Jonathan Jones breast cancer kd cheap 2 mg estrace free shipping, a 2009 doctoral graduate pregnancy nausea relief generic estrace 1mg on-line, said he encountered setbacks during his field work in India but was prepared to meet the challenges because of Dr menopause odor change discount 1 mg estrace overnight delivery. Ann Horgas Associate Professor Department of Adult and Elderly Nursing College of Nursing Ann Horgas says she has gained as much from mentoring her students in the College of Nursing as they have gained from her menopause yoga poses purchase estrace 2 mg line. Former student Lois Ellis menopause 041 buy cheap estrace 1mg, now the director of nursing programs at Santa Fe College partners in women's health harrisburg pa purchase estrace 2 mg on line, said she encountered an assortment of challenges when she returned to school after 25 years women's health clinic ringwood purchase estrace 2mg mastercard. Horgas was so sensitive to helping her juggle commitments that they even met at Starbucks on occasion women's health urinary problems generic estrace 1 mg overnight delivery. Department of Adult and Elderly Nursing Chair Joyce Stechmiller said it is a testament to her teaching that two of former Dr. Although the job market was tight when she graduated, she received three job offers, to which she credits to Dr. Hallgren says a sign of her broad influence is that her nominating letters include one from a current student, one from a recent graduate and one from a graduate of 15 years ago. Elaine Turner, interim dean of the College of Agricultural and Life Sciences, notes that Dr. Kenneth Sassaman Professor Department of Anthropology College of Liberal Arts and Sciences Kenneth Sassaman sees mentoring graduate students as more than creating the next generation of scholars. Archaeology, says the Hyatt and Cici Brown endowed professor in Florida archaeology, should be more than "the color commentary on our collective past. It would take a large cadre of thoughtful, young professionals to make archaeology more relevant. He leads annual archaeological field schools that are in high demand, said Neill J. Wallis, assistant curator in archaeology at the Florida Museum of Natural History and a former student. Sassaman co-authored 21 conference papers and published two book chapters together, all before he received his doctorate. Sassaman has been asked why so much of his endowment goes to his students, says department Chair Susan D. Sassaman says it is part of his strategy for communicating to students their responsibility to the profession, the public and the future. Stuart Carlton, now a postdoctoral researcher at Purdue University, said he is a better scientist because of her mentoring. The recipients of the 2013-2014 award, and excerpts from their personal statements, follow. Smith Professor School of Special Education, School Psychology, & Early Childhood Studies College of Education When graduate students in special education look for a mentor, they often seek Stephen W. Smith says one of the most critical aspects of the educational enterprise is the development of independent learners. Smith for providing opportunities to present research at conferences and publish, often as a co-author with him. Smith taught him to appreciate the history of the profession and today, as colleagues, they collaborate. In fact, his former students look forward to their annual professional meeting, where several academic generations of the "Sollenberger stables" get together to renew friendships and perhaps plan a few experiments together. Sollenberger is the most committed professor that I have ever observed when it comes to doctoral advising, and this relationship with his students has often continued well beyond the Ph. Sollenberger says his goal as a mentor is to graduate "capable, independent and productive scientists who are excited about what they do. Sollenberger has served on 119 graduate committees and has chaired or co-chaired the committees of 48 graduate students, including 26 doctoral students. Each academic year, the University of Florida recognizes the best, brightest and most industrious of its graduate teaching assistants for their work as instructors in the classroom and laboratory. In addition to the Graduate Teaching Awards, the top-ranked recipients receive the Calvin A. This award recognizes graduate students who participate in research and publication opportunities in the life sciences in collaboration with undergraduates. These inaugural recipients were selected from applicants representing 10 different academic departments in six colleges and units at the University of Florida. These graduate students published research with 22 different undergraduate students while mentoring far more. Howard Hughes Medical Institute Bumsoo Ahn, Department: Applied Physiology and Kinesiology Faculty Advisor: Dr. Kim, and Nicole Snyder Journals: Journal of Adolescent Health; the Encyclopedia of Crime and Punishment; the Encyclopedia of Theoretical Criminology Titles: Driving After Drinking Among Young Adults of Different Race/Ethnicities in the United States; Unique Risk Factors in Early Adolescence; Crime and Punishment in Puerto Rico; Longitudinal Research Designs Jennie Fagen, Department: Microbiology and Cell Science Faculty Advisor: Dr. Ford Journal: Polymer Chemistry Title: Insertion Metathesis Depolymerization Wendy Yoder, Department: Psychology Faculty Advisor: Dr. Even as a child, she enjoyed analyzing, critiquing and questioning the things she learned. In one lab, she studied the mechanics of cognitive behavioral therapy; in another, she assisted in research related to industrial and organizational psychology. The program enabled her to do independent research and present her findings at four conferences. Bertone joined the Argentine Student Association and worked as a Chinese conversation partner to help foreign students practice English. Bertone plans to return to college to earn a doctorate in clinical psychology and then continue doing research in an academic setting. While an intern at an Atlanta television news station, she worked 50 hours a week and submitted more news stories than any previous intern. Researching and testing her thesis for her second major, political science, consumed Ms. She wants to be an investigative or special features reporter somewhere in the Southeast. Her time as a University of Florida telecommunications student put pieces in place to accomplish that dream. She has received individual and group awards from the National Broadcasting Society and Associated Press, and has been nominated for the prestigious National Hearst Journalism Award. Denardo received the Anderson Scholar Award for academic leadership and achievement for her work as a political science student. Islam excelled in her studies - majoring in interdisciplinary biological and medical sciences with a minor in business administration. She learned to balance schoolwork, a social life and sleep, and along the way maintained a 4. Despite her already rigorous coursework, she enrolled in other classes to stimulate her critical thinking: advertising, literature and others. Islam continued conducting research, by investigating cardiac development in the hope that a future researcher will use the information she has uncovered to make even more gains in the field. Kaitlyn Johnston Two-Year Scholar the light bulb came on for Kaitlyn Johnston after reading a research article championing rhymes to teach children. The simple exercise of rhyming captured the essence of one of her life passions, studying speech and language to help others. Along with those degrees, she discovered an appreciation for education, inspired by her community college classmates: a Vietnamese immigrant learning English, a grandmother returning to school to motivate her grandchildren, and a single mother working three jobs. Johnston volunteered to teach English to non-native speakers and later spent a summer studying in Mexico to strengthen her understanding of second-language acquisition. She also directed After School Gators, a mentoring program for underserved children, and was a teaching assistant for a phonetics course. Chloe Rittenhouse Two-Year Scholar Chloe Rittenhouse has a simple core belief when it comes to education. A scholar, she believes, learns for the sake of gaining knowledge and not necessarily to earn degrees or recognition or big salaries. While majoring in economics, she enthusiastically pursued her academic passions: energy sustainability and international business. As a Career and Academic Peer mentor, she assisted fellow students with their professional development. To improve global awareness in her professional business fraternity, Alpha Kappa Psi, she co-founded a committee focused on helping members better grasp international topics and world events. Under her leadership, Florida Blue Key made community service a key component of the tournament; state-of-the-art technology was used to improve communication with students, coaches and competitors; a mobile app was created and the tournament was rebranded to appeal to a wider audience. The tournament drew more than 1,100 competitors from 15 states as far away as California and Washington. Barket co-founded Foster Teens in fall 2011 to teach living skills to young adults transitioning out of a foster care home in Citra, a small community near Gainesville. The 10-class curriculum covers financial literacy, crafting a home budget and other necessary skills. She held numerous leadership roles in a variety of groups and became an ambassador for the Machen Florida Opportunity Scholars program, which provides scholarships to first-generation college students from low-income families. Nguyen was especially active in the Warrington College of Business Administration. There, she was project manager for a student-created program to help struggling local businesses and a peer mentor. This mission explains her goal to someday create a scholarship of her own for a new generation of students. Joselyn Rivas Outstanding Female Leader Years from now when Joselyn Rivas reflects on her time as a University of Florida undergraduate, many of her memories will undoubtedly center on her service to fellow students. Rivas, a dual major in psychology and business administration, spent her senior year as student body vice president. Her love for helping others carried her into ever-increasing levels of leadership. Her tendency to remain silent soon gave way to her desire to contribute to campus life. Her dedication has helped students make connections with people they might not have otherwise met. Joshua Minchin Outstanding Male Leader Joshua Minchin often finds himself asking, "How can I serve others better It taught him that regardless of circumstances, everyone deserves to be treated with respect and dignity. He and his Bateman teammates organized a successful Guinness World Records-setting bubble wrap popping party (beating the previous record by 33 participants). Cory Yeffet Outstanding Male Leader Cory Yeffet has never been one to stand back when something needs to be done. His commitment to leadership and service at the University of Florida fueled his nomination as an outstanding leader. He helped implement a 24-hour library and increased bus routes, and as senate president oversaw an $18. Yeffet - a dual-degree student in economics and political science - was named to Florida Blue Key. Yeffet for his leadership, dedication, respect for his peers and ability to inspire others. Honorable Mentions the following students have been recognized for their scholarship and leadership at the University of Florida. Mann also proved to have a hot hand her junior season in 2012 with a nation-leading. A 2012 and 2013 American Volleyball Coaches Association First Team All-America selection, Ms. Patric Young Doug Belden Award Patric Young is a collegiate athlete whose all-around nature is truly unmatched. All who have had the pleasure of knowing him have witnessed him transform into a man, elevating himself to a campus and community figure during his four years at the University of Florida. He is a fierce competitor who averaged double-figures as a sophomore, junior and a senior. Miller Curriculum and Instruction Linda Muentener Curriculum and Instruction Arlene Ortiz Curriculum and Instruction Teresita C. 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For this reason menstruation problems symptoms 2mg estrace otc, natural experiments should be afforded weight when considering the causality of air pollution associations women's health center muskegon mi buy discount estrace 1 mg line. Although these found opportunities should be exploited menstruation uterine lining proven 1mg estrace, however breast cancer october cheap 2mg estrace otc, they will never stand alone as accountability assessments pregnancy upset stomach discount 2mg estrace with visa. For example pregnancy 0-8 weeks 1 mg estrace with mastercard, the findings of studies based on the Utah mill closure (Pope 1989 breast cancer in lymph nodes buy 2 mg estrace, Chapter 4 and this chapter) may be internally valid in that they provide accurate estimates of the effects that occurred under those specific conditions breast cancer watch estrace 1mg mastercard. The estimates these data provide may have limited relevance to the magnitude of concentration reductions that would result from intentional regulatory efforts to improve air quality. Even in such cases, however, one still needs to ensure that other factors that could confound the observed effect did not occur in concert with the randomized change in exposure. For example, confounding will occur if unemployed people do not seek medical care as readily as when they are employed and a measure of medical-care usage (hospitalizations) is the outcome of interest. Migration Studies People may change their exposure to air pollution by changing their place of residence. If one can assume that the probability of a person moving to a particular location is unrelated to his or her susceptibility to air pollution, studies in which health indicators are tracked before and after the move can be informative. This assumption may have been tenable in early studies of lung cancer among migrant populations. These studies suggest that individuals who emigrated from countries with high air pollution levels to countries with lower levels develop lung cancer at rates higher than lifetime residents of the new country but lower than lifetime residents of their country of origin. These studies could not, however, account for differences in cigarette smoking and occupational risk factors (see Reid et al 1966). More recently, Avol and colleagues (2001) studied 110 adolescents who had moved from 10 California communities that were participating in a 10-year follow-up study of air pollution and respiratory health in children. Those who moved to areas with lower levels of air pollution experienced, on average, relatively increased growth of lung function. In these communities, a relation between susceptibility and propensity to move to a particular area may be tenable because of the widespread awareness of the air pollution problem in southern California. However, these patterns were particularly pronounced when at least 3 years had elapsed between the move and the measurement of lung function. Generally, these will be produced from models, with the most straightforward being an exposure-response (or concentration-response) model to compare observed 79 Chapter 5: Model Design and Data Analysis health effects to those predicted for different (generally higher) exposures or concentrations. The observed and expected values must be compared relative to an error term that incorporates appropriate uncertainties. Failure to identify important sources of uncertainty and quantify their impact (a common situation) produces comparisons that invite overinterpretation. Effective accountability assessments will usually require combining information from a variety of sources. Quantitative synthesis (widely referred to as metaanalysis) adds value by formalizing the process, documenting assumptions, and incorporating the insights of diverse scientific disciplines. Information to be combined comes from a variety of research settings (experimental and observational): both human and animal studies from field, clinical, and laboratory settings. All relevant and valid evidence should be examined so that bias is not introduced through choice of evidence. Potential biases of individual studies should be identified and, if possible, findings of studies with offsetting biases should be synthesized. Generally, using quality assessments to down-weight particular studies is inappropriate when pooling their results. Preferably the analysis characterizes the contributions from different studies and takes advantage of possible triangulation of findings from studies having different and possibly opposing strengths and weaknesses. Research synthesis will also be central in interpreting findings of accountability assessments. Evaluation of regulations will require combining evidence over all relevant databases, similar or not. Syntheses need to include all relevant human information while also incorporating data from other lines of investigation, such as human exposures, which provide insights into mechanistic phenomena and time frames of biological processes. Ideally, including such information would be done formally by an appropriate multidisciplinary team. Important issues to consider in conducting syntheses include measurement error, lining up of studies (ie, comparison of studies in a uniform fashion or on a uniform scale[s]), and ensuring that all sources of uncertainty are tracked and reported. Bayesian statistical methods are one useful approach for documenting assumptions and ensuring that appropriate uncertainties are identified and quantified (see sidebar, p 82). Although Bayesian, hierarchical modeling may be effective in this regard, it is not a panacea. In evaluating the health effects of air pollution regulation, however, conventional hypothesis testing and generation of P values is largely irrelevant. We know a priori that exposure and health risk are related on the basis of the evidence that motivated the regulation. There is no so-called statistical free lunch, which is to say that even elegant statistical models may be incorrectly specified, data may be flawed, and ultimately, results of an analysis may be no better than information already available. However, sophisticated statistical analysis can make the best use of available information and indicate where information is most needed. Even when formal modeling is not sufficient for the task, possibly disparate sources of information must be linked to document assumptions and provide a platform for sensitivity analyses. Uncertainty Even when studies address similar endpoints in similar study populations, findings and conclusions will often be heterogeneous. Some heterogeneity in results from statistical variation, as no study has an infinite sample size, and some heterogeneity in the conclusions may result from different approaches to interpreting the same findings. However, a considerable amount of heterogeneity has been shown to be due to other factors. These factors include heterogeneity in design (reference population, study units [eg, individuals or groups of individuals], method of assigning treatments [treatment used in a generic sense], type of treatment, dependent variables, extent of follow-up, method of measurement), general study quality, differential measurement error of exposures and other inputs, statistical analysis (analytic framework [basic, hierarchical, Bayes], analytic model [Gaussian, Poisson, linear, log-linear], covariate adjustments, use of propensity scores, method of computing standard errors, multiplicity of endpoints and analyses), relation of analysis to underlying truth (that between-study heterogeneity can be induced or suppressed by incorrect analysis), and reporting. Comprehensive and quantitative treatment of these and other sources of uncertainty have been more common in risk assessment (Morgan and Henrion 1990) than in epidemiologic analysis, but this situation may be changing. Two kinds of uncertainty-sampling and nonsampling-permeate an accountability assessment (Morgan and Henrion 1990). For example, in a basic model, the standard deviation of a sample mean (sometimes termed the standard error of the mean) is proportional to 1 n, where n is sample size. Therefore, to reduce the standard error by 50% (and thereby reduce the width of a confidence interval by 50%), sample size must be increased by a factor of four. In hierarchical models, which are increasingly applied in air pollution epidemiology, these relations are even more complicated. But for a given model specification, sampling errors are relatively easy to accommodate using standard statistical approaches; they may be a source of only minor uncertainty. These include uncertainty in model specification (eg, baseline model, covariates and how they are included in the model, and structure of measurement error), prior distributions (for a Bayesian approach), and loss functions that either implicitly or explicitly guide decision making. The leverage of these uncertainties is far greater when interpreting observational studies because, unlike randomized studies, confounding and other selection effects must be correctly modeled to produce a valid causal inference. However, uncertainties have high leverage in any study in which biomedical theory is insufficient to pin down a structural model and evidence is insufficient to make definitive conclusions. In a Bayesian context, if data are insufficiently informative, prior distributions and loss functions can dominate the decision process. That is, the new evidence will have little weight in changing interpretation of the full body of evidence. Because strong evidence is unlikely to come from individual accountability assessment studies, synthesis will be necessary (but probably not sufficient) to move widely discrepant prior beliefs to a common ground. Uncertainties from nonsampling errors can be incorporated into sampling models (Morgan and Henrion 1990). For example, in a polynomial regression model for risk in relation to exposure, one can use standard model-selection techniques to select or put a prior distribution on the polynomial degree, produce a posterior distribution for it and other parameters in the model, and either use the posterior distribution to select a model or average over the posterior distribution to produce a Bayesian model averaged polynomial. One benefit of this approach is that it reports greater uncertainty in the regression equation than does a simple model. Analysts still must select a prior distribution, however; this choice remains a source of (nonsampling) uncertainty in the analysis. For example, using information on rodent bioassays in risk assessments for humans involves decisions that are primarily in the nonsampling domain. Sensitivity Analysis In all studies, but especially in observational studies, results can be sensitive to choice of statistical model. Modeling choices include variables used to adjust for confounding, specifications of these variables in the model, and model form (eg, linear or log-linear). Therefore, sensitivity analysis is needed to describe the degree of sensitivity of results to model form and specification. Sensitivity analyses will generally require multivariate modeling, not only to accommodate the possibly increased leverage of several inputs changing together but also to build in possible attenuation of such leverage. For example, in a research synthesis, a study may have two biases: one tending to inflate an estimated effect, the other tending to attenuate it. If only one of these biases is active in a particular analysis, the study may have high leverage. However, if both biases are of the same magnitude, large or small, then the net effect will be small and only a bivariate sensitivity analysis that builds in this positive correlation will produce the true, relative insensitivity. Approaches to sensitivity analysis run the gamut from relatively simple to statistically complex. Sensitivity of results to underlying assumptions and model choices can be described by reporting results for various scenarios, called a scenario approach. Bayesian model averaging offers a more formal approach, in which a prior distribution is put on model choices and the posterior expected model is reported along with its uncertainty. The scenario approach is relatively easy for nonstatisticians to understand but generally gives no sense of the relative viability (posterior weights) of candidate scenarios. Bayesian model averaging does consider important uncertainties in alternative models but is less transparent to nonexperts. Analysts might consider an approach with the benefits of both, in which scenario-specific results are compared graphically with estimates from Bayesian model averaging (and their uncertainty) and with posterior weights for several scenario-weight specifications specified a priori (eg, equal weighting, low-dimension models weighted more). The philosophy operates on the premises that personal opinion pervades all of science, that such opinions should be made explicit before analyzing the next information component, that unknowns are random variables with probability distributions (called the prior distribution), and that a formal system should be used to update prior opinions in the context of additional information. Such updating is accomplished by the Bayesian formalism, which requires a prior distribution for all unknown variables and a sampling distribution (data likelihood) that describes the probability distribution of observed data, conditional on values of unknowns. Once data related to a particular association have been observed, the updated distribution of unknowns (termed the posterior distribution) can be computed using Bayes Theorem. This distribution can be used to make inferences and to serve as the prior distribution in analyzing the next component of information. This multistage, Bayesian formalism does not depend on the so-called personal probability interpretation; it provides an analytic strategy in situations wherein the prior distribution is based on empirical evidence, is induced by random selection of experimental units, or is simply a formal component of a statistical model. The Bayesian formalism is effective in integrating information, stabilizing estimates, and tracking all relevant uncertainties. The mean and variance of the prior distribution are estimated (empirical Bayes); the posterior mean of the city-specific slope lies between the direct estimate and the estimated prior mean; the posterior variance is smaller than that for the direct estimate (shrinkage and variance reduction). Mathematical analysis, simulation, and empirical examples show that these Bayesian estimates outperform direct estimates in a broad class of applications. For example, a standard regression model is fit, but rather than using its estimates as the predictor, predictions move partway from regression model estimates toward direct estimates; the degree of movement depends on the relative precision of the regression prediction and the direct estimate. Predictions for very stable direct estimates are close to the direct estimate, whereas predictions for imprecise direct estimates are close to the regression model estimate. The formalism allows this percolation of variability in far more complicated settings, producing an honest assessment of uncertainty. Model Uncertainty Accountability assessment is subject to considerable uncertainty induced by sampling variability (eg, standard error of an estimate) and model uncertainty (eg, uncertainty regarding the model used to conduct a causal analysis). The boundary between sampling uncertainty and model uncertainty is fuzzy; a Bayesian analysis is effective in measuring and incorporating both. For example, in a polynomial regression one can put a prior distribution on the polynomial degree and produce a posterior distribution for it and other parameters in the model. The average across the posterior distribution produces a Bayesian model averaged polynomial. The posterior variance of this average reports greater uncertainty in the regression equation than does model selection. This approach has been used as an alternative to selecting degrees of freedom in a spline-based adjustment for potential confounding in time series studies of air pollution (F Dominici, personal communication, 2003). Incorporating Expert Opinion Inevitably, little or no direct empirical information is available about some components of an accountability system or about what components should be included. As a result, incorporating expert opinion and structuring complex systems and synthesis will be necessary. The Bayesian formalism is well-suited to incorporating expert opinion on possible values for parameters and systems of related components. There is a large literature concerning the elicitation of expert opinion (Morgan and Henrion 1990). Advice therein includes seeking information about quantities on which experts have information (eg, potential observables) and documenting between-expert uncertainty. Note that if little or no empirical information is available to update these a priori assessments, the posterior distribution will simply reflect prior uncertainty. The Bayesian approach, therefore, can structure complex systems (exposures that induce short-term response, longer-term frailties, and susceptibility to high levels of air pollution) and integrate information from disparate sources (see DuMouchel and Harris 1983). Bayesian Approaches and Models the foregoing discussions of uncertainty and sensitivity analysis underscore that an effective accountability assessment requires a broad synthesis of available information. Such a synthesis must account for relations among data sources, build in appropriate components of variability among data sources, track and incorporate important sources of uncertainty and bias, and integrate misaligned information. Misalignment can be spatial (some information at a coarse spatial resolution, some at a fine resolution) or can relate to available covariate information (eg, information sources vary with the types of covariates collected and coding thereof). An accountability assessment must deal with mea- surement error in inputs and outputs. To properly inform a cost-benefit analysis, an accountability assessment must produce summaries that go beyond point estimates and standard errors, delivering full joint distributions of relevant quantities so that expected utilities and other tools for decision analysis can be computed. An accountability assessment should be founded on a platform that facilitates sensitivity analyses. Finally, by necessity, an accountability assessment could incorporate expert opinion to substitute for direct information (eg, for links in a causal chain). Although it is by no means a panacea, the Bayesian approach enables syntheses with all of these features (see sidebar). Explicit incorporation of expert opinion falls almost completely outside traditional modeling. At the same time it may be an important component of dealing with some sources of uncertainty in accountability analyses, such as the choice or components of models (eg, whether a low-dose curve is linear, sublinear, or supralinear) (see sidebar). Causal Models Accountability assessments inevitably use available information to address so-called counterfactual questions, such as the following: What would have happened to air quality and human health in the absence of regulations or under different, less stringent regulations Although some relevant information on counterfactuals is usually available (eg, air pollution and health effects in other countries and at other times in the United States), it is not sufficient to pin down cause and effect relations between regulations and human health. Some aspects of short-term effects of air pollution in a small number of people can be assessed experimentally with controlled exposures of volunteers; long-term effects can be assessed experimentally in animal systems. However, most assessments of exposure-response relations depend on observational information, wherein confounding is a threat to validity and causal analysis should be used to uncover causal effects. The goal of accountability assessment is to understand the associations among changes in regulations, resultant changes in air pollution, resultant changes in personal exposures, and changes in risks for adverse health effects. People can at least partially control their own exposure through their actions, and these actions can be associated with sensitivity to exposure. If information on personal attributes that influence exposure is available, covariate adjustment can reduce bias. Success of the adjustment depends on using a correct model form, and more importantly, having measured the covariates that matter. Causal modeling provides a possibly effective approach to determining associations among personal attributes, exposures or treatments, and health effects. To understand the association between exposures and outcomes, analysts must adjust for associations between personal attributes and behaviors that influence both exposure and outcomes. Failure to do so may yield a biased analysis, one that does not provide valid, exportable information. For example, people experiencing asthma attacks during high-ozone periods may reduce their outside activities and thereby dramatically reduce the delivered dose. In extreme cases, then, data could indicate that high ozone levels are protective. Of course, this association was in fact a product of clinical management decisions and not of biology; a different clinical management policy would have produced a different association. Causal analysis attempts to eliminate or reduce such biases by jointly assessing the association between personal attributes, treatments (eg, exposures), and outcomes to yield results that are free of such selection effects. If follow-up information is not available, then no empirical evidence is available to untangle policy from biology. A variety of approaches to causal analyses are possible, all of which attempt to adjust for selection effects and more general confounding. These approaches include use of instrumental variables (common in economics [Angrist et al 1996]) and use of counterfactuals (such as: What if this population had been exposed to a different pollution level The propensity score (first introduced to adjust sample surveys) models the association between individual attributes and treatment. If the determinants of propensity are known with reasonable certainty, then comparing outcomes 83 Chapter 5: Model Design and Data Analysis for individuals with the same propensity scores and then aggregating these comparisons allows an analysis free of selection effects. Indeed, if the propensity score is known, the scientific validity of the analysis is competitive with that of a randomized study but the propensity score is never fully known in studies that are not randomized. Developing effective propensity scores depends on having measured relevant covariates at an acceptable level of precision (ie, no unmeasured confounders).
He remains active in the study of Southeast Asia womens health rights estrace 2mg visa, civil-military relations women's health clinic vernon bc generic 2 mg estrace free shipping, and the ongoing wars pregnancy journal book estrace 2mg low price. Prior to joining the War College Dean Garofano was a Senior Fellow at the Kennedy School of Government womens health orlando order estrace 1 mg overnight delivery. Army War College pregnancy constipation cheap estrace 2 mg with visa, the Five Colleges of Western Massachusetts menopause and pregnancy generic estrace 1 mg on line, and the University of Southern California premier women's health yakima discount estrace 2mg fast delivery. Genest is the Forrest Sherman Professor of Public Diplomacy in the Strategy and Policy Department and is the Area Study Coordinator for the Insurgency and Terrorism electives program menopause no period buy cheap estrace 2 mg. Before coming to the Naval War College, Professor Genest taught at Georgetown University, the U. Genest worked on Capitol Hill for Senator John Chafee and Representative Claudine Schneider. Professor Genest has received fellowships and grants from numerous organizations including the United States Institute of Peace, the Arms Control and Disarmament Agency, the Harry S. Truman Foundation, the Foundation for the Defense of Democracy, SmithRichardson Foundation and the Bradley Foundation. He has also written articles dealing with international relations theory, strategic communication, American foreign policy and public opinion. Foreign Service for twenty years as an Economic Officer, most recently as the Political/Economic Section Chief at the U. Groth served as the Economic and Commercial Section Chief in Haiti from 2008 until 2011, including before and after the January 2010 earthquake. Groth worked in the non-governmental organization field in West Africa (Senegal, Mali) and was a Peace Corps Volunteer fish culture extension agent in then-Zaire from 1979 to 1982. Groth speaks French, Haitian Kreyol and has working knowledge of German, Hungarian and Tshiluba, an African Bantu tongue. His areas of scholarly and professional expertise are coercion, deterrence, air power theory, strategy, international relations, and security studies. Air Force officer and A-10 pilot with combat tours in Iraq, Bosnia, Kosovo, and Afghanistan. He commanded an operational A-10 squadron, served as the Senior Air Force Advisor at the U. Naval War College, and Military History and National Security Studies at Yale University. Her research interests include international security, compellence, asymmetric conflict, military intervention, counterinsurgency and insurgency, terrorism and counterterrorism, the uses of military power, and U. Hazelton previously taught at the University of Rochester and spent two years as a research fellow at the Belfer Center, Harvard Kennedy School. Before returning to academia, Hazelton was an Associated Press journalist whose posts included New York, Washington, and Tokyo. Professor James Holmes is a Phi Beta Kappa graduate of Vanderbilt University and earned graduate degrees at Salve Regina University, Providence College, and the Fletcher School of Law and Diplomacy at Tufts University. He graduated from the Naval War College in 1994, earning the Naval War College Foundation Award, signifying the top graduate in his class. Maritime 28 Strategy (co-author), and Strategy in the Second Nuclear Age: Power, Ambition, and the Ultimate Weapon (co-editor). He has testified before subcommittees of the House Committee on International Relations regarding terrorism in South and Southwest Asia, and is regularly involved in discussions on security issues in those regions with the U. Hoyt served previously as Co-Chairman of the Indian Ocean Regional Studies Group at the Naval War College. He is the author of Military Industries and Regional Defense Policy: India, Iraq and Israel, and over 40 articles and chapters on international security and military affairs. He is currently working on a book on the strategy of the Irish Republican Army from 1913-2005, projects examining U. In 2011, Professor Jackson deployed as a mobilized Army reservist to Afghanistan where he served as the Executive Officer for Policy Planning for the Deputy Chief of Staff of Operations, International Security Assistance Force Afghanistan. Prior to entering academia, Professor Jackson worked for several years in the corporate sector in financial trading, telecommunications, transportation markets, and power development. He also served four years on active duty with the United States Army in Germany as an armor and cavalry officer. Kadercan specializes in the intersection of international relations theory, international security, military-diplomatic history, and political geography. The third project, in turn, examines the association between civil-military relations and the production as well as diffusion of military power. He has deployed to the Mediterranean Sea, the Northern Atlantic Ocean and the Arabian Gulf. Lane is Associate Professor of Strategy and Policy and Director of the Greater Middle East Research Study Group at the Naval War College. She specializes in Comparative Politics and International Relations of the Middle East with a focus on security sector development, ethnic and religious nationalism, and rule of law in transitioning societies. Her co-edited book Building Rule of Law in the Arab World and Beyond was published in 2016. She is currently completing research on a book manuscript about counterterrorism and state liberalization in the Middle East. She has served as a visiting research affiliate with the Truman Institute for the Advancement of Peace at the Hebrew University of Jerusalem, a U. Fulbright scholar grantee in Syria, and as a research fellow with the International Security Program at the Belfer Center for Science and International Affairs at Harvard University. Marine Corps, is a Marine artillery officer and native of New England who graduated from the University of Connecticut in 1993 with a B. His operational experience includes multiple tours with the 1st and 4th Marine and Divisions as well as a three year tour at U. Maurer is the Alfred Thayer Mahan Professor of Sea Power and Grand Strategy and served as the Chair of the Strategy and Policy. He is the author or editor of books examining the outbreak of the First World War, military interventions in the developing world, naval rivalries and arms control between the two world wars, and a study about Winston Churchill and British grand strategy. He holds the positions of Senior Research Fellow at the Foreign Policy Research Institute, on the Editorial Board of Orbis: A Journal of World Affairs, the Academic Board of Advisers of the International Churchill Centre, and Associate Editor of Diplomacy and Statecraft. At the Naval War College, he teaches in the advanced strategy program and an elective course on Winston Churchill as a statesman, strategist, politician, soldier, and war leader. In recognition for his contribution to professional military education, he has received the U. Before joining the faculty of the Naval War College, he taught history at Brewton-Parker College in Mount Vernon, Georgia. In 2001, he held a fellowship at the West Point Summer Seminar in Military History. Specializing in warfare at sea, navies, sea power, and joint operations during the "Age of Sail," he is the author of Admiral Lord Keith and the Naval War against Napoleon (University Press of Florida, 2006), as well as Utmost Gallantry: the U. His articles have appeared in Naval History, the Journal of Military History, and the Northern Mariner. In addition to these, he was recognized with the award of Civilian Educator of the Year for History in 2013. He is the author of the Rocky Road to the Great War: the evolution of trench warfare to 1914. He has also written articles on fortification and the evolution of warfare 32 in the 19th and early 20th centuries, and he is editing two books. His operational experience includes carrier-jet aviation (S-3B Viking) and naval intelligence with flying and staff deployments in three aircraft carriers and in Kabul, Afghanistan. His research interests include coercion, diplomatic communication and signaling, and decisionmaking. His first two books looked at the battle and occupation of Okinawa: Keystone: the American Occupation of Okinawa and U. His next book looked at coalition warfare: Allies Against the Rising Sun: the United States, the British Nations, and the Defeat of Imperial Japan (2009). His fourth book, Dropping the Torch: Jimmy Carter, the Olympic Boycott, and the Cold War (2010), is a diplomatic history of the 1980 Olympic boycott. He is a Fellow of the Royal Historical Society and has received five writing awards. He previously taught at Texas A&M University-Commerce, the Air War College, the University of Southern Mississippi, and the U. Before joining the Naval War College, he served as an assistant professor at Morrisville State College, and as an associate professor at Hawaii Pacific University, where he taught courses in history. This book received a distinguished book award from the Society for Military History. Satterfield is also the author of articles on several topics in military history, including irregular warfare and revolutions in military affairs. He joined the Strategy and Policy Department in 2012 as an Air Force colonel and became the Associate Dean in 2014 after retiring from active duty. His research interests include the transformative role of automation in warfare and the impact of technological change on institutions, society, and military strategy. He spent much of his military career in the high-altitude reconnaissance community as a U-2 pilot enjoying the view over interesting regions of the globe. Navy, is a Naval Aviator commissioned through Aviation Officer Candidate School in May 1989. Commander Sheehan holds degrees from the United States Naval Postgraduate School (Ph. He has logged over 3,500 flight hours and 750 arrested landings on 9 aircraft carriers. He subsequently served as engagement lead for South and East Africa at United States Naval Forces Africa in Naples, Italy. After earning his doctorate, he joined the faculty of the United States Naval War College in October 2013. Captain Soltero has completed multiple overseas deployments to the Mediterranean, Middle East, and Western Pacific and accumulated over 4,000 flight hours. He has taught at Hamilton College and at Kansas State University, where he served as director of the Institute for Military History. He has also been a fellow at the Center for Advanced Study in the Behavioral Sciences at Stanford University. His first book Hammer and Rifle: the Militarization of the Soviet Union, 19261933 (2000) won the Shulman Prize of the Association for Slavic, East European, and Eurasian Studies and the Best First Book Prize of the Historical Society. He has also published A Military History of Russia: From Ivan the Terrible to the War in Chechnya (2006), and the Russian Army in the Great War: the Eastern Front, 1914-1917 (2015). He is the author of several dozen articles and book chapters on Russian / Soviet military history and foreign policy. He holds a Masters in Aeronautical Science from Embry-Riddle University, is a 1998 graduate of the U. Professor Anand Toprani is a specialist in energy geopolitics and great power relations. He was also the recipient of the Smith Richardson Predoctoral Fellowship in International Security Studies from Yale University and the Ernest May Fellowship in History & Policy from Harvard University. His academic work has appeared or been accepted for publication in scholarly journals such as Diplomatic History, the Journal of Strategic Studies, and the Journal of Military History, and he is currently preparing a manuscript on oil and grand strategy for publication. Van Vleck, a 1981 graduate of the United States Merchant Marine Academy, Kings Point, New York. He has 27 years of commercial maritime and Military Sealift Command experience afloat and ashore. Prior to his assignment at the Naval War College, he was assigned as Military Sealift Command Pacific/Naval Fleet Auxiliary Force, West Deputy Director, later restructured as Deputy Commander, Commander Sealift Logistics. Professor Van Vleck reported to the Naval War College in 2005 to lead, manage, and field the Online Professional Military 36 Education continuum for junior officers and enlisted sailors. Before joining the War College faculty in 1998, he taught Chinese history at Harvard and at Wellesley College. He is a graduate of Marine Corps Amphibious Warfare School, Joint Forces Staff College and numerous specialized military skills schools and courses. His past assignments include service as a Rifle Platoon Commander, Rifle Company Executive Officer, and Battalion Liaison Officer with the 3rd Battalion, 3rd Marine Regiment; Series Commander and Company Commander with 2nd and 3rd Recruit Training Battalions, Marine Corps Recruit Depot, San Diego; Rifle Company Commander, Weapons Company Commander, Maritime Special Purpose Force Commander, and Battalion Operations Officer with the 3d Battalion, 5th Marine Regiment; G3 Future Operations Planner with the First Marine Expeditionary Force (Forward); Joint Assessments Branch Chief with U. Special Operations Command; Commanding Officer of the 1st Battalion, 1st Marine Regiment; Future Operations Officer and Special Operations Coordinator with the 1st Marine Division (Forward) / Task Force Leatherneck, Deputy for the Amphibious Warfare Branch, Expeditionary Warfare 37 Division, Office of the Chief of Naval Operations; and Commanding Officer of the Marine Corps Tactics and Operations Group. He has deployed overseas as part of two Unit Deployment Programs, two Marine Expeditionary Unit deployments, and for combat operations in Iraq (2003 and 2006-7) and Afghanistan (2012). Colonel Wonson also served as the first Marine Corps Fellow in the Yale International Security Studies Program. He is the author of numerous published articles and editorial pieces, and has received writing awards from both the Marine Corps Gazette and U. General: One of the primary goals of a Joint Professional Military Education lies in the desire to "develop strategic leaders who can think critically. These sometimes-complementary, sometimesconflicting works will not provide standardized answers. Instead, they will spark thought, foster debate, and underwrite the creativity needed for true critical strategic analysis. Instead, this module lays the first cornerstone in a foundation which will be augmented by others. Thucydides, Mao, Mahan, Corbett) and tested by application through a wide range of case studies drawn from across the range of military operations in the weeks to come. Both expected their students to use their minds critically and creatively-as does the Naval War College. Clausewitz was systematic in his approach, whereas Sun Tzu was suggestive, and the two came from very different cultures. In his memoirs, Colin Powell recalled the profound impact that studying On War had on his intellectual development. His On War, written 106 years `before I was born, was like a beam of light from the past, still illuminating present-day military quandaries. Recent analysts have suggested that technology may dispel these conditions-conclusions students are encouraged to consider and debate. Indeed, Sun Tzu suggests that a smart commander will try to increase the fog and friction on the enemy side. Clausewitz portrays war as a violent but purposeful clash of interacting wills, while Sun Tzu usefully adds the view of war as a contest over information. Although neither Clausewitz nor Sun Tzu claims to provide formulas for proper practice, they each offer prescriptive concepts. The ancient Chinese text also stands as a forerunner of certain aspects of contemporary information operations, especially the use of deception. Indeed, the Art of War treats information superiority as a key determinant of strategic success. Clausewitz, for his part, was skeptical that intelligence and deception could deliver what Sun Tzu promised. The most important prescriptive point in these two texts is that war must serve a rational political purpose. Both On War and the Art of War stress the need to match strategy to policy, as does our first course theme. The same is true for official documents such as the National Security Strategy of the United States and the National Military Strategy of the United States. Military (and non-military) instruments must be used in ways calculated to achieve specified political objectives. Moreover, both Clausewitz and Sun Tzu emphasize that the cost of waging war must be rationally accounted for as well. Clausewitz counsels his readers that as costs in blood, treasure, and time come to exceed the "value of the object," the use of force must be reassessed, even renounced. But keeping war rational is never easy, and Clausewitz and Sun Tzu are well aware that irrationality abounds in war. Chance, complexity, human passions, and factors beyond human control all make rational calculation very difficult. In a warning worth the close attention of contemporary theorists, Clausewitz highlights how difficult it is to anticipate the effects that the actions of one side will have on the other. It is at this point that the crucial issue of strategic leadership looms large in both On War and the Art of War, as it does in this course. Strategic leaders must master interaction with the enemy if they are to succeed in achieving policy aims within rational constraints in a dynamic security environment. Much of the detailed analysis by Clausewitz and many of the aphorisms attributed to Sun Tzu concern the characteristics and activities of strategic leadership necessary to handle the problems of rationality and interaction. What they say can be tested against the actions of the strategic leaders profiled in our historical case studies and considered in relation to contemporary models of leadership. Students should bear in mind that what makes for superior operational leadership may not make for superior strategic leadership (and vice versa), but there can be little doubt that a thorough appreciation of both is essential to the profession of arms. Two categories of strategists are in evidence in On War and the Art of War: political leaders and military commanders. Under the rubric of "civil-military relations" we will consider the interactions of these two sets of leaders throughout this course as well as the impact on command and control. Clausewitz and Sun Tzu provide much material for debate about the 40 proper roles of political and military leaders. Both agree that political leaders must determine the overall policy objectives that strategy (military and non-military) must support in any war. At the same time, the dynamics of interaction, and the other pressures faced by military commanders give rise to civil-military tensions regarding the best ways and means to employ force against the enemy. Students should carefully consider the different approaches to resolving those tensions that Clausewitz and Sun Tzu offer. Civil-military tension does not necessarily vanish in peacetime: military leaders must still provide sound strategic advice on the utility and limitations of military force to policymakers in order to promote national interests and objectives. The value is also clear in wartime: it is doubtful mission command can ever be fully realized without a keen grasp of the dynamics of civil-military relations, its requirements and its pitfalls. A hallmark of the Strategy and Policy Course is its coverage of the many different types of war and the wide range of conflicts across the range of military operations that it covers.
An ankle questionnaire known as the Performance test protocol and scoring scale for the evaluation of ankle injuries can be used to quantify the level of ankle dysfunction breast cancer hoodies purchase 2 mg estrace amex. We should assess range of motion of the spine: forward bending/backward bending women's health center elk grove ca 2 mg estrace otc, side-bending menopause zits generic estrace 2mg without a prescription, and rotation menopause 55 plus estrace 1 mg without a prescription. In addition womens health logo estrace 1 mg visa, performance of the lower limb tension tests (also known as neural tension tests) involves assessment of the various branches of the sciatic nerve womens health 95825 buy 2mg estrace free shipping, as well as the femoral women's health issues in south africa generic 2mg estrace visa, obturator womens health institute peoria il order 1mg estrace fast delivery, and saphenous nerves. Testing of the sciatic nerve can be done via combinations of four different positions to incriminate the sciatic, tibial, sural, and common peroneal nerves. Each of the tests would be deemed positive if the neurological symptoms are reproduced. Unfortunately there is not any literature on sensitivity but specificity is very high and makes the prone knee bend tests strong diagnostic assessments. Hypoactive reflexes may be the result of muscle, nerve, nerve root, or spinal cord damage. Structural impairments include screening for fractures, instability, and leg length discrepancy. Gulick, iOrtho+ Mobile App, 2016 Structural Impairments the Patella-Pubic Percussion test is used to assess for hip fractures or structural pathology. With the stethoscope in your ears, vibrate a tuning fork and place it on the patella. Comparing the involved to uninvolved side may be necessary to have an appreciation for subtle changes in the quality of the sound transmission. The positive likelihood ratio is also huge, while the negative likelihood ratio is low. Thus, this test is an exceptional test for both screening and diagnostic purposes to pick up some type of structural pathology. Data published by Teitelbaum et al (2002) reported the use of the patella, medial, and lateral hamstring reflexes to be good diagnostic tools for the detection of unilateral cerebral lesions. However, there is no statistical data on the tibialis posterior or Achilles reflex. You are strongly encouraged to not only examine the involved joint but also the joint proximal and distal. The client sits on the edge of a plinth or a chair that is high enough to have his/ her feet off the floor. The clinician weaves a hand underneath the suspected injured region of the femur to the contralateral thigh. Body weight through the Orthopedic Special Tests: Lower Extremity 15 ischial tuberosity provides proximal stabilization. The clinician applies a vertical force at the distal femur to create a fulcrum of the femur. This test is excellent for ruling out femoral stress fractures and moderate for diagnostic purposes. Hip Fulcrum Test Sign of the Buttock - 1 Gulick, iOrtho+ Mobile App, 2016 Sign of the Buttock - 2 Gulick, iOrtho+ Mobile App, 2016 Hip Fulcrum Test Sensitivity = 93%, Specificity = 75% the Sign of the Buttock is a unique test used to identify a number of non-musculoskeletal pathologies. This term was coined by Cyriax and looks to a combination of findings to identify serious pathology. Under normal circumstances, one would expect hip flexion to increase when the knee is flexed. Is it a local lesion or is it referred from the hip, sciatic nerve, or hamstrings If the following seven signs/symptoms are present, this would be considered a "red flag" and a physician referral should occur An example of how this test is used was described by VanWye (2009) with a 77 year old male with a diagnosis of lumbosacral and hip osteoarthritis. When the clinician identified a positive "sign of the buttock," empty end feels for all hip motions, and severe night pain, a referral was made. With the assistance of additional testing, a diagnosis of primary lung adenocarcinoma with widespread metastases (including the hip) was made. Some clinicians recommend holding the contralateral limb in a flexed position beyond 90 degrees to stabilize the pelvis. A limb length difference is not unusual: one study reported that 32% of 600 military recruits had a 1/5 inch (0. Although discrepancies may be common, it does not mean there are not residual effects: for example, differences of 3. However, a simple measure does not tell us whether the discrepancy is a structural (anatomic) or a functional (apparent) difference. Impingement Tests Impingement, first described by Smith-Petersen (1936), is caused by abnormal contact between the femur and the acetabulum. Cam impingement is an osseous abnormality (bone bump) at the femoral head-neck junction. Pincer impingement is an abnormality of the bony acetabulum leading to over-coverage of the femoral head, i. However, these additional maneuvers do not appear to enhance the statistical values. It cushions the hip joint and prevents the femoral head from rubbing against the acetabulum. While moving through this diagonal, a longitudinal compressive force is applied through the femur to load the hip joint. In addition to assessing labral lesions, it has been reported to be used to assess iliofemoral ligament laxity and hip impingement. Some literature has associated phantom hip disease with a prodromal upper respiratory infection. Log Roll Test Gulick, iOrtho+ Mobile App, 2016 Posterior Labral Test Start Position Gulick, iOrtho+ Mobile App, 2016 the scour test mimics the technique of scrubbing a soiled pan. The repetitive, slow-amplitude, circular motions, combined with an axial load through the femur, incriminates the acetabular labrum. If the labrum is captured, the client may experience a click, a grinding sensation, or pain. Unfortunately, of all the tests identified, only the Taking off the shoe and the Trendelenburg tests has any statistical values to support their use. Clinical application comes down to a thorough understanding of anatomy and muscle actions. If a client attempts to lift a weight heavier then he/she is capable of moving, the tendency may be to also recruit the hip adductors. This can result in a valgus moment and increased stress on the common muscular attachment. Thus, although there are different types of hernias, the test used to identify them aims to simultaneously recruit these muscles. The plinth is used as a fulcrum for the client to lean back and eccentrically recruit the rectus abdominis. The gracilis adducts, internally rotates, and flexes the hip, as well as participating in flexion of the knee. To perform the Phelps Test, the client is asked to assume a prone position and the clinician passively abducts the involved lower extremities to endrange. Since the gracilis is involved in knee flexion, this position is putting the gracilis muscle on slack and should allow for an increase in hip abduction motion. Phelps Test A sport hernia, aka athletic pubalgia, is essentially a tug-of-war between the rectus abdominis and the adductor muscles. The distal rectus abdominis and the proximal adductor muscles share a common attachment in the pubis. First the client is positioned in supine on a plinth such that the knees are hanging over the edge. The client holds the uninvolved knee to the chest and allows the involved hip to extend. However, this test has the potential to incriminate both the iliopsoas and rectus femoris. The iliopsoas is a hip flexor but the rectus femoris is biarticulate and serves to both flex the hip and extend the knee. The prone position is preferred because it can achieve better lumbar stabilization than sidelying. Limited knee flexion (< 135 degrees) or the production of hip flexion is a positive test. The Ober test is performed in sidelying with the involved hip superior and the pelvis stabilized. That being said, the testing process uses the 30 degree knee flexion point as the key to rating irritability. Pressure is applied while flexing and extending the knee over the 30 degree angle. If pain or clicking is reproduced with this translation, the test is considered positive. Popliteal angle (the angle of the shaft of the femur and the shaft of the tibia) is then measured with a goniometer. Children up to two years of age can typically achieve 180 degrees of knee extension (or 0 degrees if you read the alternative scale on the goniometer). By the age of six years, the range decreases to 155 degrees and for adults, a normal measure is 125 degrees. The client may be able to provide information about the location of the pain to distinguish the biceps femoris from the semimembranosis and semitendinosis. There has been some literature (Delp, 1999) that revealed that the piriformis functions as both an internal and external rotator depending on the amount of hip flexion that occurs. We actually see that with a number of muscles in the gluteal region: a variety of hip extensors change their angle of pull to the extent that they function as internal rotators versus external rotators as the quantity of hip flexion increases. In the supine position with hip flexed to 70-80 degrees and knee flexed to 90 degrees, the hip is maximally adducted. In standing, the client uses the contralateral foot to stabilize the ipsilateral shoe. Although there is only one study on this technique, the statistics are interesting. In addition, the timing/location of the pain and the timing/magnitude of the swelling can yield valuable information about the injury: we know that some structures are highly vascularized and will swell quickly, whereas others are poorly vascularized and will swell slowly, so the timing of the swelling can help us appreciate what type of tissue may be injured. As previously discussed, various questionnaires can be used to reveal information about pain and function. Fractures As with the examination of any joint, ruling out fractures is important. For the knee, osseous concerns can be assessed via any one of several "knee rules. In the interest of clarity, the two charts below summarize the criteria for the various "rules" and provide the statistics associated with each of the evaluative criteria. One key point when applying these rules is the precise palpation of bony structures. In order to determine if a radiograph is warranted, tenderness of bony landmarks are included in two of the four criteria. All of these "rules" demonstrate much better sensitivity than Orthopedic Special Tests: Lower Extremity 23 Gulick, iOrtho+ Mobile App, 2016 the Trendelenburg Test is used to discover the presence of gluteus medius muscle weakness. With the hip in neutral, the gluteus medius and minimus function together to abduct the thigh. With the hip flexed, the gluteus medius and minimus have been said to internally rotate the thigh. With the hip extended, the gluteus medius and minimus externally rotate the thigh. During gait, these two muscles function to support the body in unilateral stance, and in conjunction with the tensor fasciae latae, prevent the pelvis from dropping to the opposite side. Consequently, these "rules" are very good at ruling out the possibility of a fracture but if the criteria are positive, they are not good at making the diagnosis of a fracture. If the Ottawa Knee Rules had been applied, only 460 would have required a radiograph. Ligaments We will examine four main ligaments of the knee: collaterals (medial and lateral) and cruciates (anterior and posterior). The first four have been studied extensively while the latter two have no statistical data. Excessive anterior translation of the proximal tibia on the femur or a soft endfeel is a positive test. A torn posterior horn of the meniscus can wedge against the femoral condyle and result in a false negative result also. In addition, when combined with other symptoms (effusion, popping, or giving way), diagnostic ability improves. With the hamstrings relaxed and the femur stabilized, the proximal tibia is translated anterior. In supine, the client is positioned with the knee between 20-35 degrees of flexion and the feet in spacer device. Once the gauge is zeroed out, the handle is pulled to apply an anterior translation of the tibia on the femur. With the quadriceps attached to the tibial tuberosity, contraction results in anterior translation if the distal tibia is fixed. This motion can also be replicated with four other methods: a leg press machine, a forward lunge, a lateral step-up, or descending a flight of stairs. Posterior Drawer Test Sag Test Sensitivity = 46-100%, Specificity = 100% Posterior Drawer + Sag Test Sensitivity = 90%, Specificity = 99% the sag test places the client in supine with both the hips and knees flexed to 90 degrees. This test is performed in 45 degrees of hip flexion and 90 degrees of knee flexion. The distal tibia is stabilized while the client is asked to contract the quadriceps muscle. A positive test is more anterior translation of the tibia on the ipsilateral side than the contralateral side. Thus, as always, the clinician should look for multiple positive tests for a given structure to corroborate its damage. Meniscus With the meniscus, the mechanism of injury can be a rapid acceleration/deceleration, hyperflexion, a forced valgus with the tibia in external rotation, or cleats that get stuck on the playing surface to name a few. As a child the mostly peripheral region is known as the "red zone" because it is vascular. As we move towards the central region of the meniscus, the area is known as the red-white zone and then the white zone. Excessive posterior excursion, when compared to the contralateral limb, is a positive test. The test is easy and the statistics are strong, in isolation and in combination with the sag test. There have been seven meniscal tests identified in the literature: some of the techniques for meniscal assessment are global and unable to distinguish the location of the tear, and others are more precise. Overall, the magnitude of knee flexion can be of assistance in incriminating the location of a meniscal tear. For example, the Childress duck walking test is used to identify tears in the posterior horns of the meniscus because a deep squat compresses this region. However, there are other structures that could produce pain and limit the ability to perform a full squat. For these reasons, the statistical values of sensitivity (55-68%) and specificity (60-67%) are understandable. Internal rotation is used to incriminate the lateral meniscus and external rotation the medial meniscus. To assess the medial meniscus, the clinician uses one hand to grasp the distal tibia and places the other hand on the lateral aspect of the knee. To assess the lateral meniscus, the clinician uses one hand to grasp the distal tibia and the other places hand on the medial aspect of the knee. Sometimes these maneuvers need to be performed a few times to "capture" the meniscus. If the symptoms present with the knee in flexion, one might suspect a posterior meniscus injury, while symptoms in extension may be due to an anterior meniscus lesion. Fortunately, when combined with the palpation of joint line tenderness, the metrics improve dramatically. Now walk in an arc to one side of the client, go back to center, and repeat in the other direction. The goal is to have the client rotate on the knee while in a loaded/ compressed status. The Thessaly alone has strong diagnostic parameters; it has also been combined with the palpation of joint line tenderness, just like the McMurray. The Apley is performed in prone with the knee flexed to 90 degrees and a vertical compression force to the knee through the heel. The knee is stabilized proximally and the thumb and index finger are used to palpate the knee joint line. As an adaption, if a client has a current ankle problem or a history of ankle instability, the rotation forces could be applied through the tibia. The transverse restraints are the medial and lateral retinacula which joins the vastus medialis and lateralis. The patella lengthens the moment arm by increasing the distance of the quadriceps and patellar tendon from the axis of the knee. Acting as a pulley, the patella changes the line of pull of the muscle and reduces the friction between the quad tendon and the femoral condyles.
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