, on the other hand, AF-4 and AF-9 are reduced in size or undetectable (see Figure 7I). This mutant is completely unresponsive to motion, while the walks536 and exas174 mutants show residual OKR and OMR (Table 1). In all three mutants, AFs associated with the ventral tract appear normal. This observation, together with the finding that OMR and OKR are intact in darls327 mutants, which lack the ventral tract, suggest that one or more AFs in the dorsal tract play a key role in OMR and OKR.
In michs314 mutants, a subset of RGC axons make an abnormal turn shortly after crossing the midline and stall to form an ectopic AF (see Figure 7J). The location of this new retinorecipient area is highly consistent among individual mutants. Another OMR mutant, shirs362, has a severely retarded retinofugal projection at 5 dpf, which recovers by 7 dpf, although the dorsal optic tract remains thinner (Figure S4). Finally, in blins573 mutants, axon arbors in the tectal neuropil are disorganized and, in drg (two alleles), a subset of the RGC axons project to the incorrect layer of the tectum . The axon-targeting phenotypes described here are, for the most part, so subtle and localized that they would have escaped previous lipophilic carbocyanine dye-tracing screens .
Two mutants, ofrts373 and amjs391, show severe VBA defects with only minor OKR and OMR impairments. Strikingly, the VBA of amjs391 is reversed: The mutant turns dark in the light and light in the dark, which is the opposite of what is seen in WT. At what stage the photoresponse is inverted in this mutant will have to be elucidated. In addition, we discovered several mutants with VBA defects, but normal OMR and OKR, which are not included in Table 1.
Two other VBA mutants, dpgs128 and jakos326, showed normal OKR, but were impaired in the OMR. This selective deficit could not be explained by a locomotor problem, as both mutants show normal SSA and are adult viable. Specific deficits such as these may be either due to differential sensitivity to the stimuli presented in the two assays or due to differential effects of the mutation on the underlying neural circuits. Thus, our screen has discovered a small number of mutations that dissociate visual pathways underlying OMR and OKR.
While we did not systematically keep OMR mutants with swimming defects or OKR mutants that did not move their eyes, we saved a small number of mutants whose phenotypes appeared to be informative with regard to specific neural pathways. The morphologically normal beats348, pahs374, slaks564, and flans513 mutants showed reduced OMR and/or OKR in combination with motor abnormalities. The pah gene was positionally cloned and shown to encode phenylalanine hydroxylase, an enzyme required for tyrosine and catecholamine synthesis (unpublished data). These mutations appear to primarily affect motor or other nonsensory central nervous system functions, although additional defects in visual processing may also be present.
In this study, we took a forward genetic approach to identify genes involved in zebrafish visually controlled behaviors. In order to capture a large number of mutants, we screened almost 2,000 F2 families and cast a wide, dense net by screening with three complementary behavioral assays. We report here on the initial characterization of 53 specific mutations in 41 genes, only two of which had previously been described.
Choice of a suitable assay is paramount to the success of any genetic screen. We found that each of the three assays employed had its specific strengths and limitations. The OKR assay requires each fish to be mounted individually, dorsal side up, in methylcellulose and is therefore much more time-consuming than the OMR assay, for which each group of fish can just be poured into an elongated tank. The OKR assay therefore dictated the pace of the screen, and we were thus unable to test as many fish as with the OMR assay (and may therefore have missed some mutants). However, since the OKR assay records fish individually, whereas the OMR assay records a population, the OKR has the potential to find less-penetrant phenotypes than the OMR. In the primary screen, OMR and OKR assays each discovered a largely nonoverlapping set of visual mutants, which, upon retesting, showed defects in either assay. Thus, the high throughput of the OMR assay complemented the specificity of the OKR assay. This tradeoff also applies to genetic linkage mapping, which we have so far completed for 25 of the 41 loci. We found that the OMR is most useful for presorting of mutants, while the OKR is most suitable for the subsequent “weeding-out” of false positives. The VBA response, on the other hand, is extremely effective in sorting mutants for linkage mapping, but is less suited as a primary screening assay, because it is prone to missing important mutant classes. Screening with all three assays increased the likelihood of finding all mutants and often provided independent confirmation of a behavioral phenotype.
We found that at least one-quarter, and probably more than half, of the behavioral mutations discovered here affect photoreception. Their phenotypes include defects in photoreceptor formation or maintenance, phototransduction, and adaptation to sudden light changes (whose likely cellular and molecular substrate is located in the outer retina). Another sizable fraction (at least a quarter) of mutations affect RGCs and their projections to the brain. As far as we can conclude so far from our ongoing analysis, mutations affecting the development of higher visual centers (beyond the retinofugal projections) are largely absent from our collection. This could mean that the genes involved in the formation of circuits in higher brain regions are either essential for embryonic development (i.e., their loss of function would lead to early lethality), or they are redundant, which would prevent their discovery by classical mutagenesis screens.
The number of genomes screened should have been sufficient to uncover at least one mutation in each gene of interest, based on the mutation rate measured in the F0 founder males. However, the empirical allele frequency clearly contradicts this optimistic scenario. Of the 41 loci in our collection, 35 are represented by a single allele and four by two alleles. The other two genes for which we found five alleles each, mti and wud, appear to be outliers. Excluding these two loci, and assuming that the probability of finding a mutation follows a Poisson distribution, the number of genes with no hits is estimated at about 150. This back-of-the-envelope calculation shows that our screen was not saturating, and that many more genes may be discovered using our approach. Potential obstacles to future screens include the intrinsic difficulty of detecting mutants in behavior, as opposed to, say, pigmentation (which was used to measure the mutation rate), and the low mutability of some loci, as has been observed in other large-scale zebrafish screens [31,32].
Satisfyingly, we discovered new alleles of several previously identified genes. These include mutants falling within the limits of our screening criteria, such as bel and nof (Table 1), as well as others with more severe phenotypes, such as chk , bru [21,22], ome, and nok (unpublished data). It is possible that some of our mutations have generated weak (or maternally rescued) alleles of housekeeping or other essential genes, although the molecular identification of the first set of genes shows that this is not generally the case. For a precise estimate of the number of genes whose mutations lead to specific, nonlethal visual system phenotypes, a much larger screen will have to be carried out.
Zebrafish fill an important niche for the genetic study of photoreception. Human pattern vision, like that of zebrafish, is largely cone-driven. Because most genetic work has been done on the rod-dominated retinas of rodents, less is known about phototransduction in cones. Here we have already discovered two mutant alleles of zatoichi (zats125 and zats376), the gene for cone-specific guanylyl cyclase (Gc3), as well as a new allele of nof, which encodes the alpha subunit of cone transducin . It is likely that there are additional mutants in phototransduction in our collection, and it will be interesting to study their genetic interactions. Zebrafish are appealing for this work, because all their cone opsin genes have been identified , and their photoreceptors are amenable for biochemical and psychophysical studies .
The visual system operates over a wide range of luminance intensities by adjusting its sensitivity to ambient light levels. At least two adaptation mechanisms are operational in the vertebrate retina, one acting on the phototransduction cascade itself [36–38] and the other on synaptic strengths within the network of neurons . We have discovered five mutants that exhibit delayed recovery of the OKR following a sudden transition from dark to light. These mutants are otherwise normal and adult viable. We speculate that these mutants have defects in light adaptation, although further analyses, such as electroretinogram recordings, will be needed to define and localize the underlying defect. The mutations identified here should provide novel entry points into a molecular dissection of light adaptation.
We identified five genes whose mutations result in loss of photoreceptors. Several processes can lead to retinitis pigmentosa or macular degeneration in mammals, including structural defects of outer segments, excessive light illumination, and genetic disruption of the phototransduction cascade, but the molecular mechanisms of cell death induction are largely unknown . Photoreceptors are lost quickly in our zebrafish mutants (over days), in contrast to rodent models of retinal degeneration, in which the same process takes months . This is advantageous for the screening of therapeutic drugs that block photoreceptor degeneration. Tests of pharmacological rescue could be carried out in conjunction with our high-throughput behavioral assays. Our collection of zebrafish mutants with rapidly degenerating cones provides us with novel tools to examine the molecular mechanisms of macular degeneration in a model system that is not only genetically tractable, but amenable to small-molecule screens .
Our screen successfully identified a small assortment of specific axon-guidance mutants. These mutants will serve as starting points for the discovery of proteins involved in axon targeting and synaptic specificity in the visual pathway. But their phenotypes are also significant for assigning function to certain pathways in the zebrafish visual system . While most RGCs project to the midbrain tectum, nine smaller areas, or AFs, also receive direct retinal input . Different AFs are innervated by molecularly and spatially distinct subpopulations of RGCs and probably mediate different visual behaviors. Laser ablations have shown that the tectum is required for localization of prey , but is dispensable for OMR, OKR, and VBA . An intact AF-7 is also not necessary for OMR or OKR . Some of the new mutants now help us narrow down the optomotor pathway further by providing “lesions” that are impossible to obtain using surgical, pharmacological, or optical ablation techniques. For instance, in the OMR-deficient misss522 mutant, AF-4 and AF-9 are reduced. This suggests, but does not prove, that one of these underdeveloped AFs is necessary for the OMR. Conversely, darls327 mutants lack AF-2, AF-3, and AF-6, but have an intact OMR, indicating that these three AFs are dispensable for this behavior. Based on these phenotypes, we predict that either AF-4 or AF-9 (or both) are required for the OMR.
Systematic forward genetic approaches have been applied with great success to many areas of biology in a variety of model species. Mutants are not only starting points for gene discovery; their phenotypes often elucidate underlying biological mechanisms even before molecular identification of the mutated genes (e.g., ). Our behavioral screen focusing on the zebrafish visual system has achieved three major goals. First, the mutant phenotypes found here have revealed novel genes, or new functions for known genes, which can be identified by positional cloning. Second, these mutations provide novel tools to study central nervous system development and behavior, to localize functions in the brain and to explore the ways in which neuronal circuits reorganize in response to genetic perturbations. Third, our unbiased screen is yielding fundamental insight into the genetic architecture of brain functions and their pathologies. A mutational approach to circuit formation and function, while being an essential first step, should be complemented in the future by targeted manipulations of cells and synapses. Zebrafish are slated to become an excellent system for an integrated genetic approach to unravel cellular and molecular mechanisms of behavior.
We used fish from the TL strain for mutagenesis and crossed them to fish from the WIK strain for linkage mapping (see below). Embryos and larval fish were kept in E3 solution (egg water): 5 mM NaCl, 0.17 mM KCl, 0.33 mM CaCl2, and 0.33 mM MgSO4 supplemented with 1:107 w/v methylene blue. Mutations in the zebrafish genome were induced in the spermatogonia of 41 founder males (F0) by three to five treatments with ENU (3 mM for 1 h each, at weekly intervals) and bred to homozygosity over two generations, as previously described [31, 32]. Details of the screen statistics and the specific-locus test used to measure the mutation rate are given in Results.
We used microsatellite-based linkage mapping methods to locate the mutation in the zebrafish genome . Heterozygous carriers of the mutation (in the TL background) were crossed to the highly polymorphic WIK strain. Carrier pairs were identified from this hybrid progeny and mated repeatedly. Clutches were sorted for mutants and nonmutant siblings using behavioral assays (often a combination of OMR to quickly enrich for mutants, followed by OKR of the enriched population for unambiguous identification of mutants). Bulk-segregant analysis was performed using pooled DNA from siblings and mutants. This method involves PCR with a set of 192 polymorphic simple-sequence repeat markers (oligonucleotide primers targeted to unique sequences flanking dinucleotide repeats of variable length ). The markers were selected to cover the entire zebrafish genome (25 linkage groups) at roughly even intervals (K. F.-B., unpublished data). Candidate markers showing co-segregation with the mutant pool were confirmed by PCR of single-fish DNA. Map position was further verified by demonstration of linkage to additional markers located in the presumed chromosomal region.
We completed classical complementation crosses among all mutants with similar phenotypes (Table 1) or with reported mutants with similar phenotypes or similar map position (if available). Heterozygous nof carriers were obtained from S. Brockerhoff (University of Washington). Heterozygous bel carriers were obtained from C. B. Chien (University of Utah). Complementation tests for nok were carried out by S. Horne (UCSF). Complementation tests for bru were carried out by J. Malicki (Harvard).
Fish were kept on the fluorescent illuminator (950 cd/m2) for at least 20 min to light-adapt. The pigmentation of the fish was visually scored in four grades to determine the VBA score, with 1 = normal (WT), 0.7 = slightly dark, 0.3 = intermediate dark, and 0 = strongly dark. In this scoring system, the previously discovered, RGC-deficient lakritz mutant scored 0 and served as a reference to calibrate the index. The VBA score for variably dark mutants was estimated by averaging over at least ten individuals.
The OMR assay was conducted as described previously . Visual stimuli were displayed on a flat-screen CRT monitor that faced upward. The stimuli, which consisted of moving sinusoidal gratings, were generated in MATLAB (MathWorks, Natick, Massachusetts, United States), using the Psychophysics Toolbox extensions (http://psychtoolbox.org). The gamma function of the CRT was measured using a Minolta LS-100 (Tokyo, Japan) light meter, and corrected using MATLAB. The images of the fish before and after each stimulus were captured by a digital still camera (Nikon CoolPix [Tokyo, Japan]), which was triggered by MATLAB using a set of serial commands. These images were downloaded from the camera offline and analyzed using custom macros in Object-Image (http://simon.bio.uva.nl/object-image.html). Ten to 40 larvae (routinely 25) were placed in custom-built acrylic tanks, or “racetracks,” which allowed the larvae to swim in only two directions. Twelve racetracks were placed side by side on the monitor. After subtracting two consecutive images to remove the background, the position of each fish was determined by using the Analyze Particles function of Object-Image. The average position of the fish in each tank before a stimulus was then subtracted from the average position after 30 s of exposure to a standard motion stimulus. The OMR index of a recessive mutant was calculated for stimuli of 100% and 75% contrast by measuring the average distance swum by the 25% weakest responders in a clutch, divided by the distance swum by the 75% best responders. Each stimulus contrast and stimulus direction were repeated four times and the average OMR score was calculated offline.
The OKR assay was conducted as described previously . An animation of sine-wave gratings was projected on the internal wall of a drum (height, 6 cm; inner diameter, 5.6 cm), using an LCD projector (InFocus LP755 [Wilsonville, Oregon, United States]) . To focus the image at close distance, a wide-angle conversion lens (Kenko VC-050Hi [Tokyo, Japan]), a close-up lens (King CU+1 [Tokyo, Japan]), and a neutral density filter (Hoya ND4 [Tokyo, Japan]) were placed in front of the projector. Twelve zebrafish larvae were immobilized in 2.5% methylcellulose in E3 egg water with their dorsal sides up in the inverted lid of a 3.5-cm diameter petri dish and placed into the center of the drum. The fish were imaged using a dissecting microscope (Nikon SMZ-800) and a CCD camera (Cohu MOD8215–1300 [Tokyo, Japan]) to observe horizontal eye movements. Sinewave gratings with a spatial frequency of 20° per cycle moving at 10°/s were used. Image-J (http://www.rsb.info.nih.gov/ij/) was used for both stimulus generation and image analysis. Images were captured via an LG-3 video capture board (Scion; http://www.scioncorp.com) at two frames per second with Scion Java Package 1.0 for Image-J Windows. A custom-programmed Image-J plug-in (A. M., unpublished data) was used to calculate the changes in eye angles. The OKR index of a mutant was defined here as the saccade number per minute divided by the saccade number per minute observed in WT.
The dynamics of OKR in response to sudden changes in illumination was measured as described previously . Fish larvae were put in the dark for 45 min to let them dark-adapt, then subjected to the OKR recording at 2, 8, 15, and 30 min after return to a bright environment (2,400 cd/m2 underneath the larvae; 400–600 cd/m2 at the internal drum wall, where the visual stimulus was projected).
Spontaneous swimming activity was measured as described . Larvae at 7 dpf were tested in groups of six fish in a rectangular compartment (3 cm × 7.5 cm) of a four-well, clear acrylic plate (12.8 cm × 7.7 cm [Nunc, Roskilde, Denmark]). Fish images were captured by a digital camcorder (Sony TRV-9 [San Diego, California, United States]) at a rate of 0.5 Hz for 20 min in Adobe Premiere. Recorded movies were analyzed using Image-J. Each frame was subtracted (pixel by pixel) from the previous frame to extract the fish that moved during the inter-frame interval. Spontaneous activity was quantified by counting the number of moving fish across all frames. The SSA index was calculated by dividing the number of movement episodes seen in mutants by that seen in WT siblings.
Zebrafish larvae were fixed in 4% paraformaldehyde in PBS at 4 °C for 2–16 h, transferred to 30% sucrose in PBS plus 0.02% NaN3 for 16 h or more, mounted in O. C. T. Compound (Sakura Finetek USA, Torrance, California, United States), frozen, and sectioned at 10–12 μm. In some cases, after fixation, the sample was dehydrated in an ethanol series followed by xylene, embedded in paraffin, and sectioned at 6 μm. For immunohistochemistry, the section was incubated with primary antibodies, fluorescent dye-conjugated secondary antibodies (Molecular Probes, Eugene, Oregon, United States), counterstained with 4′,6-diamidino-2-phenylindole (DAPI), and mounted with Fluoromount-G (Southern Biotechnology Associates, Birmingham, Alabama, United States).
Zebrafish larvae were fixed in 4% paraformaldehyde in half-strength PBS at 4 °C overnight. The fish eye was injected with 1% 1,1′-dioctadecyl-3,3,3′,3′- tetramethylindocarbocyanine (DiI), DiD, or DiO dissolved in chloroform . Fluorescent images were observed with a confocal laser-scanning microscope (BioRad MRC 1024 [Hercules, California, United States] or Zeiss LSM [Oberkochen, Germany]).
Coronal sections of the forebrain at 7 dpf were stained with DAPI (A, C, E, and G) and zpr1, a marker of both retinal and pineal photoreceptors (B, D, F, and H). Pineal photoreceptors (arrow and inset) were consistently present in mutants in which retinal photoreceptors were depleted (D, F, and H). Scale bar is 100 μm for A–J and 25 μm for the insets.
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Sagittal sections of WT (A and C) and darls327 retina (B and D) were stained with DAPI (A and B) and zn5 (C and D), a marker for differentiated RGCs. RGCs are present in the dorsal part of the retina and sending out axons into the optic nerve head in the mutant. The mutant eyes are reduced in size compared to WT.
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RGC axon tracing, following whole-eye DiI fills at 7 dpf, reveals a subtle extension of the tectal neuropil (delineated by DAPI counterstaining) at the ventral-posterior margin (arrow). Scale bar is 50 μm
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Lateral views of the retinal ganglion cell axons labeled with DiO. Anterior to the left, dorsal to the top.
(A and B) At 7 dpf, the retinofugal projection in shirs362 (B) appears similar to WT (A), although the anterior portion may be less dense (arrow).
(C and D) At 5 dpf, RGC axon outgrowth in shirs362 (D) evidently lags behind WT (C). Scale bar is 100 μm.
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The movie shows a close-up of part of a racetrack tank during OMR testing. A visible light filter has been used to remove the stimulus, and the fish are visualized using infrared light (Sony TRV-9 video camera, night vision mode). The stimulus is represented below. Initially, a converging grating brings the fish into the field of view. After 8 s, the stimulus changes to a rightward-moving grating, and all the fish swim to the right, out of the field of view. At 18 s, the converging movie reappears, and the fish return. Playback in Quicktime runs at twice the actual speed.
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The WT larva is on the left, and a zats125 mutant is on the right. For the first 60 s no stimulus is shown, and both fish show spontaneous eye movements. After 60 s, a clockwise-rotating striped pattern is projected on the drum around the fish. The WT fish responds by tracking the pattern slowly to the right and making fast reset saccades to the left. The mutant continues to make undirected spontaneous eye movements.
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The GenBank (http://www.ncbi.nlm.nih.gov/) accession numbers of the Danio rerio genes discussed in this paper are retinal guanylyl cyclase 3 (gc3) (AY050505) and phenylalanine hydroxylase (pah) (BC056537).
We thank D. Stainier and S. Baraban, and their labs for collaboration in the screen, in particular L. D'Amico, B. Jungblut, I. Scott, D. Beis, P. Castro, and S. Jin. In addition, S. Brockerhoff, C. B. Chien, S. Horne, and J. Malicki kindly provided mutant carriers for complementation tests. We are grateful to W. Harris, P. Goldsmith, T. Roeser, and M. Taylor for advice and support and to K. Deere, A. Mrejeru, E. Janss, K. Menuz, B. Bogert, H. Haeberle, B. Griffin, M. Dimapasoc, and K. Takahashi for their assistance at various stages of the project. Doctoral and postdoctoral fellowship support came from Naito Foundation (AM), Uehara Memorial Foundation (AM), Howard Hughes Medical Institute (MBO), National Science Foundation (MCS, JNK, LMN), a National Research Service Award from the National Institutes of Health (NIH) (EG), American Heart Association (MCS), University of California, San Francisco Chancellor's Fund (MCS), an Achievement Reward for College Scientist/ARCS (AMW), American Association of University Women Educational Foundation (AMW), National Alliance for Research on Schizophrenia and Depression (PSPM), and an NIH neuroscience postdoctoral training grant (TX). HB was supported by the NIH (EY12406, EY13855, NS42328), by the Sandler Family, by the Sloan Foundation, by the Klingenstein Foundation, and by the David and Lucile Packard Foundation.
Author contributions. HB conceived the project. AM, MBO, and HB designed the experiments. AM, MBO, AMW, MCS, JNK, PSPM, EG, TX, LMN, NJG, WS, KFB, and HB performed the experiments. AM, MBO, JNK, and HB analyzed the data. AM, MBO, MCS, PSPM, KFB, and HB contributed reagents/materials/analysis tools. AM and HB wrote the paper with input from all authors.
Figure 1. Behavioral Screening Assays
(A) OMR. WT larvae in the racetrack reflexively swim in the same direction as a moving stimulus (top). Mutant larvae (for example, dlns393) with an OMR index of 0 fail to respond (bottom). A contrast-enhanced image outlining the fish is shown in the lower image. In this experiment, WT fish larvae were driven all the way to the right end of the racetrack, which differs slightly from our screening assay .
(B) OKR. Eye positions (angles shown by white arrows, far left image) were plotted over time during optokinetic stimulation in one direction. The OKR has a sawtooth profile, consisting of alternating quick and slow phases. OKR mutants show slowed eye movements (for example, nebos342), absence of the OKR (lims382), or no eye movements (flans513). Corresponding OKR indices are given in parentheses.
(C) VBA. WT (VBA index = 1) shows fully contracted melanophores in bright illumination. Mutants (edpos371, ymjs392, and amjs391) show three gradations of darker pigmentation, due to enhanced melanin dispersal. Scale bar is 1 mm.
(D) SSA. Movies of six fish per rectangular well, taken at 0.5 frame per second for 20 min, were subtracted frame by frame and projected into a single image to show the locomotor behavior over time. Blind mutants, such as mtis113 (OKR and OMR indices = 0), may show normal spontaneous activity (SSA index = 1). The mti mutants are also darker (VBA = 0.3), resulting in a higher-contrast image than WT. The walks536 mutants (OKR = 0.8; OMR = 0) show less activity, with some circling (SSA = 0.7), which could explain part of their OMR defect. In beats348 mutants, locomotion is severely compromised (SSA = 0.1). SSA-defective mutants were not systematically kept.
Figure 2. Distribution of Behavioral Phenotypes among the Three Visual Responses
OMR index is plotted over OKR index for each mutant. Each circle represents a mutant. The shading of the circles represents the VBA index for that mutant. Only mutants with SSA index greater than 0.6 are shown. OMR is strongly correlated with OKR only for very low scores (around 0). Mildly impaired mutants are often differentially affected. OMR and OKR performance is not correlated to VBA index.
Figure 3. Example of a Mutant with Abnormal Morphology of Cone Photoreceptors
Photoreceptors in a retinal section stained with DAPI (A and B) and a marker for double cones, zpr1 (C and D) at 7 dpf in WT larva (A, C, and E) and yois121 mutant retina (B, D, and F). Merged images of DAPI (in green) and zpr1 (in magenta) are also shown (E and F). Both zpr1-positive and zpr1-negative cone photoreceptors in the mutant are “stumpy” when compared to those in the control retina (arrows). B, bipolar cells; C, cone photoreceptor cells; H, horizontal cells; ONL, outer nuclear layer; OPL, outer plexiform layer. Scale bar is 10 μm.
Figure 4. Examples of Mutants with Photoreceptor Degeneration
(A–J) WT and mutant retinas (A–H, mtis113; I and J, ssds386) were sectioned and stained with DAPI (A, B, E, F, and I) and zpr1 monoclonal antibody (double-cone photoreceptor marker) (C, D, G, H, and J). At 7 dpf, photoreceptors in the central part of the retina have degenerated in both mti (A–D) and ssd (I–J). In the mti retina at 14 dpf, degeneration has spread to the inner nuclear layer (INL). Arrows show the ciliary marginal zone, from which new cells are continually added to the growing retina. Scale bar is 100 μm.
Figure 5. Example of an OKR Mutant with Normal Morphology
(A) WT sibling and zats125 mutants are indistinguishable in their appearance (shown here at 6 dpf).
(B) The mutant showed no OKR, but saccadic eye movements, which were not correlated to the motion stimulus. The zat gene encodes cone-specific Gc3.
Figure 6. Example of a Mutant with a Potential Defect in Light Adaptation
OKR is plotted at several time points before and after dark treatment for 45 min. WT sibling larvae (n = 6) recover quickly from the dark pulse, while nkis136 mutants (n = 6) show reduced responsiveness for several minutes after return to the light. Average number of saccades to a constant motion stimulus is shown for each time point. Error bars indicate standard deviation.
Figure 7. Examples of Retinofugal Projection Mutants
(A and B) Sections of WT and bojs307 retina stained with DAPI. The mutant retina has a thinner RGC layer (arrow).
(C and D) Dorsal views of RGC axons from the right eye of a WT and a bojs307 mutant labeled with DiO, showing mutant axons in the ipsilateral tectum (arrow). To show that there is no ipsilateral projection in WT, the image is overexposed.
(E–J) Lateral views of RGC axons labeled with DiO after removal of the eye. Anterior is to the left, dorsal to the top. In WT, the tectum and other retinorecipient areas are clearly visible (E). The arrow indicates AF-4. In darls327, the ventral branch of the optic tract is missing (arrow), and only dorsal tectum is innervated (F). In walks536, innervation of AF-4 (arrow) is disorderly (G). In exas174, the posterior tectum (arrow) appears to be incompletely innervated, while AF-4 is larger than in WT (H). In misss522, AF-4 (arrow) is reduced in size (I). In michs314, there is an ectopic arborization (arrow) at the root of the optic tract (J). Scale bars are 100 μm.
Figure 8. The darl Mutant Shows Retinotectal Mapping Deficits
(A and B) The nasal-dorsal quadrant of the retina was labeled with DiO (green), and the temporal-ventral quadrant was labeled with DiD (magenta). In darls327, the ventral branch of the optic tract is missing (arrow). Scale bar is 100 μm.
(C and D) Dorsal view of the tectum in the same larvae as in A and B. The ventral half of the darls327 tectum is not innervated by the dorsal-nasal RGC axons. Anterior is to the left and ventral is to the bottom. Tectal neuropil is demarcated by the dotted line, based on DAPI counterstaining (blue). Scale bar is 50 μm.
Table 1. Zebrafish Visual Behavior Mutantsa | <urn:uuid:85a322a7-e5aa-4ebd-9d76-e695da9a2b55> | {
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if any body wants answres plz kieep message here chose the best single answer part-1 1. Central (primary) lymphoid organs a. are efficient in exposing T cells to foreign antigen. b. are the primary site of antibody synthesis and release. c. filter blood and trap blood-borne antigens. d. provide the microenvironment for maturation of T and B cells. e. line the mucosal surfaces of the body for efficient antigen contact. 2. Hematopoietic stem cells are pluripotent, which means that they are a. antigen-specific cells. b. capable of developing into any blood cells. c. committed to produce cells of a single lineage. d. not self-renewing. e. T and B lymphocytes of many different antigen specificities. 3. Lymphocytes continually recirculate through peripheral lymphoid tissue in order to a. be killed before they cause autoimmunity. b. efficiently encounter antigen. c. mature from stem cells into lymphocytes. d. phagocytose antigen and kill it. e. go where no cell has gone before. 4. Peripheral lymphoid organs a. are centrally located in the abdomen to protect their vital functions. b. are designed to maximize contact between antigen and lymphocytes. c. produce antigen-specific lymphocytes from stem cells in response to antigen. d. sequester antigen to minimize its damage to the body. e. store large numbers of activated effector cells for a rapid response to antigen. 5. The PRIMARY purpose of the adaptive immune system is to a. block all pathogens from entering the body. b. cure allergic reactions. c. kill tumor cells. d. protect from disease upon re-infection with a specific pathogen. e. reject foreign transplants. 6. Rapid but non-antigen specific immune responses are produced by the a. adaptive immune system. b. innate immune system. c. leukocytes. d. lymphatic system. e. memory response. 7. Vaccination protects us from infectious disease by generating memory a. antigen. b. lymphocytes. c. macrophages. d. PMNs. e. stem cells. 8. Which situation below describes an example of innate immunity? a. antibody production by plasma cells. b. antigen removal by cilia in the respiratory tract. c. complement activation by antibody bound to the surface of a bacterium. d. memory response to influenza virus e. recognition and killing of virus-infected cells by cytotoxic T cells. 9. The antigen specificity of an adaptive immune response is due to a. activation of antigen-specific lymphocytes. b. folding of antibody to fit the pathogen. c. lysis of only certain pathogens by neutrophils. d. phagocytosis of only certain pathogens by macrophages. e. production of cytokines by antigen-specific macrophages 10. Clonal selection a. begins with inflammation. b. occurs for all leukocytes. c. occurs in response to self antigens. d. results in innate immunity. e. results in proliferation of antigen-specific lymphocytes. 11. Cytokines are NOT a. able to induce increased blood vessel permeability. b. antigen-specific. c. made in response to bacterial antigens. d. signals from one cell that affects the behavior of another cell. e. secreted by macrophages. 12. A fundamental difference between the antigen receptors on B cells (BCR) and on T cells (TCR) is their a. different requirements for antigen presentation. b. function following antigen binding. c. heterogeneity from one lymphocyte to the next. d. heterogeneity on each lymphocyte. e. membrane location. 13. Genes for immunoglobulins (antibodies) are unlike other human genes in that a. antibody genes are composed of introns and exons. b. DNA for antibody molecules is inherited from only one parent. c. gene segments must be spliced together to make each unique antibody molecule. d. several exons encode each antibody molecule. e. none of the above is true. 14. Humoral immunity can be acquired passively by a. catching a virus from a friend by shaking hands. b. receiving a vaccine of influenza virus grown in eggs. c. receiving serum from someone who has recovered from an infection. d. receiving leukocytes from an immune family member. e. sharing a soda with someone who has a cold. 15. Inflammation does NOT involve a. cytokine production by macrophages. b. migration of leukocytes out of the circulation. c. pain. d. secretion of antibodies. e. swelling at the site of infection. 16. Innate immune responses are most effective against a. antigens resembling self antigens. b. common antigens on bacteria. c. genetically engineered antigens. d. viruses. e. viruses that have previously caused infection. 17. Lymphocytes acquire their antigen specificity a. as they enter the tissues from the circulation. b. before they encounter antigen. c. depending on which antigens are present. d. from contact with self antigen. e. in the secondary lymphoid organs. 18. A secondary immune response is NOT a. faster than a primary response. b. larger than a primary response. c. longer lasting than a primary response. d. more likely to result in increased adaptive immunity than a primary response. e. preceded by a longer lag period than a primary response. 19. Antibody effector functions include all of the following EXCEPT a. activating complement on bacterial surfaces to promote phagocytosis by neutrophils. b. binding extracellular viruses to block their entry into host cells. c. binding intracellular viruses to initiate cytotoxicity. d. blocking uptake of bacterial toxins by host cells. e. coating bacteria to promote their phagocytosis by neutrophils. 20. Effector functions of complement include all of the following EXCEPT a. attracting phagocytes to the site of infection. b. facilitating phagocytosis of complement-coated bacteria. c. increasing blood vessel permeability to plasma proteins. d. lysing bacterial cells. e. presenting antigen to B cells. 21. Jenner observed that milkmaids who were infected with cowpox were later immune to smallpox infections. This is an example of a(n) a. acquired immunity of barrier skin cells. b. active immunization with a non-related organism that causes similar symptoms. c. innate immunity of milkmaids to smallpox. d. memory response to a cross-reactive antigen. e. passive immunization from contact with cow's milk antibodies. 22. Macrophages generally kill the bacteria they phagocytose by fusing lysosomes containing digestive enzymes with the phagocytic vesicle. In the case of pathogens which block this fusion, pathogen killing can still be achieved through the effector function of a. B cells. b. complement. c. cytotoxic T cells. d. opsonizing antibody. e. Th1 cells. 23. Phagocytosis a. can be stimulated by antigen binding to complement or antibody. b. is an antigen-specific process. c. must be preceded by antigen processing. d. rids the body of virus-infected cells. e. only occurs after plasma cells begin secreting antibody. 24. Several friends who went on a picnic together developed vomiting and diarrhea from eating potato salad contaminated with Staphylococcus aureus enterotoxin. Effects of the toxin could best be counteracted by a. antibody binding and neutralization of the toxin. b. antibody opsonization and phagocytosis of S. aureus. c. antibody opsonization and phagocytosis of the toxin. d. B cell binding to S. aureus. e. cytotoxic T cell binding and lysis of S. aureus. 25. Which of the following statements is FALSE? a. An example of passive humoral immunity is treatment with horse anti-snake venin. b. Antigen recognized by helper T cells must be associated with Class II MHC molecules on the surface of professional APC . c. Each lymphocyte has many antigen binding receptors, each receptor capable of binding the same antigen. d. Recognition and killing of virus-infected cells by cytotoxic T cells is an example of adaptive immunity. e. The innate immune system does not deal with endogenous antigen. part-2 1. The ability of an antigen to induce an immune response does NOT depend on the antigen's a. ability to enter the thyroid. b. degree of aggregation. c. dose. d. size. e. usual presence in the body. 2. Alum is an effective adjuvant because it a. disaggregates the antigen. b. is immunogenic for stem cells c. is immunogenic for T cells. d. slows the release of antigen. e. transports antigen into the cytoplasm of antigen-presenting cells. 3. Antibody cross-reactivity is demonstrated by antibody binding to a. a cell surface marker. b. a hapten. c. a hapten-carrier complex. d. an antigen that is structurally similar to the immunogen e. the immunogen. 4. The antibiotic penicillin is a small molecule that does not induce antibody formation. However, penicillin binds to serum proteins and forms a complex that in some people induces antibody formation resulting in an allergic reaction. Penicillin is therefore a. an antigen. b. a hapten. c. an immunogen. d. both an antigen and a hapten. e. both an antigen and an immunogen. 5. Antigen entering the body in a subcutaneous injection activates its specific lymphocytes in the a. blood circulation. b. draining lymph nodes. c. MALT. d. skin. e. spleen. 6. To detect a humoral immune response to influenza virus, you would measure a. cytotoxicity of virus-infected cells in the lung. b. cytotoxicity of virus-infected cells in tissue culture. c. dividing T cells in the draining lymph nodes. d. plasma cytokine levels. e. serum antibody titer. 7. During the lag period between antigen contact and detection of adaptive immunity, a. antigen is hidden from the immune system in macrophages. b. cellular immunity can be detected but antibodies cannot. c. innate immune effectors are eliminating antigen. d. innate immunity blocks the activation of adaptive immune effector cells. e. new B and T cells with the appropriate antigen specificity must be produced in the bone marrow. 8. To elicit the best antibodies to mouse MHC I, you should inject it into a. a goat. b. a mouse of the same genetic background (strain). c. a mouse of a different strain. d. a rat. e. the mouse you isolated it from. 9. For specific antigen recognition by T cells, a. antigen is bound by a T cell membrane antibody. b. denaturation of antigen does not reduce epitope recognition. c. MHC molecules are not required. d. soluble antigen is bound directly without processing. e. antigen exposure during T cell maturation is required. 10. The immune response to a booster vaccine is called a(n) a. cellular response. b. humoral response. c. innate response. d. primary response. e. secondary response. 11. Immunogenicity a. depends on the ability of the native antigen to be presented by MHC. b. is usually a property of "self" antigens such as eye tissue. c. is not a property of antibodies. d. is not a property of haptens. e. only applies to antigens that are composed of proteins. 12. Lymphocytes are activated by antigen in the a. blood stream. b. bone marrow. c. liver. d. lymph nodes. e. skin. 13. A molecule that can be covalently linked to a non-immunogenic antigen to make it an immunogen is called a(n) a. adjuvant. b. carrier. c. hapten. d. mitogen. e. superantigen. 14. A polyclonal antibody response a. is not antigen-specific. b. is produced only in response to polymeric antigens. c. is produced by several B cells recognizing different epitopes on the same antigen. d. occurs during the lag phase of the immune response. e. violates clonal selection. 15. Very low doses of antigen may induce a. a secondary response. b. hypersensitivity. c. immunological ignorance. d. low zone tolerance. e. low zone immunity. 16. A virus vaccine that can activate cytotoxic T cells MUST contain a. a high dose of virus particles. b. an adjuvant to stimulate T cell division. c. foreign MHC. d. live virus. e. virus peptides. 17. Which statement about antigen epitopes is FALSE? a. An epitope may be shared by two different antigens. b. A protein molecule usually contains multiple epitopes. c. B cells bind only processed antigen epitopes. d. Epitopes may be linear or assembled. e. Some epitopes are more immunogenic than others 18. CD antigens a. allow leukocytes to recognize antigen. b. are each expressed on only one cell type. c. are expressed on immune cells by immunologists to "mark" them for separation. d. are found only on leukocytes. e. function as receptors for cytokine and CAMs. 19. A patient desperately needs a bone marrow transplant, and a perfect match cannot be found. The rejection response in unmatched marrow is primarily due to the presence of mature T cells that recognize the recipient's cells as foreign. To minimize this rejection response, the marrow can be treated before transfusion into the recipient with complement plus antibody to human a. CD3. b. CD4. c. CD8. d. CD28. e. CD154. 20. Antibody to membrane receptors sometimes inhibits receptor function and sometimes mimics the action of the normal receptor ligand. (For example, some antibodies to insulin receptor block the action of insulin and some mimic the action of insulin.) An antibody which should NOT either block or stimulate B cell function would be anti- a. CD21. b. CD56. c. CD80. d. Iga. e. m chain. part-3 1. Cytokines may exhibit __________ action, signaling the cells that produce them. a. antagonistic b. autocrine c. endocrine d. paracrine. e. synergistic 2. Cytokines are NOT a. antigen specific. b. capable of activating more than one cell type. c. made by lymphocytes. d. small protein molecules. e. synthesized de novo in response to antigen or other cytokines. 3. Several cytokines may have the same effect on the cells they bind. This is an example of a. a cascade. b. antagonism. c. pleiotropism. d. redundancy. e. synergy. 4. Characterization of cytokine activities is NOT made more difficult by their a. gene structure. b. pleiotropism. c. redundancy. d. secretion close to target cell membranes. e. short half-lives. 5. Interferons a. activate B cells to make virus-specific antibodies. b. are Th2 cytokines. c. are virus proteins that interfere with activation of cytotoxic T cells. d. block virus infection of host cells. e. inhibit virus replication by infected cells. 6. A cytokine can do all of the following EXCEPT a. bind to receptors which do not share cytokine-binding subunits. b. bind to its specific receptor on the same cell that produced it. c. bind to receptor antagonists produced by pathogenic viruses. d. compete with other cytokines whose receptors share signal-transducing subunits e. upregulate (increase) synthesis of high affinity subunits for its receptor. 7. Members of a cytokine receptor family a. all bind the same cytokines. b. are grouped together because they share antigen specificity c. are often found on the same cells d. are similar in protein structure and sometimes in regions of amino acid sequence. e. are specific for cytokines produced by a single cell type 8. The ability of a cytokine to change gene expression in the target cell is influenced by all of the following EXCEPT a. presence of high-affinity receptors on the target cell. b. presence of soluble cytokine receptors. c. proximity of the producing and target cells. d. rate of transport of cytokine-receptor complexes into the cytoplasm. e. simultaneous production of another cytokine whose receptor uses the same signal transducing subunit. 9. Cytokines are NOT a. able to inhibit the function of other cytokines. b. able to stimulate the synthesis of other cytokines. c. produced by more than one cell type. d. small protein molecules. e. stored in the cell for quick release. 10. The IL-2R subfamily consists of receptors for IL-2, IL-4, IL-7, IL-9, and IL-15. This group of cytokine receptors a. bind all five cytokines to promote synergistic action on target cells. b. bind cytokines which are produced by the same cell. c. each has a unique high affinity cytokine-specific a chain. d. shift the immune response towards cellular immunity. e. each has a unique signal-transducing g chain. 11. An antagonist for cytokine X may NOT be a. cytokine A competing for a shared receptor subunit. b. cytokine B which acts synergistically with cytokine X. c. cytokine C which inhibits the activation of the cell that produces cytokine X. d. made by microorganisms. e. soluble cytokine X receptors. 12. A knock-out mouse for a particular cytokine allows immunologists to characterize cytokine function a. by doing a dose-response study with competing cytokines. b. in the absence of all other cytokines. c. on all cell types simultaneously. d. under controlled conditions of local cytokine concentrations. e. with defined cell populations. 13. Activated Tc can regulate immune responses by signaling activated lymphocytes to undergo a. apoptosis. b. clonal deletion. c. clonal proliferation. d. cytotoxicity. e. somatic hypermutation. part-4 1. Complement a. is a group of active proteolytic enzymes found in serum. b. is secreted by macrophages and hepatocytes in response to antigen binding. c. participates in both innate and adaptive immune responses. d. prevents lysis of virus-infected cells. e. All of the above statements about complement are true. 2. Complement is involved in all of the following except a. attraction of neutrophils to an infection site. b. increased presence of serum proteins in the infected tissues. c. lysis of bacteria in the absence of specific antibodies. d. opsonization of microorganisms for phagocytosis. e. sensitization of T cells to antigen 3. Complement is a. activated by binding to specific complement receptors. b. antigen-specific. c. a potent promoter of virus entry into host cells. d. a series of intracellular proteins which work with antibody to eliminate endogenous antigen. e. present in the circulation in an inactive form. 4. The alternative pathway of complement activation a. causes tissue damage in the absence of C1INH. b. occurs after the classic pathway is activated. c. occurs only if the classical pathway is ineffective in pathogen clearance. d. requires C3. e. requires C4. 5. If a person is born without C2 and C4, a. C5 can still be cleaved by the classical pathway. b. C3b will not be able to bind to bacteria. c. C9 will polymerize inappropriately and lyse host cells. d. the classical pathway will be changed into the alternative pathway. e. the amount of C3b produced during bacterial infections will be reduced. 6. Which of the following are least sensitive to complement-mediated lysis? a. Enveloped viruses b. Erythrocytes c. Gram negative bacteria d. Gram positive bacteria e. Leukocytes 7. In the membrane attack phase of the classical complement pathway, the role of C5b is to a. activate the C5 convertase activity. b. attract neutrophils to lyse the pathogen. c. initiate formation of the MAC. d. polymerize into a membrane-spanning channel. e. All of these are activities of C5b. 8. Complement receptors (CR) a. activate complement on the surface of pathogens. b. bind only activated complement proteins. c. inhibit complement activation on the surface of host cells. d. on erythrocytes remove immune complexes from the circulation. e. on macrophages signal host cells to make opsonins. 9. As complement is activated by complexes of antibody-coated bacteria, bystander lysis of nearby host cells is prevented by a. a long-lived thioester bond on active complement proteins. b. covalent attachment of all active complement proteins to the pathogen surface. c. plasma proteins that inactivate the anaphylatoxins. d. proteins on host cell membranes that inhibit MAC formation. e. the slow catalytic rates of complement proteases. 10. Complement activity is restricted by all of the following EXCEPT a. dissociation of C3 and C5 convertases. b. Gram positive cell walls that are resistant to MAC polymerization. c. host cell plasma proteins that inactivate C3a, C4a, and C5a activity. d. LPS in the outer membrane of Gram negative bacteria that inactivates C3b. e. proteolytic cleavage of complement proteins into smaller fragments. 11. A deficiency in complement proteins or in their regulators can result in a. blood in the urine from erythrocyte lysis. b. decreased levels of certain complement proteins in the circulation. c. immune complex disease. d. increased numbers of infections. e. All of the above can result from complement deficiencies. part-5 1. Phagocytosis must be preceded by a. antigen binding to the phagocyte. b. chemotaxis. c. extravasation. d. integrin binding to Ig superfamily CAMs. e. oxidative burst. 2. Phagocytes bind antigen using receptors for a. C5a. b. chemokines. c. glucose. d. LPS. e. selectins. 3. Pathogens engulfed by macrophages a. are completely degraded by hydrolytic enzymes into their component amino acids and sugars. b. are degraded to small peptides and carbohydrates which are presented on Class I MHC to Tc. c. may survive and replicate in the macrophage phagocytic vesicles. d. stimulate macrophages to adhere to B cells. e. stimulate vascular endothelium to upregulate selectin expression.. 4. An inflammatory response a. is characterized by a decrease in vascular permeability. b. is stimulated by cytokines produced by neutrophils. c. occurs only during a secondary response. d. recruits phagocytes to the infection site. e. usually lasts for many weeks to ensure antigen is completely removed 5. Natural Killer cells a. are stimulated to kill infected host cells via carbohydrate-binding receptors. b. kill normal host cells with high levels of membrane MHC Class I. c. kill virus-infected cells when the virus is acquired naturally but not by immunization. d . recognize virus-infected cells by the presence of viral peptide on MHC Class II. e. secrete the complement MAC to lyse virus-infected cells. 6. Interferons a and b do NOT a. activate NK cells to kill virus-infected cells. b. get synthesized by virus-infected cells in response to infection. c. induce macrophages to increase expression of Class II MHC. d. inhibit virus replication in infected cells. e. stimulate expression of molecules required for Class I MHC presentation of viral proteins. 7. Immune system cell adhesion molecules do NOT a. allow macrophages to leave the circulation. b. allow T cells to home specifically to peripheral or mucosal lymphoid tissue. c. attract leukocytes to an infection site. d. help cytotoxic T cells to bind to their targets. e. signal neutrophils that they have arrived at an infection site. 8. Early induced immune responses are like adaptive immunity in that they a. are antigen-specific b. demonstrate immune memory. c. involve macrophages and complement. d. involve T and B lymphocytes e. use pre-synthesized proteins which can be released quickly upon cell activation. 9. Selectins a. are present on both leukocytes and vascular endothelial cells. b. bind Ig-like vascular addressins. c. include ICAM, VCAM, and MAdCAM. d. select antigen-specific lymphocytes to extravasate into the infection site. e. select antigen-specific macrophages to extravasate into the infection site. 10. Lymphocyte recirculation a. activates inflammatory cytokines to promote antigen presentation to T cells. b. allows B cells to go to the site of infection to produce antibody. c. circulates lymphokines efficiently throughout the body. d. occurs for both naïve and effector lymphocytes e. only occurs during an infection. 11. Phagocytes kill bacteria using all of the following EXCEPT a. H2O2. b. hydrolytic enzymes. c. low pH d. lysozyme. e. strong reducing agents. 12. For a circulating neutrophil to reach the site of inflammation, it must bind to blood vessel endothelial cell and then pass between the endothelial cells in a process called a. addressinazition. b. chemotaxis. c. extravasation. d. marginalization. e. opsonization. 13. Macrophages are attracted to the site of infection by all of the following EXCEPT a. bacterial peptides. b. chemokines. c. C5a. d. IL-8. e. MAdCAM. 14. Inflammatory cytokines produced by macrophages activate all of the following EXCEPT a. B cells to secrete acute phase proteins. b. integrin on leukocytes to bind more strongly to vascular CAMs. c. neutrophils to be more cytotoxic. d. NK cells to kill virus-infected cells. e. vascular endothelium to increase expression of CAMs. part-6 1. An antibody Fab contains a. complementarity determining regions. b. H and L chain variable regions. c. one antigen binding region. d. one H-L interchain disulfide bond. e. all of the above. 2. Myeloma proteins are a. abnormally formed antibodies secreted from cancerous plasma cells. b. cancerous plasma cells that divide without requiring antigen activation. c. cell lines that secrete specific antibodies for a short time, then die. d. homogeneous antibody molecules secreted by plasma cell tumors. e. protein signaling molecules that make a plasma cell become a multiple myeloma. 3. The regions of the antibody molecule which contribute MOST to the affinity of the antibody for antigen are the a. CDR. b. Fab regions. c. Fc regions. d. framework regions. e. hinge regions. 4. Antibody Fc fragments contain a. antigen-binding sites. b. CDR. c. complement-binding sites. d. framework residues. e. light chain variable domains. 5. The immunoglobulin isotype is determined by the a. antigen specificity. b. H chain constant region. c. L chain variable region. d. number of antigen-binding sites. e. number of VH domains. 6. Which statement about antigen epitopes is FALSE? a. An epitope may be shared by two different antigens. b. A protein molecule usually contains multiple epitopes. c. B cells bind only processed antigen epitopes. d. Epitopes may be linear (composed of sequential amino acids) or assembled by protein folding from amino acids far apart in the protein primary amino acid sequence. e. Some epitopes are more immunogenic than others. 7. An example of an antigen epitope from an infectious organism would be a. a bacterial endotoxin (LPS) molecule. b. a fungal cell wall protein. c. a peptide on the surface of a virus capsid protein. d. a whole virus. e. All of the above are antigen epitopes. 8. Antibody affinity for antigen depends on a. the antibody isotype. b. the complementary shape and charge of each antibody V region for its antigen epitope. c. the number of Fab regions in each antibody molecule. d. whether the antibody is in the serum or on the cell surface. e. whether the light chains are kappa or lambda. 9. Avidity a. is a pathogenic agent, causing a very serious disease. b. occurs when the ratio of antibody to antigen is optimal. c. refers to the strength of interactions between a multivalent antibody and a multivalent antigen. d. results in a loss of antibody reactivity. e. results in cross-reactivity when antibody binds two different antigens. 10. A colleague sends you an antibody to polio virus capsid protein. You perform equilibrium dialysis on the antibody to measure its affinity. Plotting r/c versus r gives you a curved line with K= 2.5 X 108 L/mole and an r intercept of 4. From these results, you conclude that the antibody is probably a. a cross-reactive antibody. b. a monoclonal anti-polio virus antibody. c. a polyclonal IgG antibody. d. IgA anti-polio virus. e. not specific for polio virus. 11. Allotypic determinants are a. constant region determinants that distinguish each Ig class and subclass within a species. b. expressed only from the paternal chromosome. c. generated by the conformation of antigen-specific VH and VL sequences. d. Not immunogenic in individuals who do not have that allotype. e. amino acid differences encoded by different alleles for the same H or L chain locus. 12. Which of the following is NOT a characteristic of IgG? a. It contains 2 g and 2 L chains b. It crosses the placenta. c. It is the predominant immunoglobulin in blood, lymph, and peritoneal fluid. d. It is the largest of all the Igs. e. Its L chains are either k or l. 13. Human serum IgA is isolated and injected into a rabbit. The rabbit anti-IgA antibodies will react against all of the following EXCEPT human a. a chain. b. IgG. c. k chain. d. l chain. e. secretory component. 14. You have purified some Fab from an IgG myeloma protein. Under appropriate conditions, you could use this Fab to generate antibodies to a. both k and l chain. b. g chain hinge region. c. J chain. d. g chain allotypic determinants. e. the idiotype of this myeloma. 15. The Ig isotype which would be most important for neutralizing polio virus before it could infect intestinal cells would be a. secretory IgA. b. serum IgA. c. serum IgD. d. serum IgG. e. membrane IgM. 16. Which of the following changes to a serum IgM antibody molecule would definitely DECREASE its avidity? a. Increase noncovalent antigen-antibody interactions in the CDR. b. Remove the secretory component. c. Replace the Fc portion of the mu chains with the Fc portion of alpha chains. d. Replace VH and VL framework regions with those from a different antibody. e. Use limited enzyme digestion to make Fab fragments. 17. IgA can be secreted from the body because it a. binds poly-Ig receptor on mucosal epithelial cells. b. has a specialized H chain called secretory chain. c. has a special secretory idiotype. d. is small enough to pass between mucosal epithelial cells and leave the body. e. is synthesized by mucosal epithelial cells and secreted directly into the intestinal lumen. 18. The ability to make antibody with the same antigen specificity but different Fc regions a. causes allelic exclusion of Ig molecules. b. does not occur against bacterial antigens. c. improves the antigen binding specificity of an Ig molecule. d. increases the effector functions of Ig molecules. e. requires clonal elimination. 19. Allergy symptoms are produced when antigen binds to IgE on FcR on a. A cells. b. macrophages. c. mast cells. d. neutrophils. e. Th1 cells. 20. One amino acid difference in the Fc region of different human g chains is the epitope recognized by anti- a. allotype. b. idiotype. c. isotype. d. IgG. e. g chain. part-7 1. Genes for immunoglobulins are unlike other human genes in that a. each polypeptide chain is encoded by several exons. b. Ig genes are composed of introns and exons c. somatic recombination occurs before mRNA is transcribed d. there is less Ig genetic material in mature B cells than in other somatic cells e. both c and d are true. 2. The gene segments needed to encode the variable region of a k chain are a. one Jk plus one Dk. b. one Jk plus one Ck. c. one Vk plus one Dk. d. one Vk plus one Jk. e. one Vk plus one Jk plus one Dk. 3. Pseudogenes are DNA sequences which look very similar to functional genes except for the presence of a(n) a. intron. b. leader sequence. c. promoter codon. d. signal sequence. e. stop codon. 4. Combinatorial diversity says that by random combination of 40 functional Vk segments with five Jk segments, the number of possible different k chains that could be made are a. 40. b. 45. c. 70. d. 200. e. 1200. 5. Which does NOT contribute to Ig antigen-binding diversity a. Any L chain can combine with any H chain to form a functional antibody. b. Any Vk can be joined to any Jk to encode the light chain V region. c. Many CH genes are present in the germline DNA. d. Random numbers of N nucleotides can be added during somatic recombination. e. VJL and VDJH joining is imprecise. 6. The proper joining of one VL to one JL is regulated by a. heptamer and nonamer sequences. b. leader sequences. c. P-nucleotide addition sites. d. 12 and 23 nucleotide spacers between heptamer and nonamer sequences. e. TdT binding site for DNA. 7. Since each B cell productively rearranges a single H and L chain allele, it exhibits a. affinity. b. allelic exclusion c. antibody restriction. d. antigen-binding diversity. e. cross-reactivity 8. Primary mRNA for H chain encodes a. one VH, one DH, and one JH segment. b. one VH, one DH, and multiple JH segments. c. multiple VH, one DH, and one JH segments. d. multiple VH, one DH, and multiple JH segments. e. multiple VH, DH, and JH segments. 9. Somatic recombination occurs a. in the bone marrow stem cell. b. in the progenitor cell as it is becoming a B cell. c. in the mature B cell following antigen contact. d. in the plasma cell after antigen contact. e. in the plasma cell after antibody secretion. 10. Junctional diversity affects primarily the amino acid sequence in a. all CDR equally. b. CDR1. c. CDR2. d. CDR3. e. FR3. 11. Isotype switching a. changes the leader sequence exon so the antibody is secreted. b. improves the antigen binding specificity of an Ig molecule. c. increases the affinity of antibodies in a process called affinity maturation. d. increases the functional diversity of Ig molecules. e. occurs randomly between switch regions. 12. Isotype switching resembles somatic recombination because both processes a. are catalyzed by the products of RAG1 and RAG2 b. are regulated by helper T cell cytokines. c. can result in stop codons in coding sequences. d. occur in developing B cells in the bone marrow. e. result in the irreversible loss of DNA from the B cell. 13. Alternative mRNA splicing a. allows the B cell to improve its antigen-binding fit after antigen contact. b. allows the B cell to make membrane IgM from the mature mRNA for secreted IgD. c. can be used for the simultaneous production of any two Ig isotypes. d. is a process by which a B cell can simultaneously synthesize m and d chains. e. occurs in response to T cell cytokines. 14. Because of the order of the CH gene segments (Cm, Cd, Cg3, Cg1, pseudogene Ce, Ca1, Cg2, Cg4, Ce, and Ca2), a human B cell which undergoes isotype switching from IgM to IgG1 can never in the future secrete a. IgA. b. IgE. c. IgG2. d. IgG3. e. IgG4. 15. Isotype switching is always productive because a. B cells produce all isotypes simultaneously. b. isotype switching does not involve recombination of DNA gene segments. c. no DNA is deleted from the chromosome in isotype switching. d. no effector diversity results from isotype switching. e. recombination between switch sites occurs in introns so it cannot introduce stop codons into coding regions. 16. Somatic hypermutation does NOT a. occur by somatic recombination. b. occur during B cell proliferation. c. occur in the B cell following antigen stimulation. d. result in increased affinity of antibodies secreted later in immune responses. e. result in the death of some B cells which no longer bind antigen. part-8 1. Which of the following is NOT True about TCR? a. All TCRs on a particular T cell have identical idiotypes. b. CDR3 of TCR has the most sequence variability from molecule to molecule. c. TCR has binding sites for both antigen and self MHC. d. TCR is a disulfide-bonded heterodimer. e. The ab or gd isotype of TCR determines the biological function of its secreted form. 2. The antigen-binding region of TCR is formed by the folding of a. Va and Vb chains. b. Va, Vb, and CD3 chains. c. Va and Vb2-microglobulin chains. d. Vg and Va chains. e. VL and VH chains. 3. Which of the following properties are NOT shared by TCR and BCR? a. Antigen-binding avidity is increased by the presence of two antigen binding regions on each receptor. b. Antigen-binding diversity is generated through gene rearrangement. c. Folding of protein domains is maintained by intrachain disulfide bonds. d. Membrane expression and lymphocyte activation by antigen require receptors to be associated with signal transduction molecules. e. Receptor antigen-binding sites are formed from two polypeptide chains. 4. TCR most closely resembles a. Class I MHC. b. Class II MHC. c. Fab region of immunoglobulin. d. Fc region of immunoglobulin. e. light chain of immunoglobulin. 5. Rearrangement of both TCR and BCR gene segments does NOT a. generate diversity of antigen binding by recombination of a large pool of germline V, D, and J segments. b. lead to CDR3 being the most hypervariable region in the receptor chains. c. require RAG-1, RAG-2, and TdT expression. d. result in allelic exclusion of membrane receptors. e. result in isotype switching after antigen stimulation of the mature lymphocytes. 6. The amount of diversity in TCR generated within one individual by somatic recombination a. is higher than BCR diversity. b. is about the same as for BCR diversity. c. is lower than BCR diversity. d. is lower than Class I MHC diversity. e. is lower than Class II MHC diversity. 7. T cells use all of the following for generating antigen-recognition diversity on the TCR, except a. combinatorial association of chains. b. combinatorial association of segments. c. large germline pool of gene sequences. d. N region addition of nucleotides. e. somatic hypermutation. 8. CD8 is a co-receptor on T cells that binds a. CD3. b. endogenous antigen peptide. c. the constant region of Class I MHC. d. the constant region of TCR. e. the variable region of Class I MHC. 9. All of the following are true for antigen receptors on both B cells and T cells EXCEPT a. associated with signal transduction molecules in the membrane. b. generated by somatic recombination during lymphocyte development. c. members of the Ig gene superfamily. d. MHC-restricted in their ability to bind antigen. e. specific for a single antigen epitope. 10. Which of the following statements is FALSE? a. TCR is allelically excluded on individual T cells. b. CD4 and CD8 co-receptors are also signal transducing molecules for T cell activation. c. The arrangement of a chain gene segments most closely resembles that of k chain. d. The gene segments for the d chain are interspersed with those for the g chain. e. The T cells that are most likely to react against allogeneic kidney cells are CD8+ cytotoxic T cells. part-9 1. Exogenous antigen includes all of the following EXCEPT a. bacterial toxins. b. extracellular protozoan parasites. c. most bacteria. d. ragweed pollen. e. viruses. 2. Human Class I MHC a chain molecules are a. b2-microglobulin. b. H-2 D, K, and L. c. H-2 IA and IE d. HLA-A. -B, and -C. e. HLA-DR, -DP, and -DQ. 3. Cells which have MHC Class II are _________________, which present _____________ antigen to Th cells. a. antigen presenting cells, endogenous b. antigen presenting cells, exogenous c. infected cells, inflammatory d. target cells, endogenous e. target cells, exogenous 4. Signaling to a cytotoxic T cell that a liver cell is infected with hepatitis virus depends on a. binding of Ii to Class I MHC until the peptide is loaded. b. binding of TCR on the cytotoxic T cell to Class II MHC on the infected cell. c. binding of processed antigen to liver cell Class I MHC. d. processing the hepatitis virus peptides to the correct size and anchor residues in the endosomal pathway. e. both c and d are correct. 5. Endogenous antigen presentation requires delivery of antigen peptides to the endoplasmic reticulum by a. Class I MHC and invariant chain. b. calnexin and tapasin. c. HLA-DM. d. leader sequence. e. TAP-1 and TAP-2. 6. Following virus infection, peptides produced from the proteasome are more likely to be presented on the surface of the target cell because a. MHC Class I is synthesized in response to virus infection. b. proteasomal enzymes which produce shorter peptides are synthesized in response to virus infection. c. TAP-1 and TAP-2 specifically bind virus peptides. d. virus amino and carboxyl terminal amino acids bind better to Class I MHC than peptides from self proteins. e. virus infection induces expression of proteases which cut proteins at sites which bind best to TAP-1 and TAP-2. 7. Exogenous antigen is processed a. after presentation by antigen presenting cells. b. by nearly every nucleated cell. c. by the cytosolic processing pathway. d. in the presence of b2-microglobulin. e. in acidified endosomes. 8. Class II MHC does not efficiently present endogenous antigen because a. antigen synthesized inside the cell never makes it to the endosomal compartment. b. endogenous antigen cannot be processed into peptides small enough. c. HLA DM transports Class II to the surface before it can bind endogenous peptide. d. invariant chain blocks binding of endogenous peptide in the ER. e. phagocytosed antigen binds Class II as rapidly as Class II is synthesized. 9. MIIC is a specialized intracellular compartment where a. HLA DM promotes the release of CLIP and peptide binding to Class II MHC. b. invariant chain binds to Class II MHC a and b chains. c. peptides are transported into the ER for binding to Class II. d. proteins are broken down into peptides by proteasomes. e. some pathogens live protected from lysosomal enzymes. 10. In order to have pathogen peptide plus Class II MHC molecules expressed on the membrane of host cells, all of the following are required EXCEPT a. b2-microglobulin. b. CLIP. c. HLA-DM. d. HLA-DR, -DP, and -DQ alpha chains. e. Ii . 11. Invariant chain (Ii) a. inhibits binding of endogenous peptide to Class I MHC. b. is degraded in the MIIC compartment to CLIP. c. is released from Class II upon binding of b2-microglobulin. d. is the constant region of Class I peptide binding site. e. prevents exogenous peptide binding to Class II MHC in the ER. 12. Antigen binding by Class I MHC molecules a. accommodates many different peptides. b. preferentially occurs for peptides 13-18 amino acids in length. c. occurs at a site on Class I MHC formed by folding of a1 and b2-microglobulin domains. d. occurs only on antigen presenting cells. e. takes place at the plasma membrane of the infected cell. 13. Both Class I and Class II MHC molecules are a. composed of a and b chains with variable and constant regions. b. expressed constitutively on all nucleated cells. c. expressed on the B cell membrane. d. part of the T cell receptor for antigen. e. synthesized in response to antigen processing. 14. The major histocompatibility complex has a. dozens of loci for Class I and Class II proteins. b. genes that encode proteins associated with antigen processing. c. only genes encoding Class I and Class II molecules. d. single loci for Class I and Class II proteins. e. three regions encoding Class I, Class II, and Class III receptors. 15. MHC polymorphism a. is generated by recombination of HLA A, B, and C gene segments. b. is present primarily in the peptide-binding regions of MHC proteins. c. is the result of random association of many alpha and beta genes. d. restricts the ability of B cells to bind antigen. e. results in expression of dozens of MHC alleles on each APC. 16. T cells are MHC-restricted in their ability to respond to antigen because a. all antigen must be processed and presented to activate lymphocytes. b. during an infection, all cells in the body present antigen on MHC Class I. c. MHC binds antigen more specifically than TCR does. d. TCR must recognize both antigen and MHC molecules. e. the T cells should not respond to antigen on allogeneic cells. 17. Linkage of a disease to an HLA allele means that a. everyone with that allele will eventually get the disease. b. people with that allele have a higher risk for the disease. c. the MHC protein encoded by that allele is defective. d. the allele will eventually disappear from the population. e. None of the above is true. 18. All of the following are associated with the expression of Class I MHC molecules EXCEPT a. antigen peptide presentation on membrane Class I MHC to Tc. b. graft rejection. c. increased risk of certain autoimmune diseases. d. lysis of virus-infected cells. e. stimulation of antibody production. 19. Human Class II MHC molecules a. are encoded by the genes HLA-A, B, and C. b. are found on all nucleated cells. c. have an antigen binding site formed from regions of two polypeptide chains. d. must be associated with b2-microglobulin molecules to bind peptide. e. present antigen to CD8 cytotoxic T cells. 20. Humans inherit from each of their parents a. a random set of MHC Class I, Class II, and Class III genes. b. enough diversity in MHC to present epitopes from most pathogens. c. enough diversity in MHC to present every possible antigen epitope. d. genes for a and b chains that can be recombined to increase their diversity. e. the same Class I and Class II MHC genes as their siblings. 21. The a chain of HLA-DR a. can be expressed with the b chain of any MHC molecule. b. can be expressed with the b chain of any Class II MHC molecule. c. can be expressed with the b chain of any Class II DR molecule. d. must be expressed with b2-microglobulin. e. must be expressed with the b chain of Class II DR from the same chromosome. 22. Which of the following statements is TRUE? a. Each individual expresses all the diversity of MHC protein structure. b. If a family has four children, no two of them will have the same MHC genotype. c. Someone with bare lymphocyte syndrome who expressed no MHC proteins would die in infancy. d. TCR on Tc cells binds a1 and b2 domains of Class I MHC protein. e. The chances of finding a tissue match are much higher between children and their parents than between siblings. 23. Which of the following statements is FALSE? a. All MHC alleles in the population have been counted. b. CD4 T cells see antigen on self Class II MHC but not on self Class I MHC. c. Human Class II MHC proteins are called HLA DP, HLA DQ, and HLA DR. d. Class I and Class II MHC are less antigen-specific than Ig. e. Peptides presented by Class I MHC must be 8-10 amino acids long. 24. Which of the following statements is FALSE? a. A peptide binding to Class I must have certain amino- and carboxyl-terminal amino acids to bind tightly to the ends of the Class I binding cleft. b. A transplant is most likely to be successful between people who share the same alleles at all Class I and Class II MHC loci. c. Identical twins share all their Class I and Class II MHC alleles. d. Peptide binding to TCR is influenced by both its own conformation and the conformation of the MHC protein to which it is bound. e. The gene for b2-microglobulin is in the Class I region of the MHC. part-10 1. An antigen binding signal at the membrane results in the mature B lymphocyte changing its a. antigen-binding specificity. b. color. c. Ig V-D-J gene rearrangement. d. gene expression. e. signal transduction molecules. 2. Signal transduction is the process of converting a. a B cell to a T cell. b. a binding signal to a chemical signal. c. a hapten to an antigen. d. IgA to secretory IgA. e. a kinase to a phosphatase. 3. A ligand is a. a cytokine. b. a molecule that specifically binds a receptor. c. an antigen. d. an enzyme. e. all of the above are ligands. 4. A tyrosine kinase which is activated by antigen binding is found in the __________ of the BCr or TCR complex. a. cytoplasmic domain b. extracellular domain. c. Ig superfamily domain. d. transmembrane domain. e. variable domain. 5. The ligand for TCR is a. BCR. b. MHC c. MHC + peptide. d. peptide. e. TCR ligand. 6. An oncogene is a gene that is associated with a. apoptosis. b. cancer. c. ITIMs. d. TCR and BCR signal transduction. e. viruses. 7. Antigen binding to B cells is most effective at sending an activation signal to the B cell if it causes a. antigen processing and presentation on Class II MHC. b. BCR clustering. c. BCR internalization. d. inflammation. e. opsonization. 8. An enzyme which puts a phosphate group on a protein molecule is called a a. co-receptor. b. ITAM. c. kinase. d. phosphatase. e. receptor. 9. Gene expression does NOT necessarily involve a. changes in a cell's activities (phenotype). b. mRNA synthesis. c. protein synthesis. d. DNA synthesis. e. transcription factors. 10. The signal transduction molecules associated with TCR are a. CD1. b. CD3. c. CD4. d. CD8. e. CD22. 11. The signal transduction molecules associated with BCR are a. CD21 and CD81. b. Iga and Igb c. IgD and IgM. d. ITAMs and ITIMs. e. RAG-1 and RAG-2. 12. The second messenger IP3 increases the cytoplasmic concentration of a. antigen. b. calcium. c. Class I MHC. d. phosphate. e. sodium. 13. DAG and IP3 are released from PIP2 by the action of a. adaptor protein. b. phospholipase C (PLC). c. protein kinase C (PKC). d. small G protein. e. TdT. 14. Small G proteins (like Ras) convert GTP to GDP by their ___________ activity. a. GEF. b. kinase. c. phosphatase. d. polymerase. e. protease. 15. Transcription factors a. increase synthesis of mRNA. b. increase synthesis of DNA. c. inhibit synthesis of mRNA. d. promote DNA phosphorylation. e. synthesize mRNA. 16. An enzyme cascade is a a. case where the enzyme catalyzes its own inactivation, like small G proteins. b. pair of enzymatic reactions that have opposite effects, like kinases and phosphatases. c. series of enzymatic reactions that result in cancer. d. series of enzymatic reactions where the product of one reaction catalyzes the next reaction. e. small waterfall. 17. Signal transduction complex associates with TCR in the membrane through a. agonist peptides. b. covalent bonds. c. enzyme cascades. d. reverse phosphorylation. e. salt bridges. 18. If IgaIgb cannot be made, B cells a. cannot express BCR. b. cannot express Class II MHC. c. express 1,000-fold less BCR than usual d. synthesize CD3 and become T cells. e. require 1,000-fold more antigen to be activated. 19. The immune system of a person who had a mutation in CD3 could NOT fight a viral hepatitis A infection by a. blocking Hepatitis A virus from infecting liver cells with neutralizing IgG antibodies. b. generating cytotoxic T cells to lyse infected liver cells c. lysing virus-infected cells with NK cells. d. phagocytosing complement-opsonized Hepatitis A virus. e. Both 1 and 2 are correct. 20. Amino acid sequences in lymphocyte signal transduction complexes which are phosphorylated following antigen binding are called a. ITAMs. b. ITIMs. c. MAPs. d. PTKs. e. syks. 21. An immune deficiency resulting from a defective PTK in the activation cascade in B cells would probably be characterized by a. high numbers of circulating B cells. b. high numbers of circulating lymphocytes. c. high concentrations of plasma immunoglobulins. d. low concentrations of plasma immunoglobulins. e. low numbers of circulating T cells. 22. B cell co-receptor complex CD19, CD22, and CD81 a. allows B cells to be activated with 1,000-fold less complement-coated antigen. b. allows B cells to be activated with 1,000-fold more complement-coated antigen. c. decreases B cell expression of BCR. d. increases B cell expression of BCR. e. prevents B cell activation by self antigen. 23. The anti-rejection drugs cyclosporin A and FK506 block rejection of transplanted organs by interfering with a. activation of a T cell transcription factor required for T cell activation. b. antibody synthesis required for ADCC of transplanted cells. c. CD3 expression. d. MHC Class I expression. e. processing of graft peptides and presentation on Class I MHC. 24. Antagonist peptides a. fail to bind to T cells. b. fully activate T cells. c. interfere with T cell activation by agonist peptides. d. partially activate T cells. e. require partial agonist peptides to fully activate T cells. 25. Antibody-dependent cell-mediated cytotoxicity (ADCC) is a process in which antibody-coated cells are killed by a. the antibodies. b. complement. c. cytotoxic T cells. d. cells with Fc receptors for IgG3. e. cells with Fc receptors for IgE. 26. When IgE on mast cell FceR is cross-linked by, antigen, the mast cell responds by a. apoptosis. b. presenting the antigen to Th cells. c. secreting IgE. d. secreting histamine and other allergic mediators. e. stimulating macrophage and neutrophil phagocytosis of the coated antigen. 27. Homeostasis is a. macrophage activation by bacterial antigens. b. programmed cell death. c. the normal process of signal transduction. d. the synthesis from all leukocytes from bone marrow stem cells. e. the regulation of biological systems within normal limits. 28. STAT proteins are NOT a. cytosolic proteins. b. involved in cytokine signaling. c. JAK kinases. d. signal transducers. e. transcription activators. 29. Cells receive a death signal through a. bcl-2 receptor. b. death receptor. c. Fas. d. Fas ligand. e. STAT ligand. 30. The most important receptor through which lymphocytes receive life and death signals is a. antigen receptor. b. bcl-2 receptor. c. Fas receptor. d. FcR. e. growth factor receptor. | <urn:uuid:ada61735-1fcf-4ed7-a169-f3c0489aad99> | {
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Transcranial magnetic stimulation
||The lead section of this article may need to be rewritten. (May 2014)|
|Transcranial magnetic stimulation|
Transcranial magnetic stimulation (schematic diagram)
Transcranial magnetic stimulation (TMS) is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain. TMS uses electromagnetic induction to induce weak electric currents using a rapidly changing magnetic field; this can cause activity in specific or general parts of the brain with little discomfort, allowing for study of the brain's functioning and interconnections. According to the United States National Institute of Mental Health, TMS "uses a magnet instead of an electrical current to activate the brain. An electromagnetic coil is held against the forehead and short electromagnetic pulses are administered through the coil. The magnetic pulse easily passes through the skull, and causes small electrical currents that stimulate nerve cells in the targeted brain region. Because this type of pulse generally does not reach further than two inches into the brain, scientists can select which parts of the brain will be affected and which will not be. The magnetic field is about the same strength as that of a magnetic resonance imaging (MRI) scan." A variant of TMS, repetitive transcranial magnetic stimulation (rTMS), has been tested as a treatment tool for various neurological and psychiatric disorders including migraine, stroke, Parkinson's disease, dystonia, tinnitus and depression.
Early attempts at stimulation of the brain using a magnetic field included those, in 1910, of Silvanus P. Thompson in London. The principle of inductive brain stimulation with eddy currents has been noted since the 20th century. The first successful TMS study was performed in 1985 by Anthony Barker and his colleagues at the Royal Hallamshire Hospital in Sheffield, England. Its earliest application demonstrated conduction of nerve impulses from the motor cortex to the spinal cord, stimulating muscle contractions in the hand. As compared to the previous method of transcranial stimulation proposed by Merton and Morton in 1980 in which direct electrical current was applied to the scalp, the use of electromagnets greatly reduced the discomfort of the procedure, and allowed mapping of the cerebral cortex and its connections.
- 1 Medical uses
- 2 Adverse effects
- 3 Society and culture
- 3.1 Regulatory approvals
- 3.2 Health insurance considerations
- 4 Technical information
- 5 Research
- 6 See also
- 7 References
- 8 Further reading
- 9 External links
The uses of TMS and rTMS can be divided into diagnostic and therapeutic uses.
TMS can be used clinically to measure activity and function of specific brain circuits in humans. The most robust and widely accepted use is in measuring the connection between the primary motor cortex and a muscle to evaluate damage from stroke, multiple sclerosis, amyotrophic lateral sclerosis, movement disorders, motor neuron disease and injuries and other disorders affecting the facial and other cranial nerves and the spinal cord. TMS has been suggested as a means of assessing short-interval intracortical inhibition (SICI) which measures the internal pathways of the motor cortex but this use has not yet been validated.
For neuropathic pain, a condition for which evidence-based medicine fails to treat a significant number of people with the condition, high-frequency (HF) rTMS of the brain region corresponding to the part of the body in pain, is effective.
For treatment-resistant major depressive disorder, HF-rTMS of the left dorsolateral prefrontal cortex (DLPFC) is effective and low-frequency (LF) rTMS of the right DLPFC has probably efficacy. The American Psychiatric Association,:46 the Canadian Network for Mood and Anxiety Disorders, and the Royal Australia and New Zealand College of Psychiatrists have endorsed rTMS for trMDD.
For loss of function caused by stroke LF-rTMS of the corresponding brain region has probable efficacy.
As of 2014, all other potential uses have only possible or no efficacy; TMS has failed to show effectiveness for the treatment of brain death, coma, and other persistent vegetative states.
Although TMS is generally regarded as safe, risks increase for therapeutic rTMS compared to single or paired TMS for diagnostic purposes. In the field of therapeutic TMS, risks increase with higher frequencies.
Other adverse effects of TMS include:
- Discomfort or pain from the stimulation of the scalp and associated nerves and muscles on the overlying skin; this is more common with rTMS than single pulse TMS.
- Transient induction of hypomania
- Transient cognitive changes
- Transient hearing loss
- Transient impairment of working memory
- Burns from scalp electrodes
- Induced currents in electrical circuits in implanted devices
Society and culture
Nexstim obtained FDA 510K clearance for NexSpeech navigated brain stimulation device for neurosurgical planning in June 2011.
eNeura Therapeutics obtained classification of Cenera System for use to treat migraine headache as a Class II medical device under the "de novo pathway" in December 2013. The FDA gave clearance for eNeura to be marketed in May 2014.
Health insurance considerations
Commercial health insurance
In July 2011, the Technology Evaluation Center (TEC) of the Blue Cross Blue Shield Association, in cooperation with the Kaiser Foundation Health Plan and the Southern California Permanente Medical Group, determined that TMS for the treatment of depression did not meet the TEC's criteria, which assess whether a technology improves health outcomes such as length of life, quality of life and functional ability. The TEC's report stated that "the meta-analyses and recent clinical trials of TMS generally show statistically significant effects on depression outcomes at the end of the TMS treatment period. However, there is a lack of rigorous evaluation beyond the treatment period", which was, with a few exceptions, one to four weeks. The Blue Cross Blue Shield Association's medical advisory panel concluded that "the available evidence does not permit conclusions regarding the effect of TMS on health outcomes or compared with alternatives."
In 2013, several commercial health insurance plans in the United States, including Anthem, Health Net, and Blue Cross Blue Shield of Nebraska and of Rhode Island, covered TMS for the treatment of depression. In contrast, UnitedHealthcare issued a medical policy for TMS in 2013 that stated there is insufficient evidence that the procedure is beneficial for health outcomes in patients with depression. UnitedHealthcare noted that methodological concerns raised about the scientific evidence studying TMS for depression include small sample size, lack of a validated sham comparison in randomized controlled studies, and variable uses of outcome measures. Other commercial insurance plans whose 2013 medical coverage policies stated that the role of TMS in the treatment of depression and other disorders had not been clearly established or remained investigational included Aetna, Cigna and Regence.
There is no national policy for Medicare coverage of TMS in the United States. Policies vary according to local coverage determinations (LCDs) that Medicare administrative contractors (MACs) for the Centers for Medicare and Medicaid Services (CMS) make for geographical areas over which they have jurisdiction. CMS presently has ten to fifteen MAC jurisdictions that each cover several U.S. states.
LCDs for individual MAC jurisdictions can change over time. For example:
- In early 2012, the efforts of TMS treatment advocates resulted in the establishment by a MAC with jurisdiction over New England of the first Medicare coverage policy for TMS in the United States. However, a new MAC for the same jurisdiction subsequently determined that Medicare would not cover services for TMS performed in New England on or after October 25, 2013.
- In August 2012, the MAC whose jurisdiction covered Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma and New Mexico determined that, based on limitations in the published literature,
... the evidence is insufficient to determine rTMS improves health outcomes in the Medicare or general population. ... The contractor considers repetitive transcranial magnetic stimulation (rTMS) not medically necessary when used for its FDA-approved indication and for all off-label uses.
- However, the same MAC subsequently determined that Medicare would cover TMS for the treatment of depression for services performed within the MAC's jurisdiction on or after December 5, 2013,
- In December 2012, Medicare began covering TMS for the treatment of depression in Tennessee, Alabama and Georgia.
CMS maintains a searchable database that enables users to find current Medicare LCDs for TMS for individual U.S. states.
National Health Service
The United Kingdom's National Institute for Health and Care Excellence (NICE) issues guidance to the National Health Service (NHS) in England, Wales, Scotland and Northern Ireland. NICE guidance does not cover whether or not the NHS should fund a procedure. Local NHS bodies (primary care trusts and hospital trusts) make decisions about funding after considering the clinical effectiveness of the procedure and whether the procedure represents value for money for the NHS.
The NICE has issued guidance to the NHS for TMS for the following two indications:
- Treatment of severe depression (IPG 242)
- Treating and preventing migraine (IPG 477)
1. TMS for treatment of severe depression
The NICE evaluated TMS for severe depression (IPG 242) in 2007. The Institute subsequently considered TMS for reassessment in January 2011 but did not change its evaluation. The Institute's recommendation states:
Current evidence suggests that there are no major safety concerns associated with transcranial magnetic stimulation (TMS) for severe depression. There is uncertainty about the procedure's clinical efficacy, which may depend on higher intensity, greater frequency, bilateral application and/or longer treatment durations than have appeared in the evidence to date. TMS should therefore be performed only in research studies designed to investigate these factors.
2. TMS for treating and preventing migraine
In January 2014, the NICE reported the results of an evaluation of TMS for treating and preventing migraine (IPG 477). The Institute's recommendation states:
Evidence on the efficacy of TMS for the treatment of migraine is limited in quantity and for the prevention of migraine is limited in both quality and quantity. Evidence on its safety in the short and medium term is adequate but there is uncertainty about the safety of long-term or frequent use of TMS. Therefore, this procedure should only be used with special arrangements for clinical governance, consent and audit or research. ....
TMS uses electromagnetic induction to generate an electric current across the scalp and skull without physical contact. A plastic-enclosed coil of wire is held next to the skull and when activated, produces a magnetic field oriented orthogonal to the plane of the coil. The magnetic field passes unimpeded through the skin and skull, inducing an oppositely directed current in the brain that activates nearby nerve cells in much the same way as currents applied directly to the cortical surface.
The path of this current is difficult to model because the brain is irregularly shaped and electricity and magnetism are not conducted uniformly throughout its tissues. The magnetic field is about the same strength as an MRI, and the pulse generally reaches no more than 5 centimeters into the brain unless using the deep transcranial magnetic stimulation variant of TMS. Deep TMS can reach up to 6 cm into the brain to stimulate deeper layers of the motor cortex, such as that which controls leg motion.
Mechanism of action
From the Biot–Savart law
it has been shown that a current through a wire generates a magnetic field around that wire. Transcranial magnetic stimulation is achieved by quickly discharging current from a large capacitor into a coil to produce pulsed magnetic fields of 1-10 mT. By directing the magnetic field pulse at a targeted area of the brain, one can either depolarize or hyperpolarize neurons in the brain. The magnetic flux density pulse generated by the current pulse through the coil causes an electric field as explained by the Maxwell-Faraday equation,
The exact details of how TMS functions are still being explored. The effects of TMS can be divided into two types depending on the mode of stimulation:
- Single or paired pulse TMS causes neurons in the neocortex under the site of stimulation to depolarize and discharge an action potential. If used in the primary motor cortex, it produces muscle activity referred to as a motor evoked potential (MEP) which can be recorded on electromyography. If used on the occipital cortex, 'phosphenes' (flashes of light) might be perceived by the subject. In most other areas of the cortex, the participant does not consciously experience any effect, but his or her behaviour may be slightly altered (e.g., slower reaction time on a cognitive task), or changes in brain activity may be detected using sensing equipment.
- Repetitive TMS produces longer-lasting effects which persist past the initial period of stimulation. rTMS can increase or decrease the excitability of the corticospinal tract depending on the intensity of stimulation, coil orientation, and frequency. The mechanism of these effects is not clear, though it is widely believed to reflect changes in synaptic efficacy akin to long-term potentiation (LTP) and long-term depression (LTD).
MRI images, recorded during TMS of the motor cortex of the brain, have been found to match very closely with PET produced by voluntary movements of the hand muscles innervated by TMS, to 5–22 mm of accuracy. The localisation of motor areas with TMS has also been seen to correlate closely to MEG and also fMRI.
The design of transcranial magnetic stimulation coils used in either treatment or diagnostic/experimental studies may differ in a variety of ways. These differences should be considered in the interpretation of any study result, and the type of coil used should be specified in the study methods for any published reports.
The most important considerations include:
- the type of material used to construct the core of the coil
- the geometry of the coil configuration
- the biophysical characteristics of the pulse produced by the coil.
With regard to coil composition, the core material may be either a magnetically inert substrate (i.e., the so-called ‘air-core’ coil design), or possess a solid, ferromagnetically active material (i.e., the so-called ‘solid-core’ design). Solid core coil design result in a more efficient transfer of electrical energy into a magnetic field, with a substantially reduced amount of energy dissipated as heat, and so can be operated under more aggressive duty cycles often mandated in therapeutic protocols, without treatment interruption due to heat accumulation, or the use of an accessory method of cooling the coil during operation. Varying the geometric shape of the coil itself may also result in variations in the focality, shape, and depth of cortical penetration of the magnetic field. Differences in the coil substance as well as the electronic operation of the power supply to the coil may also result in variations in the biophysical characteristics of the resulting magnetic pulse (e.g., width or duration of the magnetic field pulse). All of these features should be considered when comparing results obtained from different studies, with respect to both safety and efficacy.
A number of different types of coils exist, each of which produce different magnetic field patterns. Some examples:
- round coil: the original type of TMS coil
- figure-eight coil (i.e., butterfly coil): results in a more focal pattern of activation
- double-cone coil: conforms to shape of head, useful for deeper stimulation
- four-leaf coil: for focal stimulation of peripheral nerves
- H-coil: for deep transcranial magnetic stimulation
Design variations in the shape of the TMS coils allow much deeper penetration of the brain than the standard depth of 1.5-2.5 cm. Circular crown coils, Hesed (or H-core) coils, double cone coils, and other experimental variations can induce excitation or inhibition of neurons deeper in the brain including activation of motor neurons for the cerebellum, legs and pelvic floor. Though able to penetrate deeper in the brain, they are less able to produce a focused, localized response and are relatively non-focal.
Devices available for transcranial magnetic stimulation include:
- Coils: This is the main component of a TMS system and the part applied directly to the head. A coil can be of different types.
- Stimulators: The stimulator is the machine delivering high intensity pulses of electrical current in the coil to produce electromagnetic induction in the brain. It allows setting all important stimulation parameters and defining complex patterns of pulses to be delivered to the brain. In case of rTMS, the stimulator often contains a cooling system to evacuate the heat produced by repetitive pulses of current.
- Neuronavigation systems: Neuronavigation is a technique originally used in neurosurgery. It makes uses of a software system able to load MRI and possibly fMRI data to localize stimulation spots directly in a 3D reconstruction of the brain. Combined with optical motion tracking systems focusing on the head, neuro-navigation provides computer-assisted TMS allowing for personalized stimulations. In traditional TMS indeed, the coil is positioned based on anatomical landmarks on the skull (including, but not limited to, the inion or the nasion), thereby deriving the location of stimulation spots from the anatomical position of the brain in the head.
- Coil positioning systems: positioning systems help to keep the coil in place for the whole duration of a TMS session. Such systems can be simple static coil holders or computer-controlled robotic arms. Static holders need to be manually adjusted at the stimulation site. Robotic arms are controlled by neuronavigation to adjust the coil position automatically.
Areas of research include the rehabilitation of aphasia and motor disability after stroke, tinnitus, anxiety disorders, obsessive-compulsive disorder, amyotrophic lateral sclerosis, multiple sclerosis, epilepsy, Alzheimer's disease, Parkinson's disease,schizophrenia, substance abuse, addiction, and posttraumatic stress disorder (PTSD).
It is difficult to establish a convincing form of "sham" TMS to test for placebo effects during controlled trials in conscious individuals, due to the neck pain, headache and twitching in the scalp or upper face associated with the intervention. "Sham" TMS manipulations can affect cerebral glucose metabolism and MEPs, which may confound results. This problem is exacerbated when using subjective measures of improvement. Placebo responses in trials of rTMS in major depression are negatively associated with refractoriness to treatment, vary among studies and can influence results. Depending on the research question asked and the experimental design, matching the discomfort of rTMS to distinguish true effects from placebo can be an important and challenging issue.
- Cranial electrotherapy stimulation
- Electrical brain stimulation
- Transcranial direct current stimulation
- Electroconvulsive therapy
- Cortical stimulation mapping
- National Institute of Mental Health (2009). "Brain Stimulation Therapies". nimh.nih.gov. Retrieved 12 December 2013.
- Barker, AT; Jalinous, R; Freeston, IL (1985). "Non-Invasive Magnetic Stimulation of Human Motor Cortex". The Lancet 325 (8437): 1106–1107. doi:10.1016/S0140-6736(85)92413-4. PMID 2860322.
- Merton, PA; Morton, HB (1980). "Stimulation of the cerebral cortex in the intact human subject". Nature 285 (5762): 227. doi:10.1038/285227a0. PMID 7374773.
- Groppa, S.; Oliviero, A.; Eisen, A.; Quartarone, A.; Cohen, L. G.; Mall, V.; Kaelin-Lang, A.; Mima, T.; Rossi, S.; Thickbroom, G. W.; Rossini, P. M.; Ziemann, U.; Valls-Solé, J.; Siebner, H. R. (2012). "A practical guide to diagnostic transcranial magnetic stimulation: Report of an IFCN committee". Clinical Neurophysiology 123 (5): 858–882. doi:10.1016/j.clinph.2012.01.010. PMID 22349304.
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- More on the diagnostic utility of Transcranial Magnetic Stimulation
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Concepts of schizophrenia
Each account of the concept of ‘schizophrenia’ reaches into the past from a viewpoint in a contemporary present. Berrios and Hauser (1988) commented that such accounts were unhistorical because we still lived in a Kraepelinian world. That was fair comment at the time and could be applied to many emerging disciplines whose concepts became temporarily stuck.
It is also true that most people who have been concerned with such concepts over a professional lifetime find that the accumulation of new knowledge requires them to take a critical look back along several progressively different sightlines. This section is limited to the past two centuries, but a comment by John Locke over 300 years ago illustrates the confusion arising from terms used to describe severe deviations from mental health.
Locke was ‘astonished at the Obstinacy of a worthy man,
who yields not to the Evidence of reason, though laid before
him as clear as Day-light . . . I shall be pardoned for calling it
by so harsh a name as Madness, when it is considered that
opposition to Reason deserves that Name and is really
Madness; and there is scarce a man so free from it, but that if
he should always on all occasions argue or do as in some
cases he constantly does, would not be thought fitter for
Bedlam, than for Civil Conversation. I do not here mean
when he is under the power of an unruly Passion, but in the
calm steady course of his Life.’ (Locke 1959)
Locke carefully distinguished ‘madness’ in the sense of unreasonableness, which was as common in his time as in ours, and the effects of being overpowered by ‘an unruly passion’, which was rare. His terminology is upside down to current readers but his distinction is clear and surprisingly modern.
Nevertheless, Michel Foucault would have none of it. To him, madness was always a form of opposition to ‘established’ reason. He thought that the way people react to it was a function of the historical epoch in which they lived (Foucault 1967).
Such issues have not gone away, but one of the strongest tendencies in modern psychiatry is towards accepting Locke’s basic differentiation between ‘unreasonableness’, which is common, and illness, which is rare. The international acceptance of specified definitions for mental disorders, with ‘schizophrenia’ as perhaps the outstanding example, may, however, have created an undue confidence in the durability of the global concepts. It is less likely that definitions of the constituent ‘symptoms’, about which people understandably complain and which are the most obvious and accessible phenomena, will change much in the foreseeable future. However, there is a gradual acceptance that standardized definitions of symptoms, plus new means of investigating brain functions, might eventually lead to the combination, break-up or abandonment of some current disease concepts, schizophrenia conceivably among them.
Even to the sceptical eye of the present authors, there has been sufficient advance in knowledge during the past decade to make another retrospective worthwhile, both for its own sake and because of the possible implications for future development.
J.K. Wing and N. Agrawal
Steven R. Hirsch
MD FRCP FRCPsych
Professor of Psychiatry Emeritus, Division of Neuroscience and Psychological Medicine Imperial College Faculty of Medicine and Director of Teaching Governance, West London Mental Health NHS Trust
Daniel R. Weinberger MD
Chief, Clinical Brain Disorders Branch
Intramural Research Program
National Institute of Mental Health
MD 20982, USA
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- Kendler, K.S. (1985) Diagnostic approaches to schizotypal personality disorder: a historical perspective. Schizophrenia Bulletin 11, 538 - 553.
- Kleist, K. (1960) Schizophrenic symptoms and cerebral pathology.Journal of Mental Science 106, 246 - 255.
- Kraepelin, E. (1896/1987) Dementia praecox. In: The Clinical Roots of the Schizophrenia Syndrome (eds J. Cutting & M. Shepherd), pp. 15 - 24. Cambridge University Press, Cambridge. Translated from Lehrbuch der Psychiatrie, 5th edn, pp. 426 - 441. Barth, Leipzig.
- Kraepelin, E. (1920) Die Erscheinungsformen des Irreseins. Zeitschrift fur Neurologie und Psychiatrie 62, 1 - 29.
- Kretschmer, E. (1966/1974) The sensitive delusion of reference. In: Themes and Variations in European Psychiatry (eds S.R. Hirsch & M.Shepherd). Wright, Bristol. Translated from Der sensitiver Beziehungswahn. Springer, Heidelberg.
- Laing, R.D. & Esterson, A. (1964) Sanity: Madness and the Family. Tavistock, London.
- Leekam, S.R., Libby, S.J., Wing, L. et al. (2002) The diagnostic interview for social and communication disorders. Algorithms for ICD 10 childhood autism and autistic spectrum disorders. Journal of Child Psychology and Psychiatry 43, 325 - 327.
- Leonhard, K. (1957) Aufteilung der Endogenen Psychosen. Akademie Verlag, Berlin.
- Locke, J. (1959) Essay Concerning Human Understanding, Vol. 1, 2nd edn (ed. A.C. Fraser ). Dover, New York.
- Lorr, M. (1966) Explorations in Typing Psychotics. Pergamon, London.
- McKenna, P.J., Lund, C.E., Mortimer, A.M. & Biggins, C.A. (1991)
- Motor, volitional and behavioural disorders in schizophrenia. II. The 'conflict of paradigms' hypothesis. British Journal of Psychiatry 158, 328 - 336.
- Magnan, V. (1893) Lecons Cliniques Sur les Maladies Mentales. Battaille, Paris.
- Robins, L.N., Wing, J., Wittchen, H.U. et al. (1988) The Composite International Diagnostic Interview: an epidemiological instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Archives of General Psychiatry 45, 1069 - 1077.
- Rogers, D. (1992) Motor Disorder in Psychiatry: Towards a Neurological Psychiatry. Wiley, New York.
- Scheff, T.J. (1966) Being Mentally Ill. Aldine, Chicago.
- Schneider, K. (1959) Clinical Psychopathology. Translated by M.W.Hamilton. Grune & Stratton, New York.
- Schneider, K. (1976) Klinische Psychopathologie, 11th edn. Thieme, Stuttgart.
- Spitzer, R.L., Endicott, J. & Robins, E. (1975) Research Diagnostic Criteria: Rationale and Reliability. Hodder and Stoughton, London.
- Sturt, E. (1981) Hierarchical patterns in the distribution of psychiatric symptoms. Psychological Medicine 11, 783 - 794.
- Szasz, T. (1971) The Manufacture of Madness. Routledge, London. Tantam, D. (1988) Asperger's syndrome. Journal of Child Psychology and Psychiatry 29, 245 - 255.
- Wing, J.K. (1961) A simple and reliable subclassification of chronic schizophrenia. Journal of Mental Science 107, 862 - 875.
- Wing, J.K., ed. (1975) Schizophrenia from Within. National Schizophrenia Fellowship, London.
- Wing, J.K. (1978) Reasoning About Madness. Oxford University Press, London.
- Wing, J.K. (1991) Social psychiatry. In: Social Psychiatry: Theory, Methodology and Practice (ed. P.E. Bebbington), pp. 3 - 22. Transaction, New Brunswick.
- Wing, J.K. & Brown, G.W. (1961) Social treatment of chronic schizophrenia: a comparative survey of three mental hospitals. Journal of Mental Science 107, 847 - 861.
- Wing, J.K. & Brown, G.W. (1970). Institutionalism and Schizophrenia.Cambridge University Press, London.
- Wing, J.K., Cooper, J.E. & Sartorius, N. (1974) The Description and Classification of Psychiatric Symptoms: an Instruction Manual for the PSE and CATEGO System. Cambridge University Press, London.
- Wing, J.K., Sartorius, N. & Ustun, T.B. (1998) Diagnosis and Clinical Measurement in Psychiatry: the SCAN System. Cambridge University Press, Cambridge.
- Wing, L. (1981) Asperger's syndrome. Psychological Medicine 11, 115 - 129.
- Wing, L. (1982) Development of concepts, classification and relationship to mental retardation. In: Psychoses of Uncertain Aetiology (eds
- J.K. Wing & L.G. Wing), pp. 185 - 190. Cambridge University Press, Cambridge.
- Wing, L. (2000) Past and future research on Asperger Syndrome. In: Asperger Syndrome (eds A. Klin, F. Volkmar & S. Sparrow). Guildford Press, New York.
- Wing, L. & Gould, J. (1979) Severe impairments of social interaction and associated abnormalities in children: epidemiology and classification. Journal of Autism and Developmental Disorder 9, 11 - 29.
- Wing, L. & Shah, A. (2000) Catatonia in autistic spectrum disorders. British Journal of Psychiatry 176, 357 - 362.
- Wing, L., Leekam, S.R., Libby, S.J. et al. (2002) The diagnostic interview for social and communication disorders. Journal of Child Psychology and Psychiatry 43, 307 - 325.
- Wolff, S. (1995) Loners: The Life Path of Unusual Children. Routledge, London.
- World Health Organization (1973) The International Pilot Study of Schizophrenia. WHO, Geneva.
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As a professional medical coder, you will need to understand how vital your job is for providing a proper diagnosis. An accurate diagnosis is needed to screen the general population’s health, correct reimbursement and to ensure that the operation within the facility is running smoothly and efficiently. For the reason mentioned above it is imperative that you have a firm and steadfast understanding of the codes and the transition between the ICD-9 to the ICD-10.
As of October 2013 the ICD-10 code set will permanently replace the ICD-9 code set as the industry wide coding system throughout the U.S. According to the American Academy of Professional Coders (AAPC), while there are some differences between the ICD-10 and the ICD-9, there are also many things that are the same. Some of the three similarities include:
For those that have the ability to code ICD-9-CM will find that the transition to ICD-10 coding system not as difficult, however, there are some key differences that as a coder you will need to be prepared for.
The soon to be extinct ICD-9-CM coding set is generally made up of codes with 3-5 digits. The changes in the ICD-10 coding set will be alphanumeric codes that will consist of 3-7 digits. The reasoning behind the extended characters is that it will provide an extension on the information provided concerning the type of disease, the severity of the disease and its relation to the anatomy.
The ICD-9-CM will go from 13,600 codes and the ICD-10-CM will have around 69,000.
ICD-10-CM code sets will not just pinpoint a certain disease but how that particular disease manifested.
As the new coding set will impact the way you work, it will also impact the technology and the software that you use.
There are currently some challenges that will exist within the ICD-9-CM coding system. According to the AMA (American Medical Association), one of the major concerns that concern the current coding system is that there is a lack of specific information in the codes themselves. The new ICD-10 coding system takes on the challenge of filling in the gaps in information with coding characters that will increase details provided and the information offered.
There is no more room to add chapters in the ICD-9 coding system, in other words no more codes can be added. So what the ICD-9 coding system has done to add more codes was to add more chapters, and instead of helping the situation it makes it even more difficult for locating codes. In the new system the code characters are longer which will allow the number of codes for use in the future.
In short, the ICD-9 to ICD-10 codes will mean the following:
- More details
- Changes in terminology
- Expanded concepts (laterality, injuries and other related factors)
To prepare yourself with the ICD-10 is that you will need to be prepared and the sooner you prepare the better, you can allow yourself more time to get ahold of necessary changes and your marketability to the health care facilities and doctors that are looking for qualified individuals that are trained in the ICD-10 coding system.
You may also consider taking an online course that will specialize in training you about the new changes in the ICD-9 coding system. As a current professional billing and coder you will enjoy having the flexibility of being able to work and still further their education. So get started as soon as you are able because before you know it October 2013 will be here. | <urn:uuid:88503c59-7c60-44d0-830c-f4ad6115b15d> | {
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Diagnosis Code D3A.019
Information for Medical Professionals
The diagnosis code D3A.019 is grouped in the following Diagnostic Related Group(s) (MS-DRG V35.0)
- 393 - OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC
- 394 - OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC
- 395 - OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC
Convert to ICD-9 General Equivalence Map
The ICD-10 and ICD-9 GEMs are used to facilitate linking between the diagnosis codes in ICD-9-CM and the new ICD-10-CM code set. The GEMs are the raw material from which providers, health information vendors and payers can derive specific applied mappings to meet their needs.
- 209.40 - Ben crcnoid sm intst NOS
- Benign carcinoid tumor of small intestine
- Carcinoid tumor of small intestine
Information for Patients
Also called: Benign cancer, Benign neoplasms, Noncancerous tumors
Tumors are abnormal growths in your body. They can be either benign or malignant. Benign tumors aren't cancer. Malignant ones are. Benign tumors grow only in one place. They cannot spread or invade other parts of your body. Even so, they can be dangerous if they press on vital organs, such as your brain.
Tumors are made up of extra cells. Normally, cells grow and divide to form new cells as your body needs them. When cells grow old, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when your body does not need them, and old cells do not die when they should. These extra cells can divide without stopping and may form tumor.
Treatment often involves surgery. Benign tumors usually don't grow back.
NIH: National Cancer Institute
- Biopsy - polyps (Medical Encyclopedia)
- Cherry angioma (Medical Encyclopedia)
Carcinoid tumors are rare, slow-growing cancers. They usually start in the lining of the digestive tract or in the lungs. They grow slowly and don't produce symptoms in the early stages. As a result, the average age of people diagnosed with digestive or lung carcinoids is about 60.
In later stages the tumors sometimes produce hormones that can cause carcinoid syndrome. The syndrome causes flushing of the face and upper chest, diarrhea, and trouble breathing.
Surgery is the main treatment for carcinoid tumors. If they haven't spread to other parts of the body, surgery can cure the cancer.
- 5-HIAA (Medical Encyclopedia)
- Carcinoid syndrome (Medical Encyclopedia)
- Serum serotonin level (Medical Encyclopedia)
Small Intestine Disorders
Your small intestine is the longest part of your digestive system - about twenty feet long! It connects your stomach to your large intestine (or colon) and folds many times to fit inside your abdomen. Your small intestine does most of the digesting of the foods you eat. It has three areas called the duodenum, the ileum, and the jejunum.
Problems with the small intestine can include:
- Celiac disease
- Crohn's disease
- Intestinal cancer
- Intestinal obstruction
- Irritable bowel syndrome
- Ulcers, such as peptic ulcer
Treatment of disorders of the small intestine depends on the cause.
- Duodenal atresia (Medical Encyclopedia)
- EGD - esophagogastroduodenoscopy (Medical Encyclopedia)
- EGD discharge (Medical Encyclopedia)
- Enteritis (Medical Encyclopedia)
- Enteroscopy (Medical Encyclopedia)
- Meckel's diverticulectomy (Medical Encyclopedia)
- Small bowel bacterial overgrowth (Medical Encyclopedia)
- Small bowel resection (Medical Encyclopedia)
- Upper GI and small bowel series (Medical Encyclopedia) | <urn:uuid:3f9c9aab-5a13-4e80-8500-115885454873> | {
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Get the facts about bipolar disorder, including the different types and symptoms of each.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Acne Important facts about acne and what causes it.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
- Erectile Dysfunction Facts about erectile dysfunction (ED), including causes.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Michael M Saal has the following 2 specialties
- Adolescent Medicine
Adolescent specialists are doctors who have advanced training in the health issues that adolescents face. These physicians deal with issues like the onset of puberty, reproductive health, eating disorders, irregular periods, mood changes, drugs and pressures from home and school. For girls entering adulthood, adolescent specialists can act as both pediatrician and gynecologist, so they only have to see one doctor for all their needs.
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
Dr. Michael M Saal has the following 10 expertise
- Eating Disorders
- Birth Control
- Substance Abuse
- Anxiety Disorders
- Bipolar Disorder / Manic Depressive Disorder
- Panic Disorder
- Parenting Issues
- Sexually Transmitted Diseases
Showing 5 of 19
Dr. Saal has changed my life for the better and continues to do so today. He is a great man, person and first rate psychiatrist. Always accommodating, flexible and knows how to make his patients feel comfortable and at ease in his office. While other doctors often deteriorate and retire, Dr. Saal has been getting even better over the years. The more you get to know him, the more you will realize that he truly cares about his patients and always keeps their best interests at heart. A true professional and highly highly recommended to all!
Doctor has been flexible and understanding. He has been supportive and protected the confidentiality of the patient which is admirable. He is pro-patient and realistic when it comes to meeting the needs of the patient and not just the insurance companies or anyone else. Nevertheless, grateful comes to mind when asked to describe him.
Dr. Saal,I do want to thank you so much for all your help with our daughter. Your diagnosis and treatment have changed her so much. She is getting better day by day. I will be scheduling her with a doctor at Kaiser and I'm sure they will be contacting you for her records.Thank you again for changing our lives for the better!
I don't know who this other reviewer is talking about because that does not describe the Dr. Saal my son has been seeing for the past three years. Dr. Saal is extremely caring, competent, and consistent. He has frequently been more than willing to go out of his way for us when we have waited until the last minute to get a prescription. I would recommend him to anyone who is looking for a truly wonderful child psychiatrist.
On-Time Doctor Award (2015, 2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Patients' Choice Award (2012, 2015, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2012, 2015)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
38 Years Experience
Loma Linda University School Of Medicine
Graduated in 1980
Ucsf Medical Center
Dr. Michael M Saal accepts the following insurance providers.
- Aetna Savings Plus of CA
BCBS Blue Card
- BCBS Blue Card PPO
Blue Cross California
- Blue Cross CA PPO Prudent Buyer Small Group
- Blue Cross CA PPO Prudent Buyer Individual
- Blue Cross CA PPO Prudent Buyer Large Group
- Blue Cross CA Select PPO
- CIGNA HMO
- CIGNA PPO
Locations & DirectionsMichael Martin Saal Md, 311 Miller Ave Ste B, Mill Valley, CA
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Get the facts about birth control so you can decide which type is right for you.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Denise L Blocker has the following 2 specialties
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Denise L Blocker has the following 6 expertise
- Weight Loss
Dr. Denise L Blocker has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 2 of 2
Patients' Choice Award (2008)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
27 Years Experience
Medical College Of Georgia School Of Medicine
Graduated in 1991
Ohio State University Medical Center
Dr. Denise L Blocker accepts the following insurance providers.
- First Health PPO
- HealthSpan Access PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
Medical Mutual of Ohio
- MMOH SuperMed POS Select
- MMOH SuperMed PPO Plus
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Take a minute to learn about Dr. Denise L Blocker in this video.
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- Seasonal Allergies Facts about seasonal allergies, the different types and the symptoms.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Margaret V Blanchard has the following 1 specialty
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Margaret V Blanchard has the following 6 expertise
- Pediatric Diabetes
Dr. Margaret V Blanchard has 1 board certified specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Margaret V Blanchard is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 3 of 3
Dr. Blanchard is rude and obnoxious. She seems to think as a doctor she is above talking to parents directly, refusing requests for callbacks, having her staff take the slam for her poor decisions. She has on occassion seen us, failed to make a diagnosis and sent us on our way. I assure you she didnt fail to bill us. She has refused referals that even the issurance company said she should of filled out for us. Years ago my wifes mentor warned us about this office and this lady - unfortunately we had to discover it for ourselves. Great office, but I would refuse to see her with your child - she is only after he bottom line.
Patients' Choice Award (2009)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Dr. Blanchard is affiliated (can practice and admit patients) with the following hospital(s).
Dr. Margaret V Blanchard accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Anthem HealthKeepers HMO POS
- Anthem KeyCare PPO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry Southern Health PPO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Multiplan PPO
- PHCS PPO
- Optima Health OptimaFit Direct HMO
- Optima Vantage HMO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Optimum Choice Preferred POS
- UHC Options PPO
Locations & DirectionsChildrens Clinic, 321 Main St Ste 1, Newport News, VA
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Urinary Incontinence The symptoms and causes of urinary incontinence or urge incontinence.
- Alzheimer's Disease Facts about Alzheimer’s Disease, including the symptoms and stages.
- Atrial Fibrillation Facts about atrial fibrillation, including symptoms and risk factors.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. John J Pirrello has the following 2 specialties
- Geriatric Medicine
A geriatric specialist is a physician who treats the elderly population and the conditions that most commonly affect them. These doctors have special training in the effects of aging on the body and mind of a patient.
Geriatric specialists treat common ailments faced by senior citizens, such as frailty, incontinence, memory problems, arthritis, senility, decreased functioning and more.
In addition, geriatric specialists keep abreast of the different medications that an elderly person is prescribed to treat their more complex health issues in order to decrease adverse side effects and avoid dangerous drug interactions.
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. John J Pirrello has the following 8 expertise
- Weight Loss
- Weight Loss (non-surgical)
- Alzheimer's Disease
- Family Planning
Dr. John J Pirrello is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 5 of 41
Dr. Pirello, MD. and Terry, Pa. are wonderful, caring individuals whom I've know for (Dr. P.), over 15 years now. His staff is always welcoming and very professional. Doc always takes the time to talk with you and very compassionate. He enjoys his work and so does Terry love them both. Thank you for being there always.
Made my appointment and had to cancel twice due to having 2 heart procedures Finally got to see Dr Pirillo today 8/29/2016. He was very professional and was interested in discussing and addressing all my concerns. The Dr spent an hour learning about my medical history and I am so happy since I relocated from New Jersey I now found my new primary caring DR
Dr Pirello has been our family doctor for nearly 25 years and we could be happier.
Patients' Choice Award (2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2016, 2018)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
36 Years Experience
Creighton University School Of Medicine
Graduated in 1982
Dr. John J Pirrello accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- Florida Blue BlueCare HMO
- Florida Blue BlueOptions
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry FL Employer Group HMO Open Access
- Coventry FL Employer Group PPO
- Humana ChoiceCare Network PPO
- Humana HMO Premier
- Humana National POS
- Humana Tampa Bay HUMx HMOx
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsMedical Associates Of West Fl, 7575 State Road 52, Hudson, FL
Dr. John J Pirrello is similar to the following 3 Doctors near Hudson, FL. | <urn:uuid:3bca4209-14f9-4507-802c-51f2adc6d68e> | {
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As usual, you're working under a tight deadline. Your client is getting angrier by the minute because the graphic you produced for him doesn't look good in print, even though it looked fine on your monitor. Now time's running out and you're wracking your brain trying to figure out what went wrong. Here's what you can do to make sure it never happens again.
In 1993, Adobe, Agfa-Gevaert, Apple, Kodak, Microsoft, Sun Microsystems, and Taligent formed The International Color Consortium (ICC). The intent of this consortium of industry leaders was to develop a standardized, open, vendor-neutral, and cross-platform color management system. They succeeded, and the result of their collaboration was the development of the ICC profile specification. Now with over 70 members, the ICC proposes standards for creating cross-platform device profiles. In other words, the ICC works to get us consistent color output from the plethora of devices and computer systems on the market today, regardless of who manufactured it, the operating system being used, and what the device may be.
So why calibrate? It's pretty simple, if you think about it. With the huge variety of professional/industrial and consumer video cards, monitors, printers, scanners, and cameras available, there's an equally huge variation in output. Something as simple as replacing your ATi video card with one from Nvidia could cause things to look very different on your system, even though your monitor hasn't changed. Output can even vary across two monitors of the same make and model, as you may have noticed if you've got dual displays on your system, that are both plugged into a single video card. Printers can vary from one manufacturer to another, and even using generic ink or different types of paper in your printer can cause different results. To further complicate things, neither monitors nor printers can reproduce the entire range of colors visible to the human eye. CMYK is particularly troublesome because it has a different and smaller color reproduction range than the RGB system used on monitors. In case you're wondering, CMYK is the color model used for printing. The name stands for Cyan, Magenta, Yellow and blacK. The letter K in black is uses so that people don't confuse it with the B in Blue. RGB is the color model used by monitors, scanners and digital cameras, and RGB stands for Red, Green and Blue. RGB is additive while CMYK is subtractive. Add Red, Green and Blue to get White. Add Cyan, Magenta and Yellow to get Black (or Dark Brown).
Now we're going to explore color management and attempt to calibrate Photoshop, a monitor, printer, scanner, and even a digital camera, to ensure that the color output is as accurate with one another as possible, whether the device's color space is RGB or CMYK.First we'll create a color profile and bring data in through the digital camera and scanner, then display it on the monitor and then finally output it to a printer, all the while comparing, noting, and tweaking the results. By calibrating your monitor and creating an ICC profile, you're ensuring that your monitor isn't displaying too much of any particular color and that grays are as neutral as possible. You want to make sure that the colors in your images are being displayed accurately and consistently, and that they will continue to be so in the future.
Figure 1 A scanned photo of my daughters (I just wish Erin had kept her eyes open).
Getting Down to Business
The first thing to tackle is your monitor. If your monitor is out of calibration then every image you produce will be as well. Viewing your work through rose-colored glasses is not a good way to go in this case. You need to see things as they really are, or as close as you can get them anyway.
You've basically got two calibration options unless you choose to go with a third-party calibrator. Actually, you only have one if you discount the option of going with the default hardware setting on your printer, monitor, or scanner. (This is a no-brainer once you consider the fact that these devices have a wide range of factory default color settings.) So if you're on a PC you have the option of using Adobe Gamma, or on a Mac you can use the Display Calibrator Assistant, both included as part of their respective operating systems. The latter is the preferable option, considering the ICC based its specification on Apple's ColorSync profile format, although it's still not as accurate as using a color calibrator.
Adobe Gamma and Apple's Display Calibrator Assistant
If you're a PC user, you can use Adobe Gamma to roughly calibrate your monitor. I say "roughly" because like me, you're probably a human being and not a machine, which means you may have subconscious preferences for certain colors (my favorite is blue). For example, when I try to select a neutral gray square during the Gamma adjustment portion of Adobe Gamma's setup, I may very well go with a square that's slightly tinted with blue. If you do choose to go with Adobe Gamma, here's the best way to do it. It's best to adjust the lighting in your room to a setting that you usually work with. Overhead lighting is always a bad idea since it can cause screen glare, as can light from a nearby window, so it's best to leave your lights off and your blinds closed while you work in Photoshop.
With Windows, you'll do the following:
- Select Start --> Control Panel --> Adobe Gamma. From here you can choose either the Wizard or Control Panel. The Wizard is easier, and presents you with the same options as the default Control Panel, so let's go with that.
- Click Wizard at the bottom right of the dialog. It's a good idea to add a name in the Description: field so you can recognize your new profile when you go to load it in Photoshop later.
- Click Next. Set your monitor's contrast to maximum, as suggested. Then, adjust the brightness so that the smaller box, in the center of the black box, is as dark as possible while still remaining visible. Be sure to keep the surrounding white box as white as possible.
- Click Next and then select the phosphors for your monitor. (Mine's a Sony so I selected Trinitron.) You may need to refer to your monitor's manual or do an online search to be sure what your monitor uses.
- Click Next again to move to the Gamma setting section (shown in
Figure 2). Deselect "View Single Gamma Only" so that
you can view the gamma settings for each of your Red, Green, and Blue channels.
Use the sliders to adjust the gamma setting so that the center box
"fades" or blends into the surrounding box for each color. A useful
tip here is to squint at the boxes to make it easier to see solely the intensity
of the colors and not the lines surrounding each box. This makes it possible to
get a good match easily and quickly.
Figure 2 Setting Red, Green, and Blue Gamma.
- Set the desired gamma setting fly-out to match your operating system. Here we'll choose 2.20, the Windows Default. Make sure that you're happy with your adjustments.
- Click Next again. Here you'll set your hardware white point by clicking on the Measure button and selecting from the gray boxes I mentioned earlier. The idea here is to choose a neutral gray. After I adjusted the white point using the Measure button, Adobe Gamma chose 6500 k (daylight) for me. You may need to select "Same as Hardware" if your monitor is already adjusted to the correct white point measurement.
- Click Next again to move to the final step. Here you can select the Before and After radio buttons to see the difference between your original and adjusted monitor settings.
- Click the "Use as Default Monitor Profile" box and then select the
Finish button to save your settings. When you look at the white point boxes
shown in Figure 3, you'll notice that none of them is a
pure gray. That's one of the shortcomings of using Adobe Gamma to adjust
Figure 3 The gray boxes in Adobe Gamma's white point dialog are all slightly tinted.
On a Mac, you can also use either the Adobe Gamma, or the Display Calibrator Assistant. To use the Assistant on Mac OS X:
- Choose Apple --> System Preferences --> Displays --> Color.
- Click the Calibrate button and follow the steps. For further accuracy, you can use the DigitalColor Meter.
- Open it by selecting Applications --> Utilities --> DigitalColor Meter. Use it to sample the colors in your Photoshop Swatches palette and check them for accuracy.
Unfortunately, if you've got an LCD monitor, your options are kind of limited since Adobe Gamma wasn't designed to work with LCDs. This is where a 3rd party calibrator like the Spyder2Pro comes in.
I was quite impressed with my results using Adobe Gamma—until I saw the vastly different results I got using the Spyder2Pro. At first, I couldn't believe the difference and thought there must be something wrong. I assumed I had a faulty unit, and actually requested and received a replacement. When I got the exact same results with the second unit, I knew it was my perception that was faulty. Once I got over my shock, I decided to use the profiles I'd created with the Spyder for my LCD and CRT displays.
With the Spyder2Pro you can adjust gamma, color temperature (white point), and luminance, allowing for the best flesh tones and the purest grays. Opinions on how often to calibrate your monitor vary from as often as once per week to as little as once per month. Recalibration needs to happen because monitors drift out of calibration and color quality degrades with age, but, as a rule of thumb, calibrating every two weeks is probably adequate for most users.
Your workflow will vary a little, depending upon whether you're calibrating a CRT or an LCD monitor. Other factors include the kinds of controls your particular monitor has for adjusting its output.
With CRTs you might have RGB sliders, a Kelvin slider, or Kelvin presets for adjusting color. You can also adjust the gamma by selecting from a list of presets, entering a number of your own, or creating a custom gamma curve. You can set the white point to Native, select it from a list, or enter your own setting.
Figure 4 The Spyder2Pro doing its thing on a CRT monitor.
For LCDs, you might have brightness, contrast, and backlight controls, plus the previously mentioned controls such as RGB sliders, a Kelvin slider, or Kelvin presets for adjusting color.
Let's step through setting up both a CRT and LCD monitor. Note that we won't get into the advanced settings for the Spyder2Pro (such as measured luminance), because they're beyond the scope of this article.
For setting up a CRT monitor:
- Install the Spyder2Pro calibration software and enter your name and serial number. You should be greeted with a welcome screen that explains what will be adjusted as you work through the steps.
- Select Next to see a screen that cautions you to allow your monitor to warm up, turn off any screensavers and adjust the lighting in your room so that there's no overhead light hitting the screen. It also advises you to set your video display to at least 16-bit color, preferably 24-bit.
- Hit Next again to select your monitor (if you have two, otherwise it will just default to your main display).
- Move to the next screen to select your monitor type. My main display is a Sony CRT so I'll select CRT from the list.
- On the next screen, select your target gamma setting and white point. 2.2 and 6500k are the default settings, so you can either choose that setting or select 2.2-Native, which will use your monitor's current white point.
- On the next screen you'll select Visual as the Luminance Mode. You can also select Measured, but as I mentioned that's a more advanced topic that won't be covered here.
- Click Next to review your settings.
- Click Next again to identify the controls on your monitor. I have options to use all three types of controls, but my monitor defaults to a Kelvin Slider, so I'll go with that. However, if you go with Native, note that you may not see the Identify Controls screen.
- Click Next. This moves you to the white level setting screen. Like Adobe Gamma, this screen allows you to adjust your contrast to get the best white balance.
- Click Next. On this screen you'll set your brightness or black level manually. This is where Spyder's similarities to Adobe Gamma end.
- Click next to move to the next screen, which involves preparing the Spyder to calibrate your display. You'll need to remove the LCD baffle, which exposes the suction cups used to affix the Spyder to your CRT's screen.
- Click Continue to move to the next screen and place the Spyder according to the instructions.
- Click Continue again to start the calibration process. The Spyder will now do its thing, and take readings of your Red, Green, Blue, and Gray levels, as well as your white and black points. When it's finished, it will create a profile for your monitor and ask you to give the profile a name.
- Finally, it moves to a screen that warns you not to change your brightness or contrast settings, and gives you the option of quitting the program or calibrating another monitor.
We may as well calibrate the secondary monitor while we're at it. This one's an LCD so we'll indicate that on the monitor type list.
This particular monitor has Brightness and Contrast controls, so as we move to the Identify Controls list, I'll select their check boxes and move to the next screens where we'll adjust the White Luminance, then the Black Luminance.
- First, we need to identify the color controls, which in this case consist of RGB Sliders. With that checked, let's move to the next screen.
- Here, you'll learn the process for setting the monitor up to achieve a
proper color temperature (white point). You need to replace the LCD baffle at
this point to protect the display's surface, and then continue to the RGB
Levels screen where the Spyder takes Red, Green and Blue samples, reads the
white point, and then brings up an RGB Gain Control display to show you the
colors that need adjusting.
Figure 5 RGB Gain adjustment of an LCD monitor.
- Now you need to go into your LCD's setup and increase or decrease the RGB levels as indicated in the software's RGB Levels dialog. You may need to do this several times before you manage to get the colors within the allowable 0.5 difference range.
- Click the Update button to take a new reading and repeat until you've achieved the desired results, then click Continue.
- At this point the software reads the monitor's black point, red, green and blue samples, gray samples and verifies the color temperature. Once it's finished you're taken through the same steps you were for the CRT monitor, starting with Step 13 above.
- Give the profile a sensible name and then quit the program.
Windows can be funny and the profiles I created didn't show up in the Profile Chooser installed with the Spyder software. To fix this, if this happens to you:
- Right-click on your desktop.
- Choose Properties --> Settings and then choose the Advanced button.
- Click on the Color Management tab, choose Add and then select your profile from the list. Unfortunately, you can't assign a separate profile to your secondary monitor in the Display Settings unless it's connected to its own video card. You can, however, add the profile so that it appears in the Profile Chooser software's profile list.
- Click on your default monitor's profile.
- Control-click your secondary monitor's profile to select that as well, and then click Add, OK to dismiss the Color Management dialog. Hit OK again to dismiss the Display Properties dialog.
- Now you can open the Profile Chooser and select your profiles. A window
opens on each monitor and you can select the appropriate profile for each, but
you'll need to repeat this step to reset your secondary monitor's
profile every time you reboot Windows. It's kind of a pain, but worth it if
you want your monitors to appear properly calibrated. The advantage here is that
if you have two of the same monitor you can apply the same profile to both and
Figure 6 A screen photo of the adjusted CRT, color-corrected to approximate the results.
Whether you've used Adobe Gamma, Display Calibrator Assistant, a Spyder, or other device to calibrate your monitor, you'll need to set up Photoshop in order to use the profile you created. Here's how you do it:
- Open Photoshop and choose Edit > Color Settings (Photoshop > Color Settings on a Mac).
- Choose Load RGB in the RGB: fly-out in the Working Spaces area within the dialog and select your profile from the list that appears.
A good profile name comes in handy here -- I called mine "1-SONY GDM-F520 March 18.icm" which indicates that it's monitor 1 and makes it easily recognizable by the date and monitor name. You can also opt to use a different working space in Photoshop, especially if you're creating Web graphics and images intended to be viewed on a monitor. But,if you want to print and maintain consistent color across multiple devices, then a custom profile is the way to go. Note that if you're going to use one of Photoshop's predefined profiles, choosing Web Graphic Defaults from the Settings fly-out will load the sRGB IEC61966-2.1 profile for the RGB working space. However, sRGB has a smaller gamut and may not print certain colors to your expectations.
Color management and printing is a little trickier. Monitors use the RGB color model and can display 16.7 million colors, but printers, on the other hand, use the CMYK color model, which can reproduce considerably fewer colors. In turn, each monitor or printer operates within a certain color space, which determines its gamut or color range.
The Spyder2Pro ships with DoctorPro software to help with printing, but unfortunately, I found the software to be more trouble than it's worth. Instead, I just stuck to using my custom profile and used the CMYK output, which I set to U.S. Web Uncoated v2. After some experimentation, I used File --> Print with Preview (shown in Figure 7), and loaded my printer's profile (an Epson Stylus Color 740) into the print space profile. I then set the Intent to Relative Colorimetric, which gave me even better results. Relative Colorimetric will shift the colors in your image that are outside your printer's gamut to the closest color within its gamut, with usually satisfactory results. It attempts to preserve as many of the original colors in your image as possible, and is the standard for North American and European printing. Make sure that "Show More Options" is checked so that you have access to these settings. You can also allow the printer to handle the color by selecting "Printer Color Management" under the Profile: list and then using the printer's properties settings under Print > Properties > Advanced and selecting the settings you want to use to print. However, using Photoshop's output settings along with a color profile created for your specific monitor will give you better results with less fiddling around. Just remember to set the paper type in your printer's properties so the printer distributes the ink properly. Plain paper will absorb more ink than coated paper or photo quality inkjet paper, so the printer needs to be told what you're printing on or your output will be off. I learned that the hard way when I printed a photo from a digital camera on photo quality inkjet paper and left the printer's paper setting at plain. As a result, subtle shadow areas came out as pure black. When I reprinted with the proper paper setting I could see the differences clearly, so these aren't just guidelines being offered by your printer—they're there for a reason!
Figure 7 The Print with Preview dialog set for optimum printing.
Viewing a proof of your image is a quick and reasonably accurate way of seeing how your image will look when printed. To view a proof:
- Select View --> Proof Setup --> Custom.
- Choose the profile you want to use from the fly-out list and set your intent to Relative Colorimetric or Perceptual. Photoshop will emulate the way your image will look when printed, usually with satisfactory results.
- If you're curious about which colors are outside of your printer's gamut, selecting View --> Gamut Warning will show you which colors need be shifted to fit your printer's working space. You can see an example of this in Figure 8.
- Once you've got your printer set up the way you want, do a test print.
If the test looks good, print a high quality copy and compare it to the original
version on your screen. It may take some trial and error but you should have
output from your printer that closely resembles your monitor's output.
Figure 8 An image showing out of gamut areas.
Setting up a scanner is a breeze compared to setting up your printer. A scanner can use the same ICC profile you created for your monitor, and then it's just a matter of tweaking the scanned images to ensure they match the profile you assigned. I found the scans from my Epson Perfection 1650 were lacking in tonal range, so I used Levels to adjust the highlight and shadow values by hand to get my scanned images looking the way I wanted. And, as an added bonus, they matched the printed output and the original photograph quite well.
Figure 9 The Levels dialog with corrected highlights and shadows
Figure 10 The printed image rescanned and adjusted to show the approximate results of printing from Photoshop with the appropriate profile.
Cameras can define their own color profiles too. My Sony Cyber-Shot DSC-P73 uses the sRGB IEC61966-2.1 profile. Many professional photographers opt to use camera raw, a sort of "digital negative" that gives them much more control over their images since they're not processed in any way by the camera. That means they're free to work with the raw data and manipulate it however they please.
I found I had the best results when I imported the images from my camera and converted it to my current working space. Then, I applied Auto Color and Auto Levels to images taken indoors with the flash. Outdoor shots also required some tweaking, though not as much – usually just a quick application of Auto Color did the trick. Images with the default sRGB IEC61966-2.1 profile were also acceptable but looked even better with their colors and Levels adjusted.
Figure 11 An adjusted digital photo | <urn:uuid:f308e6df-22ae-450d-996e-2d17e6957917> | {
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About Dr. Marie S Rink
Dr. Marie S Rink, MD is a Doctor primarily located in Phoenix, AZ. She has 23 years of experience. Her specialties include Internal Medicine. Dr. Rink is affiliated with Carondelet Holy Cross Hospital & Health Center and Honorhealth Deer Valley Medical Center. Dr. Rink has received 1 award. She speaks English.
Dr. Marie S Rink has the following 1 specialty
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Marie S Rink has the following 6 expertise
- Weight Loss
Showing 5 of 10
I called to obtain information on a office visits and had follow up questions for the nurse particionar. I was told that the RNP could not speak to patients. If I had follow up questions I would need to pay to speak with the Dr. I did not need to speak with Dr but wanted to speak to the RNP who did the exam. Again I was told RNP could not speak to patients! Really? I had only 3 simple follow up questions to ask. The RNP could not spend a few minutes with me on the phone. I was even willing to pay for a visit but again I was told they don't speak. If they don't speak how do they communicate with there patients. Really! I am changing doctors.
Patients' Choice Award (2008, 2009, 2011, 2012, 2013)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Dr. Rink is affiliated (can practice and admit patients) with the following hospital(s).
23 Years Experience
University Of New Mexico School Of Medicine
Graduated in 1995
St Joseph Hospital
Dr. Marie S Rink accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Savings Plus of AZ
- Aetna Signature Administrators PPO
- Aetna Whole Health Banner Health Network HMO
- BCBS AZ Alliance Network
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- First Health PPO
- Health Net AZ HMO ExcelCare Network
- Health Net AZ PPO HSA
- Humana Choice POS
- Humana National POS
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsAcacia Internal Medicine, 20040 N 19th Ave Ste A, Phoenix, AZ
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2 Chapter I 5th March 20091.1 Introduction1.2 Units and Definitions, Radiation Sources1.3 Interaction of Radiation with MatterChapter II 12th March 20092.1 General Characteristics of gas detectors, Electronics for HEP detectors2.2: Transport Properties2.3: Wire-based DetectorsTool
3 Electromagnetic Interaction of Particles with Matter If particle’s velocity is greater than the speed of light in the medium -> Cherenkov Radiation. When crossing the boundary between media, ~1% probability of producing a Transition Radiation X-ray.From Riegler Lecture 2: IntroductionInteraction with atomic nucleus. Particle undergoes multiple scattering. Could emit a bremsstrahlung photon.Interaction with atomic electrons. Particle loses energy; atoms are excited or ionized.
4 Cross-sectionMaterial with atomic mass A and density ρ contains n atomsA volume with surface S and thickness dx contains N=nSdx atomsSdxProbability, p of incoming particle hitting an atomProbablity that a particle hits exactly one atom between x and (x + dx)Average collisions/cmMean free path l
5 Differential Cross-section Differential cross-section is the cross-section from an incoming particle of energy E to lose an energy between E and E’Total cross-sectionProbability (P(E)) that a particle of energy, E, loses between E’ and E’ + dE’ in a collisionAverage number of collisions/cm causing an energy loss between E’ and E’+dE’Average energy loss per cm
6 Stopping PowerLinear stopping power (S) is the differential energy loss of the particle in the material divided by the differential path length. Also called the specific energy loss.Bethe-Bloch FormulaStopping Power of muons in CopperPDG, Ch 27 p 3.Particle Data GroupEnergy loss through ionization and atomic excitation
7 Stopping PowerLinear stopping power (S) is the differential energy loss of the particle in the material divided by the differential path length. Also called the specific energy loss.Bethe-Bloch FormulaStopping Power of muons in CopperPDG, Ch 27 p 3.Particle Data GroupEnergy loss through ionization and atomic excitation
8 Bethe-Bloch FormulaDescribes how heavy particles (m>>me) lose energy when travelling through a materialExact theoretical treatment difficultAtomic excitationsScreeningBulk effectsPhenomenological description
9 Bethe-Bloch Formula m – electronic mass v – velocity of the particle (v/c = b)N – number density of atomsI – ‘Effective’ atomic excitation energy – average value found empiricallyGas is represented as a dielectric medium through which the particle propagatesAnd probability of energy transfer is calculated at different energies – Allison CobbPDG, Ch 27 p 3.Particle Data Group
10 A very rough Bethe-Bloch Formula X or Y? zebyrθxZeConsider particle of charge ze, passing a stationary charge ZeAssumeTarget is non-relativisticTarget does not moveCalculateMomentum transferEnergy transferred to targetX or Y?
11 Bethe-Bloch Formula Projectile force Change of momentum of target/projectileEnergy transferred
12 Bethe-Bloch Formula Consider α-particle scattering off Atom Mass of nucleus: M=A*mpMass of electron: M=meBut energy transfer isEnergy transfer to single electron is
13 Bethe-Bloch FormulaEnergy transfer is determined by impact parameter bIntegration over all impact parametersbdbze
14 Bethe-Bloch Formula Calculate average energy loss There must be limits Dependence on the material is in the calculation of the limits of the impact parametersDec 2008Alfons Weber
15 Bethe-Bloch Formula Simple approximations for From relativistic kinematicsInelastic collisionResults in the following expression
16 Bethe-Bloch Formula This was a very simplified derivation IncompleteJust to get an idea how it is doneThe (approximated) true answer iswithε screening correction of inner electronsδ density correction (polarisation in medium)
17 Energy Loss Function 1.6 1.5 1.4 To mips 1.3 Rel Fermi Plateau 1.2 1.1 Relativistic RisebgMinimum ionizing particles (mips)
23 Energy-loss in Tracking Chambers The Bethe Bloch Formula tool for Particle Identification
24 Straggling Mean energy loss Actual energy loss will scatter around the mean valueDifficult to calculateparameterization exist in GEANT and some standalone software librariesForm of distribution is important as energy loss distribution is often used for calibrating the detector
25 Straggling Energy Loss Is a statistical process Simple parameterisationLandau function
27 δ-rays Energy loss distribution is not Gaussian around mean. In rare cases a lot of energy is transferred to a single electronIf one excludes δ-rays, the average energy loss changesEquivalent of changing Emax
28 Restricted dE/dxSome detectors only measure energy loss up to a certain upper limit EcutTruncated mean measurementδ-rays leaving the detector
29 Electrons Electrons are different light Bremsstrahlung Pair production
30 Multiple ScatteringParticles not only lose energy … but also they also change direction
31 Multiple ScatteringAverage scattering angle is roughly Gaussian for small deflection anglesWithAngular distributions are given by
32 Correlation bet dE/dx and MS Multiple scattering and dE/dx are normally treated to be independent from eachNot truelarge scatter large energy transfersmall scatter small energy transferDetailed calculation is difficult, but possibleAllison & Cobb
33 Range Integrate the Bethe-Bloch formula to obtain the range Useful for low energy hadrons and muons with momenta below a few hundred GeVPDGRadiative Effects important at higher momenta. Additional effects at lower momenta.
34 Photon and Electron Interactions Electrons: bremsstrahlungPresence of nucleus required for the conservation of energy and momentumeeγpnCharacteristic amount of matter traversed for these interactions is the radiation length (X0)Photons: pair productionPDGepnγe
35 Radiation LengthMean distance over which an electron loses all but 1/e of its energy through bremsstralungEnergy Loss in Leadalso7/9 of the mean free path for electron-positron pair production by a high energy photonpdg
36 Energy Loss by electrons A charged particle of mass M and charge q=Z1e is deflected by a nucleus of charge Ze (charge partially shielded by electrons)The deflection accelerates the charge and therefore it radiates bremsstrahlungElastic scattering of a nucleus is described byPartial screening of nucleus by electronsRiegler/PDG
37 Electron Critical Energy Energy loss through bremsstrahlung is proportional to the electron energyIonization loss is proportional to the logarithm of the electron energyCritical energy (Ec) is the energy at which the two loss rates are equalPDGElectron in Copper: Ec = 20 MeVMuon in Copper: Ec = 400 GeV!
38 Energy Loss by electrons Contributing Processes photo electric cross sectionStrong dependence of ZAt high energies ~ Z5Energy Loss by electronsContributing ProcessesAtomic photoelectric effectRayleigh scatteringCompton scattering of an electronPair production (nuclear field)Pair production (electron field)Photonuclear interactionLight element: CarbonHeavy element: LeadPDGAt low energies the photoelectric effect dominates; with increasing energy pair production becomes increasingly dominant.
39 Photon Pair Production Probability that a photon interaction will result in a pair productionDifferential Cross-sectionTotal Cross-sectionPDGWhat is the minimum energy for pair production?
40 Electromagnetic cascades A high-energy electron or photon incident on a thick absorber initiates an electromagnetic cascade through bremsstrahlung and pair productionLongitudinal Shower ProfileLongitudinal development scales with the radiation lengthPDGElectrons eventually fall beneath critical energy and then lose further energy through dissipation and ionizationMeasure distance in radiation lengths and energy in units of critical energy
41 Electromagnetic cascades Visualization of cascades developing in the CMS electromagnetic and hadronic calorimetersFrom CMS outreach site
42 Muon Energy LossFor muons the critical energy (above which radiative processes are more important than ionization) is at several hundred GeV.Pair production, bremsstrahlung and photonuclearIonization energy lossMean range
43 Muon Energy LossCritical energy defined as the energy at which radiative and ionization energy losses are equal.Muon critical energy for some elementsFrom PDG
44 Muon TomographyLuis Alvarez used the attenuation of muons to look for chambers in the Second Giza PyramidHe proved that there are no chambers presentRiegler Lectures – thought it was a neat illustration
45 X-Ray Radiography for airport security Riegler Lectures – thought it was a neat illustration
46 Signals from Particles in a Gas Detector Signals in particle detectors are mainly due to ionisationAnd excitation in a sensitive medium – gasAlso:Direct light emission by particles travelling faster than the speed of light in a mediumCherenkov radiationSimilar, but not identicalTransition radiation
47 Cerenkov Radiation Moving charge in dielectric medium Wave front comes out at certain angleslowfast
48 Cerenkov Radiation (2)How many Cherenkov photons are detected?
49 Transition RadiationTransition radiation is produced, when a relativistic particle traverses an inhomogeneous mediumBoundary between different materials with different diffractive index n.Strange effectWhat is generating the radiation?Accelerated chargesDec 2008Alfons Weber
50 Transition Radiation (2) Before the charge crosses the surface, apparent charge q1 with apparent transverse vel v1After the charge crosses the surface, apparent charges q2 and q3 with apparent transverse vel v2 and v3
51 Transition Radiation (3) Consider relativistic particle traversing a boundary from material (1) to material (2)Total energy radiatedCan be used to measure g
52 From Interactions to Detectors From the Particle Adventure
57 Key Points: Lecture 1-3 Energy loss by heavy particles Multiple scattering through small anglesPhoton and Electron interactions in matterRadiation LengthEnergy loss by electronsCritical EnergyEnergy loss by photonsBremsstrahlung and pair productionElectromagnetic cascadeMuon energy loss at high energyCherenkov and Transition Radiation
58 Exercise: Lecture 1-3 Estimate the range of 1 MeV alphas in Aluminium MylarArgonIndicate major interaction processes in:1 MeV g in Al10 MeV g in Argon100 keV g in Iron | <urn:uuid:86f18143-7ed3-47ca-9ea1-610181abd687> | {
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Lin Shan has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Lin Shan has the following 6 expertise
- Weight Loss
- Family Planning
Dr. Lin Shan is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 4 of 4
While I was hospitalized and under the care of another physician, Dr Shan actually stopped by my room on his way out from visiting other patients a few times. Not only that, but he explained things to me that other doctors just hadn't bothered to talk about. His english isn't great, but he does a very good job of making you understand what he's saying, and listens intently when you speak. A very kind and detail oriented man.
I just turned 43 & am happy to report that after years of complaining on deaf ears, I'm happily shareing with whomever listens that I'm feeling better than I have in YEARS... Dr. Shan is truely someone who cares, always listens listening to every word about how one is feeling. You leave his office with questions answered and a gameplan on how to repair the years of damage and neglect one does to their body over the years.... Thank You, Doctor.
NCQA Patient-Centered Medical Home
The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into what patients want it to be. Medical homes can lead to higher quality and lower costs, and can improve patients' and providers' experience of care.
Bridges to Excellence: Physician Office Systems Recognition Program
This program is designed to recognize practices that use information systems to enhance the quality of patient care. To obtain Recognition, practices must demonstrate that they have implemented systematic office
Dr. Shan is affiliated (can practice and admit patients) with the following hospital(s).
18 Years Experience
The University Of Texas School Of Medicine At San Antonio
Graduated in 2000
Dr. Lin Shan accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
Group Health Coop
- Group Health Coop Alliant Plus Connect
- Group Health Coop Core
- Moda Health First Choice Network
- Premera Heritage Signature
- Premera Heritage and Heritage Plus 1
- Premera LifeWise Connect
Regence Health Plans
- Regence WA Preferred Provider Network
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsSea Mar Community Health Center, 1400 N Laventure Rd, Mount Vernon, WA
Take a minute to learn about Dr. Lin Shan in this video.
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Dennis F Scharfenberger has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. Dennis F Scharfenberger has the following 19 expertise
- Family Planning
- Lyme Disease
- Sinus Infection (Sinusitis)
- High Blood Pressure (Hypertension)
- Irritable Bowel Syndrome (IBS)
- Smoking Cessation
- High Cholesterol (Hypercholesterolemia)
- Primary Headache Disorders
- Weight Loss
Showing 5 of 27
He is a nice man, a compassionate dr and a good primary physician (especially considering that there is barely any other choice in the immediate location). That said, there is no other positive which can be offered. Staff is at best disinterested and at worst (DONNA) abusive. His wife, the head nurse, is kind enough but the entire staff acts like they are doing YOU a favor and want to rush you out the door. God forbid you call the office and ask for anything. It is unreal how unprofessional his sister's best friend - DONNA - is to patients. How is that woman a nurse? She clearly missed compassion 101 day in nursing school. Ask around and any of his patients will tell you how bad the service is getting there and how his practice has slipped since she came on board. None including the dr will go above or beyond for patients - just barely the minimum. Everything gets referred to ER/hospital and the wait times are incredibly disrespectful of your time. Bring a book and be prepared to wait first in reception and then in the room. Also be prepared to be treated like garbage by Donna and ignored by Michelle.
I've been a patient of Dr. Scharfenberger for about 15 + years now. His manner is wonderful and he takes the time to get to know the whole person he's treating. Never have I felt rushed to let him go onward to the next patient. Still and all, people are moved through his care at a decent pace. I have felt at times that his staff could be a bit more courteous, but have never had an issue with the doctor himself.
Be careful! Before you can even try to get an appointment with this doctor his staff is very unprofessional. DONNA(that nasty B) answers the phone in a nasty tone&the others seem afraid and back her up including the wife. DOC you better get rid of her before she scares all your patients away! This is very important to me when I am checking out a doctor office &his staff. Turned me off immediately. I asked around about this office and I got the same feedback from others that have called. I found that others have had a problem with her. Hope the doc will see this&re-hire a whole new staff. You girls need to take a class on customer service skills. Doc you lost a money and a new patient.
I can't say enough about this Doctor and his staff. He saved my father's life twice and is always right on with his diagnosis. He is extremely patient, always treats everyone with such respect and is never condescending as many doctors can be. He always calls back quickly when I call his office with a question. Can't ask for a better a doctor.
Dr. Scharfenberger will spend whatever time it takes to listen to your symptoms and concerns. He never seems rushed or hurried and is not above listening to your concerns or ideas. He seems to order the appropriate tests before making his diagnosis. His bedside manner is excellent and he is just a generally kind and caring human being. His caring and kindness are natural to him. An excellent doctor
Patients' Choice Award (2008, 2009, 2010, 2011, 2012, 2013)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
Compassionate Doctor Recognition (2010, 2011, 2012, 2013, 2015)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
Patients' Choice 5th Anniversary Award (2012, 2013)
The Patients' Choice Award - 5 Year Honoree is a recognition granted only to those doctors whose ratings have reflected excellence in care for five years in a row. Only 1% of all doctors in the United States are bestowed this honor by their patients.
Dr. Scharfenberger is affiliated (can practice and admit patients) with the following hospital(s).
Bronx Lebanon Hospital Center
Dr. Dennis F Scharfenberger accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
Capital District Physicians Health Plan
- CDPHP HMO
- CDPHP New York State of Health - Small Business
- CDPHP PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Connecticare Flex Connecticut
- Empire Blue Priority EPO
- Empire HMO
- Empire PPO
- Empire Prism EPO Blue Priority
MVP Health Plan
- MVP HMO
- MVP Preferred PPO
- MVP Premier Plus HMO Small Groups
- Multiplan PPO
- PHCS PPO
- Oxford Freedom
- Oxford Liberty
- Oxford Metro
Locations & DirectionsWarwick Family Practice Pllc, 214 West St, Warwick, NY
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. William N Timmins has the following 2 specialties
- Hospice & Palliative Medicine
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. William N Timmins has the following 6 expertise
- Family Planning
- Weight Loss
Dr. William N Timmins has 2 board certified specialties
Dr. William N Timmins is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
22 Years Experience
University Of California Davis School Of Medicine
Graduated in 1996
Ucsd Medical Center
Dr. William N Timmins accepts the following insurance providers.
- Anthem CO Blue Priority PPO
- Anthem CO HMO
- Anthem PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsPikes Peak Hospice And Palliative Care, 2550 Tenderfoot Hill St, Colorado Springs, CO
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Asthma More than 22 million Americans suffer from asthma. Get the facts.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Childhood Asthma Childhood asthma facts, including causes, symptoms & complications.
- Grass Pollen Allergy Get the facts about grass pollen Allergy.
- HIV/AIDS The differences between HIV & AIDS; signs, symptoms & complications.
- Home Allergies Facts about indoor allergies, including symptoms & common allergens.
- Persistent Asthma Facts about persistent asthma, including the criteria for diagnosis.
- Pregnancy Facts about pregnancy, including symptoms you can expect to have.
- Ragweed Allergy Ragweed allergy facts: symptoms, how to avoid it, trigger foods.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
About Dr. Arlene E Dent
Dr. Arlene E Dent, MD is a Doctor primarily located in Cleveland, OH. She has 19 years of experience. Her specialties include Pediatric Infectious Diseases, Infectious Disease and Pediatrics. Dr. Dent is affiliated with University Of Cincinnati Medical Center, Akron Childrens Hospital and Marymount Hospital. Dr. Dent has received 1 award. She speaks English.
Dr. Arlene E Dent has the following 3 specialties
- Pediatric Infectious Diseases
- Infectious Disease
An infectious disease specialist has specialized training in the diagnosis and treatment of contagious diseases.
Infectious diseases, also known as contagious or transmissible diseases, are those that stem from pathogen from a host organism. These infections may spread to other carriers through physical touch, airborne inhalation, bodily fluids or contaminated foods.
Infectious disease specialists identify whether the disease is caused by bacteria, a virus, a fungus or a parasite often through blood tests and then determine what course of treatment, if any, is necessary.
A pediatrician is a doctor who specializes in the regular care of children, as well as the diagnosis and treatment of illness in children. Young patients are often more complicated to treat because they are still growing and developing.
While pediatricians may sub-specialize in specific therapy areas like oncology, surgery, ophthalmology, and anesthesiology, in general, pediatricians provide services like vaccinations, health exams, and treatment of common ailments and injuries. In addition, pediatricians are trained to handle the complex emotional and behavioral issues faced by children, especially during puberty.
Pediatricians normally see their patients from birth until the age of 18, although some may agree to treat patients into their early 20s, if requested.
Dr. Arlene E Dent has the following 7 expertise
- Hepatitis C
- HIV Infections
- Human Immunodeficiency Virus (HIV/AIDS)
Dr. Arlene E Dent has 2 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Dr. Arlene E Dent is Board Certified in 2 specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Castle Connolly Regional Top Doctors
Castle Connolly is America's trusted source for the identification of Top Doctors. Their physician-led research team reviews and screens the credentials of tens of thousands of physicians who are nominated by their peers annually, via a nationwide online process, before selecting those physicians who are regionally or nationally among the very best in their medical specialties. Castle Connolly believes strongly that Top Doctors Make a Difference™.
Dr. Dent is affiliated (can practice and admit patients) with the following hospital(s).
19 Years Experience
Indiana University School Of Medicine
Graduated in 1999
Childrens Hospital And Medical Center
Dr. Arlene E Dent accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- Anthem Blue Access PPO
- Anthem Blue Preferred HMO
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS IL PPO
- BCBS MI PPO Plans Group Enrollees
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- HealthSpan Access PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
Medical Mutual of Ohio
- MMOH SuperMed POS Select
- MMOH SuperMed PPO Plus
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsUh Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Lupus Get the facts about lupus, including symptoms, risk factors, and the different types.
- Menopause Facts about menopause, including the stages, symptoms, and types.
- Ulcerative Colitis Facts about ulcerative colitis, including causes, signs and symptoms.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Warren E Frick has the following 2 specialties
- Allergy & Immunology
- Internal Medicine
An internist is a physician who focuses on the diagnosis and treatment of conditions that affect the adult population—both acute and chronic.
These doctors are often who adults see as their primary physicians because they treat a broad range of illnesses that do not require surgical or specialist interventions. They also work to help a patient maintain optimal health in order to prevent the onset of disease.
In addition to treating the common cold and flu, internists also treat chronic diseases like diabetes and heart disease.
Dr. Warren E Frick has the following 15 expertise
- Hay Fever
- Food Allergy (Hypersensitivity)
- Watery Eyes
- Nasal Allergies
- Sinus Infection (Sinusitis)
- Nasal Allergy (Rhinitis)
- Food Allergies
Showing 5 of 5
My wife had severe hives and thought she might be allergic to detergent but wasn't sure. Dr said "we don't deal with chemicals." (But full charge was still assessed.) We waited 3 weeks for an appt and then not even examined. because of our "suspicions". Another allergist in KC took the time to run the tests. Turns out to be tree pollen.
35 Years Experience
Southern Illinois University School Of Medicine
Graduated in 1983
University Of Wisconsin Hospital
Dr. Warren E Frick accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
BCBS Kansas City
- BCBS KC Preferred Care Blue PPO
- CIGNA HMO
- CIGNA Open Access Plus
- CIGNA PPO
- Cigna MISSOURI NET - NET POS Seamless
Coventry Health Care
- Coventry KS PPO
- Coventry OA EPO Exchange - KS/MO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsAsthma & Allergy Associates Pa, 4601 W 6th St Ste B, Lawrence, KS
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- COPD Get the facts about chronic obstructive pulmonary disease (COPD), including symptoms and complications.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. Andrea M Pincham Benton has the following 1 specialty
- Emergency Medicine
An emergency physician is a doctor who is an expert in handling conditions of an urgent and extremely dangerous nature. These specialists work in the emergency room (ER) departments of hospitals where they oversee cases involving cardiac distress, trauma, fractures, lacerations and other acute conditions.
Emergency physicians are specially trained to make urgent life-saving decisions to treat patients during an emergency medical crisis. These doctors diagnose and stabilize patients before they are either well enough to be discharged, or transferred to the appropriate department for long-term care.
Dr. Andrea M Pincham Benton has the following 3 expertise
Dr. Andrea M Pincham Benton has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 5 of 5
After waiting for an hour, a lady came in who I assumed was the doctor. No name tag, no introduction. I had a sinus headache and she didn't look in my nose, ears or throat, just my eyes. Then checked my lungs???? Wanted to do an eye exam with and without glasses. She left and I waited another hour. Then I found a nurse and told her I was leaving. She didn't bother arguing with me. Went to a real doctor on Monday, was diagnosed and treated properly. This Family Care center doesn't really care.
36 Years Experience
University Of Illinois College Of Medicine
Graduated in 1982
Dr. Andrea M Pincham Benton accepts the following insurance providers.
- Aetna Choice POS II
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
- BCBS AL PPO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA HMO
- CIGNA PPO
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana National POS
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
Dr. Andrea M Pincham Benton is similar to the following 3 Doctors near Birmingham, AL. | <urn:uuid:15f47fd2-7df3-4e2b-bc49-66f0419cf8dc> | {
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Your bladder is the hollow, muscular organ in your lower belly where urine is stored. When you urinate, the muscles of your bladder contract and push urine out through a tube called the urethra. Bladder cancer starts when cells in the bladder start to grow out of control. These cells can form into a bladder tumor. They can also spread outside your bladder to lymph nodes and to structures far from the bladder, like your bones, lungs or liver. This is known as metastasis.
- Metastatic Melanoma The facts about metastatic melanoma, a serious skin cancer.
- Skin Cancer Get the facts about skin cancer, including the types and symptoms.
- Bladder Cancer Facts about Bladder Cancer, including symptoms and treatment options
- Bowel Incontinence Facts about bowel incontinence, including causes & who's most at risk.
- Colonoscopy Facts about colonoscopy, including how and why it's done.
- Colorectal Cancer Facts about Colorectal cancer, including symptoms and treatment options
- Endometriosis Facts about endometriosis, including symptoms.
- Head and Neck Cancer Facts about head and neck cancer, including symptoms and treatment options
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
About Dr. Thomas E Gaines
Dr. Thomas E Gaines, MD is a Doctor primarily located in Knoxville, TN. He has 39 years of experience. His specialties include Vascular Surgery. Dr. Gaines is affiliated with University Of Tennessee Medical Center and Physicians Regional Medical Center. Dr. Gaines has received 3 awards. He speaks English.
Dr. Thomas E Gaines has the following 1 specialty
- Vascular Surgery
Vascular surgeons treat and manage disorders in your veins, arteries and your lymphatic system to ensure blood circulation in your heart and in brain is the best it can be. They're well-versed on how your vascular system works with the rest of your body and they can treat conditions that may cause blockages or buildup.
They can perform many of the same diagnostic testing as interventional radiologists can, such as angiography and MRIs. In addition to diagnosis, they provide critical care and treatment for aneurysms, artery blockages and trauma injuries that involve your veins. They can also help patients manage diabetes, blood pressure and cholesterol as well as treat artery disease. Treatment for more serious cases might include bypass surgery or surgery to remove plaque.
Dr. Thomas E Gaines has the following 5 expertise
- Varicose Veins
- Deep Vein Thrombosis
- Diabetes Complications
- Vascular Malformations
Dr. Thomas E Gaines has 0 board certified specialties
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience
Showing 4 of 4
Dr. Gaines did surgery on my husband in 2014. He had to have his esophagus removed, it was because his esophagus had torn. We couldn't have chosen a better Dr to do the job. He is a wonderful man who cares deeply about his patients with a serious attitude about their health. His work has been complimented by other doctors we have seen many times, in these past few years during my husbands recovery. I would highly recommend him to friends and family.
Patients' Choice Award (2017, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
On-Time Doctor Award (2018)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Castle Connolly Regional Top Doctors
Castle Connolly is America's trusted source for the identification of Top Doctors. Their physician-led research team reviews and screens the credentials of tens of thousands of physicians who are nominated by their peers annually, via a nationwide online process, before selecting those physicians who are regionally or nationally among the very best in their medical specialties. Castle Connolly believes strongly that Top Doctors Make a Difference™.
Dr. Gaines is affiliated (can practice and admit patients) with the following hospital(s).
39 Years Experience
University Of Washington School Of Medicine
Graduated in 1979
United States Army Medical Center
Dr. Thomas E Gaines accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS TN Blue Network E
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- First Health PPO
- Humana Choice POS
- Humana ChoiceCare Network PPO
- Humana Knoxville PPOx
- Humana National POS
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & DirectionsUniversity Heart And Chest Services, 1940 Alcoa Hwy Ste E260, Knoxville, TN
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Type 2 Diabetes
Type 2 diabetes is a chronic disease in which your body is unable to maintain a normal blood sugar (glucose) level.
- Birth Control Facts about birth control to help decide which type is right for you.
- Type 2 Diabetes Basic facts about type 2 diabetes & risk factors to be aware of.
- Binge Eating Disorder Facts about binge eating disorder, including symptoms and causes.
- Chronic Idiopathic Constipation Learn about chronic idiopathic constipation, including treatment
- Diabetic Macular Edema Facts about diabetic macular edema, including the different types.
- Eating Disorders Facts about different types of eating disorders.
- Flu Facts about influenza (flu), including symptoms and vaccines.
- Food Allergy Facts about food allergy, including the symptoms and signs.
- GERD Get the facts about gastroesophageal reflux disease (GERD).
- Gout Get the facts about gout, including the risk factors.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. John E Hetlinger has the following 1 specialty
- Family Medicine
A family practitioner is a doctor who specializes in caring for people of all ages, at all stages of life. Rather than focusing on the treatment of one disease or patient population, family practitioners are often the doctors that people see for their everyday ailments, like cold and flu or respiratory infections, and health screenings. When necessary, family practitioners will provide referrals for conditions that require the expertise of another specialist.
The doctors may also provide physicals, inoculations, prenatal care, treat chronic diseases, like diabetes and asthma, and provide advice on disease prevention.
Dr. John E Hetlinger has the following 6 expertise
- Family Planning
- Weight Loss
Showing 5 of 11
Lost my Dr of 12 yrs to Indiana. Moved over to Hetlinger for 11 months. In that 11 months, he did not move the records, and canceled 3 appointments . One for a staff meeting. I don't go to the Dr. for the fun of it. When I need to go to wait 3 or 4 days or to have an appointment canceled is total bull. You can have him.
dr hetlinger is the first dr i have had that doesn't have a higher opinion of him self then ever body else and doesn't try to push pills. his prices are fare and he gets right to the problem. if you are looking for a DR in Parsons Ks then i recommend Dr John "Jed" Hetlinger,MD.
Patients' Choice Award (2016)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
15 Years Experience
University Of Kansas School Of Medicine
Graduated in 2003
Dr. John E Hetlinger accepts the following insurance providers.
- Aetna Choice POS II
- Aetna HMO
- Aetna Managed Choice POS Open Access
- Aetna Signature Administrators PPO
BCBS Blue Card
- BCBS Blue Card PPO
- CIGNA Open Access Plus
- CIGNA PPO
Coventry Health Care
- Coventry KS PPO
- Coventry OA EPO Exchange - KS/MO
- First Health PPO
- Multiplan PPO
- PHCS PPO
- UHC Choice Plus POS
- UHC Navigate HMO
- UHC Navigate POS
- UHC Options PPO
Locations & Directions
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Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Bipolar Disorder Facts about bipolar disorder, including different types and symptoms.
- ADHD Attention Deficit Hyperactivity Disorder (ADHD), including the different types and who gets them.
- Adult ADHD Facts about attention deficit hyperactivity disorder (ADHD) in adults.
- Alzheimer's Disease Facts about Alzheimer’s Disease, including the symptoms and stages.
- Autism Spectrum Disorder Get the facts about Autism Spectrum Disorder (ASD).
- Chronic Pain Facts about chronic pain, including body parts most commonly affected.
- Clinical Depression Clinical depression facts; symptoms & other depressive disorders.
- Depression Facts about depression, including the symptoms of the condition.
- Diabetic Neuropathy Facts about diabetic neuropathy, including the symptoms and doctors.
- Epilepsy Facts about epilepsy, including different types, symptoms and causes.
- View All Care Guides Prepare for your next visit with our extensive library of Care Guides
Dr. James R Wright III has the following 2 specialties
A psychiatrist is a doctor with specific training in the diagnosis and treatment of mental illness.
He or she can not only provide the counseling necessary to both diagnose and treat a patient, but can also prescribe medication when needed. In some cases, a psychiatrist will only provide the medication and the counseling will be provided by another healthcare specialist, like a certified counselor or psychologist.
Like other doctors, psychiatrists employ diagnostic tools like CT scans and MRI in order to observe the structure and function of a patient's brain.
Once a diagnosis is made, these specialists may use behavior or cognitive therapy in order to address the patient's condition, or a multitude of other types of therapy, in conjunction with or in place of medication.
A neurologist is a physician who diagnoses and treats disorders of the nervous system which is comprised of the brain, spinal cord and nerves. These doctors do not perform surgery, but refer patients to neurological surgeons when they determine that surgical intervention is necessary.
Some of the conditions that neurologists diagnose and treat are epilepsy, aneurysms, hydrocephalus, Parkinson's disease, multiple sclerosis, stroke, spinal disc herniation, and spinal disease.
In addition to using diagnostic tests like MRI, CT scans, EEG and EMG, neurologists also employ neurological testing to gauge muscle strength and movement, balance, reflexes, sensation, memory, speech, and other cognitive abilities.
Dr. James R Wright III has the following 15 expertise
- Mood Disorders
- Sleep Disorders
- Erectile Dysfunction (ED)
- Obsessive-Compulsive Disorder (OCD)
- Anxiety Disorders
- Closed Head Injuries
- Personality Disorder
- Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)
- Mental Illness
- Depressive Disorder
- Attention-Deficit/Hyperactivity Disorder (ADHD)
- Bipolar Disorder
Dr. James R Wright III is Board Certified in 1 specialty
See the board certifications this doctor has received. Board certifications provide confidence that this doctor meets the nationally recognized standards for education, knowledge and experience.
Showing 5 of 97
He fell asleep while I was talking to him. I feel like he never listened to me because his eyes wouldn't meet mine. He was looking my way but I had to repeat things several times. The staff-disorganized, forgot to answer faxes from my pharmacy which led me to going to the ER. They NEVER answer the phone. They have been rude to my husband and I by informing us that if we didn't pay a 25.00 balance that my appt would be canceled, I would be fired as a patient & my account would go to their collection agency. Wow! My husband called on the weekend and his answering service tried contacting Dr. Wright and he never returned any of my calls. I was suicidal and in a dark place. Beware. I felt like a number in the last couple of years.
Ive been a patient for 2 years. I was seeing Jeanete who represented herself as a nurse practitioner. After many visits & always feeling like she would throw medication at me, I did some research. She's not even a nurse practitioner as her cards, door & staff says she is. THIS IS AGAINST THE LAW to misrepresent herself! I saw other patient charts laying around. Front desk staff named Tanya, should be fired. She was rude to me several times I called. She refused my refill & I had an appt within the week. I had major withdrawals and almost took a handful of pills because I didn't want to live once I started feeling the withdrawal of NOT having my medication. jeanete gave me her cell # but would never respond to my texts.She spent our appts cussing and complaining about the office staff. All of their old staff is gone and they were the ones who were caring. The new staff is awful. I started with the doctor & he was the most unresponsive man I've ever met. DO NOT GO!
Patients' Choice Award (2009, 2010, 2018)
Patients' Choice recognition reflects the difference a particular physician has made in the lives of his/her patients. The honor is bestowed to physicians who have received near perfect scores, as voted by patients.
On-Time Doctor Award (2014)
Vitals On-Time + Promptness Award recognizes doctors with consistent high ratings for timeliness of appointments. The honor is granted based on a physician's overall and promptness scores.
Compassionate Doctor Recognition (2011)
Compassionate Doctor certification is granted to physicians who treat their patients with the utmost kindness. The honor is granted based on a physician's overall and bedside manner scores.
43 Years Experience
The University Of Texas School Of Medicine At San Antonio
Graduated in 1975
University Of Texas Health Science Center
Dr. James R Wright III accepts the following insurance providers.
BCBS Blue Card
- BCBS Blue Card PPO
- BCBS TX Blue Advantage HMO
- BCBS TX BlueChoice
- BCBS TX HMO Blue Texas
- CIGNA HMO
- CIGNA LocalPlus
- CIGNA Open Access Plus
- CIGNA PPO
- First Health PPO
- Multiplan PPO
- PHCS PPO
Locations & DirectionsJames Robert Wright Iii Md, 14340 Torrey Chase Blvd Ste 325, Houston, TX
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