The effect and severity of a meltdown also can vary because plaintiffs are individuals of different ages and sizes skin care 85037 permethrin 30 gm lowest price. The family determined that with only three Re-ad Passes remaining per person acne early sign of pregnancy buy permethrin 30gm without a prescription, it would not be possible to visit all of A skin care 6 months before wedding safe 30 gm permethrin. So we got smart and [had the elder sister] running to get return times skin care 3 months before marriage purchase 30 gm permethrin amex, and we were trying to coordinate those with the [Re-ad Passes] that we had in conjunction-or in the case of one other park skin care 6 months before wedding buy permethrin 30 gm amex, the Fast Pass Plus acne images discount permethrin 30gm free shipping. James emphasized the "brain-behavior relationships" that inform scientific understanding of autism acne 38 weeks pregnant buy 30 gm permethrin fast delivery. James reported: "Good executive functioning requires sustained attention and effort acne aid soap order 30gm permethrin mastercard, inhibition of the parties each filed motions to exclude certain expert reports or portions of them based on, inter alia, Daubert v. The district court granted summary judgment in favor of Disney and did not rule on those motions. At this juncture, we consider these expert reports as part of the record on appeal. James indicated that individuals with autism, like plaintiffs, demonstrate "global deficits in executive functioning, both in terms of behavioral regulation. James explained that "[i]ndividuals with poor executive control typically have difficulty regulating their emotions, controlling impulses, using good judgment, sustaining attention, making sound decisions, initiating appropriate courses of action, and flexibly changing course when receiving feedback that current plans of action and behavior are not working. James cited a study of school-age children, which found that individuals with autism "struggled particularly with shifting- that is, the capacity to move freely from one situation, activity, or aspect of a problem to another as the situation demands, to transition, and solve problems flexibly. James also testified that for a person with autism, a routine or prescribed order is "more than [a] preference," and is "a biologically driven mechanism. Myers, Identification and Evaluation of Children with Autism Spectrum Disorders, 120 Pediatrics 1183, 1194 (2007). Plaintiffs cite another authority that describes "the need to preserve sameness" as one of the "behavioral symptoms seen in children with autism. The same book suggests that these "behavioral symptoms" are related to "physiological abnormalities" including "physiological overarousal to novel events and underarousal and slower rates of habituation. As to the inability to defer gratification, plaintiffs cite a study which found that children at the high functioning end of the autism spectrum demonstrated a reduced ability to exercise "effortful control" and delay gratification. Susan Faja & Geraldine Dawson, Reduced Delay of Gratification and Effortful Control Among Young Children with Autism Spectrum Disorders, 19 Autism 91, 99101 (2015). That study examined 42 children, half of whom had autism and half of whom did not. One at a time, the children were left for 15 minutes alone in a room, where they were seated at a table with a small candy treat and a larger candy treat. The children were not told the wait time, but were told that if they waited at the table until the investigator returned, they could have the larger treat, but if they did not wait, they could have only the smaller treat. Plaintiffs claim their impairments are far more severe than those in the Faja-Dawson study. Kelderman acknowledged that individuals with autism spectrum disorder can evince "[r]igidity, which can include insistence on sameness or nonfunctional routines. Kelderman explained that "[i]ntroducing alternative behaviors (a technical term for distraction technique) is helpful not only for individuals with disabilities, but their typically developing peers. Kelderman stated 33 Case: 16-12647 Date Filed: 08/17/2018 Page: 34 of 65 that there is no body of research outlining the inability of people with autism to (1) "browse" or to (2) "impulsively enjoy substitute experiences. Kelderman acknowledged that individuals with autism can have more difficulty with waiting than do people without autism, "because it is anxiety-provoking. Spector noted that "[c]hildren, developmentally disabled or not, typically do not handle delays and waits" as well as adults do, and "may have little experience with having to wait in line as much as is required on a typical day at a Disney theme park. Spector opined that the inherent challenges of taking any child to a Disney theme park make it difficult to attribute any particular negative experience 35 Case: 16-12647 Date Filed: 08/17/2018 Page: 36 of 65 to autism. Spector opined that parents of children with autism are capable of "utilizing the same behavioral tactics, plans, and preparations as do every other parent anticipating a visit to a Disney theme park. Having reviewed the evidence, we outline the procedural history that led to the summary judgment motions. District Court for the Central District of California, and were transferred to the district court in Florida. During the litigation, 6 of the plaintiff families voluntarily dismissed their claims, leaving 37 separate lawsuits. In September 2016, the district court granted summary judgment for Disney in the 37 remaining cases. The district court entered substantially the same summary judgment order in each case. The district court determined that there were no issues of material fact and that plaintiffs had not made the required showing that their requested modifications were "necessary" to afford them "equal access" to the benefits of a Disney theme park. In those cases where the issue was contested, the district court also concluded that plaintiffs "can deviate from [their] preordained route[s]. While the district court also concluded that plaintiffs lack standing, Disney now agrees that plaintiffs have standing, and independently we agree too. A district court properly grants summary judgment when there is no genuine dispute as to any material fact and the moving party is entitled to judgment as a matter of law. The court draws all inferences and reviews all evidence in the light most favorable to the nonmoving party. The court does not weigh conflicting evidence or determine the credibility of witnesses. A nonmoving party seeking to establish that there is a dispute of fact must set forth specific facts showing that there is a genuine issue for trial. The nonmoving party may not rest upon the mere allegations or denials of his pleading. Upon discovering a genuine material dispute, the court must deny summary judgment and proceed to trial on that issue. The "General rule" in § 12182(a) provides that "[n]o individual shall be discriminated against on the basis of disability in the full and equal enjoyment of the goods, services, facilities, 40 Case: 16-12647 Date Filed: 08/17/2018 Page: 41 of 65 privileges, advantages, or accommodations of any place of public accommodation. As discussed later, the "General prohibitions" in § 12182(b)(1) describe ways in which discrimination may occur, and the "Specific prohibitions" in § 12182(b)(2) provide examples of actions or omissions that may result in discrimination. The statute provides a non-exhaustive list of "major life activities" that includes "caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working. In turn, the benefits of a modification that are "obtainable by children at one end of the [autism] spectrum will differ dramatically from those obtainable by children at the other end, with infinite variations in between. First, Disney has not contested that all plaintiffs have severe autism and/or cognitive impairments. Second, based on annual figures, Disney has about 55,000 visitors a day at Magic Kingdom and a minimum of 26,000 visitors a day at other parks. This is not a case where a plaintiff guest has been denied accommodations across the board. This is a case where a public place has many thousands of guests each day and provides an identifiable and quantifiable accommodation based on its assessment of its most severely disabled guests. Plaintiffs request this standardized pass to create a "predictable experience" for autistic children. Because this Court has not previously addressed a claim under § 12182(b)(2)(A)(ii), we review § 12182(b) to place that subsection in context. Section 12182(b)(1) contains "General prohibitions" against discrimination, including the "denial of the opportunity" for a disabled person "to participate in or benefit" from services or facilities. Another "General prohibition" provides that it is discriminatory to afford a disabled person "the opportunity to participate in or benefit from" services or facilities "that [are] not equal to that afforded to other individuals. Along with these general principles, § 12182(b)(2) provides for "Specific prohibitions," which are examples of actions or omissions that constitute such discrimination. The plaintiff bears the burden of proving not only that he is disabled but also that his requested modification is both "reasonable" and "necessary. The defendant private entity bears the burden of proof on the fundamental alteration inquiry. The three inquiries are: (1) whether the requested modification is "reasonable"; (2) whether the requested modification is "necessary" for the disabled individual; and (3) whether the requested modification would "fundamentally alter the nature" of the public accommodation. The Supreme Court instructed that "[w]hether one question should be decided before the others likely will vary from case to case, for in logic there seems to be no necessary priority among the three. In some cases, "the specifics of the claimed disability might be examined within the context of what is a reasonable or necessary modification. The district court did not rule on the reasonableness or fundamental alteration inquiries. The Supreme Court instructed: "In such cases, an accommodation might be reasonable but not necessary. The plaintiff in Martin could not walk the entire 18-hole course or compete without a golf cart. Even with a cart, the plaintiff had to get in and out of the cart, walk over a mile during an 18-hole round, and suffered fatigue "undeniably greater" than that endured by able-bodied competitors from walking even that limited amount. It was undisputed that the plaintiff was disabled and that the cart did not put him at a competitive advantage. Yet hard questions are presented by the legal contours and factual complexity of what is "necessary" for these severely disabled plaintiffs. As to the legal standard, two circuit courts after Martin have addressed how to define "necessary" in § 12182(b)(2)(A)(ii). The Ninth Circuit in Baughman explained that "[p]ublic accommodations must start by considering how their facilities are used by nondisabled guests and then take reasonable steps to provide disabled guests with a like experience. Public accommodations have "to provide disabled patrons an experience comparable to that of able-bodied patrons. Facilities must "help disabled guests have an experience more akin to that of nondisabled guests. But any safety regulation Disney imposes "must be based on actual risks and not on mere speculation, stereotypes, or generalizations about individuals with disabilities. Indeed, in Liese this Court observed that the task of determining what is "necessary" under the Rehabilitation Act is "inherently fact-intensive" and "largely depends on 52 Case: 16-12647 Date Filed: 08/17/2018 Page: 53 of 65 context. The Silva Court added that "[n]onetheless, this does not mean that every request for an auxiliary aid that is not granted precludes summary judgment or creates liability. Reversing the grant of summary judgment, we concluded that plaintiffs presented sufficient evidence to create a fact issue on whether they were denied the auxiliary aids "necessary to ensure that a deaf patient was not impaired in exchanging medically relevant information with hospital staff," with a "level of communication. Analysis of "Necessary" We first agree with our sister circuits that public accommodations must start by considering how their facilities are used by nondisabled guests and then must take reasonable steps to provide disabled guests with a "like experience. All nondisabled guests must plan ahead in order to reserve FastPass+ times and can obtain only three FastPass+ reservations in advance. For the most popular rides, nondisabled guests often must endure wait times of over an hour and must stand all together in a physical line. We recognize the district court relied on the fact that plaintiffs have waited in cars or airplanes for many hours until they get to their travel destinations. Disney submits the gratification from these trips-reaching the desired destination-was delayed significantly and not instant. Disney argues that living in society requires waiting in cars, on planes, and in a myriad of other places, such as schools, medical offices, and restaurants. Nonetheless, plaintiffs presented conflicting evidence as to this behavioral aspect of their disabilities. But Disney theme parks are high-commotion environments and plaintiffs must virtually wait therein. The record, however, creates factual issues about whether plaintiffs are able to transition to other activities without meltdowns or other behavioral challenges when they cannot access rides in their already-fixed routine orders or cannot access the same ride repeatedly. Because factual disputes exist as to those impairments, we must reverse the grant of summary judgment in favor of Disney on the necessary-modification inquiry. Plaintiffs point out that the district court did not address those issues and should do so first. Undisputedly, this Court has the power to affirm a grant of summary judgment on any basis supported by the record. More specifically, plaintiffs ask this Court to implement this fix by ordering Disney to provide either: (1) a card offering automatic access to the FastPass lines for all rides at all times; or (2) between 6 and 10 guaranteed Re-ad Passes for the disabled guest and each person in the group. We thus conclude that the reasonable and fundamental alteration inquiries must be addressed by the district court in the first instance, and we leave it to the district court how best to approach those issues on remand and whether further record development is needed. Among other things, the district court will 61 Case: 16-12647 Date Filed: 08/17/2018 Page: 62 of 65 need to determine whether material issues of fact, if any, exist as to these two inquiries. Of course, nothing in this opinion addresses, or prevents plaintiffs on remand from presenting, intent evidence at trial that is admissible under the Federal Rules of Evidence. That issue is premature because evidentiary matters at trial are for the district court to decide in the first instance. Given that the complaints do not include intentional or disparate-impact discrimination claims, we also do not decide that legal issue. On appeal, plaintiffs argue that the district court erred as to their Unruh Act claims. Health careassociated infections (ie, hospital-onset and health careassociated community-onset), which made up 82% of the total infections, were included in this analysis. This analysis included only population catchment areas participating in the surveillance program continuously since January 2005. Cases were identified from microbiology reports provided by all clinical microbiology laboratories in acutecare facilities and reference laboratories that receive specimens for residents of the areas under surveillance. Surveillance personnel complete a standard case report form using data abstracted from inpatient and outpatient medical records. A more detailed description of the methods used for the project is available elsewhere. Cases were also categorized into infection syndromes based on diagnoses present in the medical records. Syndromes were classified as pneumonia or empyema, skin and soft tissue infections, bone and joint infections, urinary tract infections, endocarditis, or "other. This activity was also evaluated independently at each program site and either deemed a public health assessment or human subjects research and approved by local review boards when applicable. Statistical Analysis Because the focus of this evaluation was on health careassociated incidence rates, this analysis included only hospital-onset and health careassociated community-onset infections. Changes in incidence over time, stratified by epidemiological category, were preliminarily assessed using a Poisson regression model among Emerging Infections Program sites. To estimate the overall rate of change for all sites from 2005 through 2008, a hierarchical modeling method was used (hereafter referred to as the modeled rate). When using different dichotomous age break points (ie, 18 vs 18 years, and 40 vs 40 years) in separate models, the change estimate did not differ substantially from the estimate generated by the primary model. In addition, including age as a continuous variable (without race in the model) did not change the point estimates. Including age as a continuous variable with race in the same model could not be accomplished do to limited power in the resulting individual strata. The yearly decrease in dialysis patients was also modeled using a similar hierarchical modeling method; however, because race and age information was not available for the dialysis denominator, we were unable to adjust these models for these variables. These final models were also used to determine the adjusted incidence for each epidemiology category for each year studied. Of these, 21 333 reports (99%) allowed categorization into epidemiological classes: 12 235 infections (57%) were health careassociated community-onset, 5273 (25%) were hospital-onset, and 3825 (18%) were communityassociated. The percentage of overall infections that were health care- associated community-onset did not change significantly over the 4 Table 1. Invasive Methicillin-Resistant Staphylococcus aureus Infections Representing Specific Syndromes, January 2005-December 2008 No. Overall, 17 508 cases were either hospital-onset or health care associated community-onset and were included in this analysis. The mean age of case-patients with these infections was 61 years and did not vary significantly over time. Similarly, the age distribution in the catchment area did not change significantly over the study period. Other common infection syndromes included pneumonia or empyema (2427 [14%]), skin and soft tissue infections (1861 [11%]), bone and joint infections (2005 [11%]), urinary tract infections (1107 [6%]), and endocarditis (879 [5%]). Incidence of Invasive Methicillin-Resistant Staphylococcus aureus Infections, by Select Demographics and Epidemiological Classification, Active Bacterial Core Surveillance/Emerging Infection Program Sites, by Year, 2005-2008 Incidence per 10 000 a Actual Count Demographic Sex Male Female Age, y b 1 1 2-4 5-17 18-34 35-49 50-64 65 Race c White Black Other Overall 2005 2679 2038 48 1 11 26 312 909 1208 2202 2436 1760 136 4717 2006 2592 1887 56 5 11 7 307 862 1216 2014 2315 1627 150 4479 2007 2611 1752 41 4 15 22 293 779 1253 1956 2253 1640 137 4363 2008 2314 1635 41 3 7 25 267 660 1136 1808 1991 1442 145 3949 Health CareAssociated Community-Onset 2005 2. Overall incidence rates are point estimates for each year using the modeled b Age is missing from 1 case in 2006 and 2 cases in 2008. This would represent about a 19% decrease in these infections over the 4-year period. The annualized decrease in incidence was greatest for hospital-onset infections (9. Examples of such initiatives on a regional scale occurring outside of our surveillance program include the Michigan Keystone intensive care unit project and the Pittsburgh Regional Health Initiative project. However, because the total population of the catchment areas is used as the denominator in these incidence measures and not hospital patientdays, shorter lengths of stay could reclassify some infections from hospitalonset to community-onset. If patient length of stay did decrease, the incidence of hospital-onset infections might decrease simply because more of these infections occur after patients are discharged. However, we also found significant, albeit smaller reductions, in the incidence of health care associated, community-onset infections suggesting shorter length of stays does not explain all the observed changes in incidence rates. Further work is needed to understand the epidemiology of these infections among these groups, to guide the development and implementation of interventions aimed at prevention. First, data from the Emerging Infections Program/Active Bacterial Core surveillance system represent data from 9 metropolitan areas. Second, this surveillance system does not include nonresidents of the catchment area, so facility-specific incidence rates cannot be determined. For this reason, we are unable to use facility patient-days as a denominator to calculate valid facility-specific or overall incidence rates per patient-day. Third, the denominators used for both the primary and dialysis analyses are estimates and may not completely reflect the total number of patients nor their exact contribution in person-time; however, these issues would be unlikely to have changed over the study period. Author Contributions: Dr Kallen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Acquisition of data: Bulens, Reingold, Petit, Gershman, Ray, Harrison, Dumyati, Schaffner, Patel. Analysis and interpretation of data: Kallen, Mu, Reingold, Ray, Townes, Schaffner, Fridkin. Critical revision of the manuscript for important intellectual content: Kallen, Mu, Bulens, Reingold, Petit, Gershman, Ray, Harrison, Lynfield, Dumyati, Townes, Schaffner, Patel, Fridkin.
More than 90% of the acreage in the United States and over 70% of the soy17 Billion bushels Million acres bean acreage in Argentina and Brazil are treated with herbicides acne extraction buy 30gm permethrin with amex, which emphasizes the importance of weeds and their control worldwide in the prevention of soybean yield losses (Oerke 1994) acne mask cheap permethrin 30gm with amex. The incidence and severity of insects and fungi is higher in Argentina and Brazil than in the United States acne in children discount 30 gm permethrin mastercard, mainly because of tropical climates that favor pest infestations acne meaning generic permethrin 30gm overnight delivery. In the southern United States skin care diet buy permethrin 30 gm otc, the most damaging defoliating insects are velvetbean caterpillar (Anticarsia gemmatalis) and soybean looper (Pseudoplusia includens) (Higley and Boethel 1994) acne types buy 30 gm permethrin amex. The larval stages of these pests feed on leaf tissue skin care treatments buy 30gm permethrin overnight delivery, and heavy infestations can defoliate entire fields acne you first generic permethrin 30gm fast delivery. In addition to lepidopteran pests mentioned as problems in the United States, other prominent insect pests in Brazil and Argentina include Nezara viridula (green stink bug), Piezodorus guildinii (soybean stink bug), and Euschistus heros (neotropical brown stink bug) (Oerke 1994). Root and stem rot, Diaporthe phaseolorum, and Colletotrichum species are among the most damaging soybean diseases in U. Soybean cyst nematode and root knot nematodes are the principle nematode species causing economic yield losses in the United States (Oerke 1994). Root knot nematodes are the primary nematode species in South America (Oerke 1994). Over the past 2 to 3 yr, it has become an increasingly serious production problem in the North Central and Northern Great Plains states. These two viruses interact synergistically, resulting in more severe yield losses than caused by either virus alone (Reddy et al. Crop Development Techniques Development of agronomically acceptable, highyielding, pest-tolerant cultivars allows effective management of soybean pests while potentially decreasing dependence on chemical control options. Traditional methods of soybean improvement include selection in combination with hybridization or mutation breeding. Plants are selected for breeding after screening for a particular trait of interest. Desirable traits from different soybean varieties may be introduced into a single variety using conventional breeding methods. A germplasm collection of approximately 18,000 different soybean lines, mostly from Asia where soybean originated, is maintained in Stoneville, Mississippi, as a source of inherent resistance when a new pest problem arises (Barnes 2000; Hartwig 1987). Within this base of genetic characteristics, soybean varieties vary in many characteristics, including the ability to withstand pest infestations. This narrow base limits the development of soybean for such traits as pest resistance using conventional plant breeding methods (Christou et al. Limited levels of herbicide tolerance, insect resistance, and other pest control characteristics have been developed by means of conventional breeding. Through exposure to chemical and physical mutagens, the soybean genome is rearranged. In this manner, the production of desirable traits can result, although at low frequencies; most induced mutations have detrimental affects. Herbicide tolerance has also been developed through mutation breeding, for example a soybean resistant to sulfonylurea-containing herbicide was developed through mutation breeding. Modern biotechnology holds much promise for the continued improvement of soybean through introduction of traits that may not be available in the current soybean germplasm. Thus far, modern biotechnology has been used successfully in the development of herbicide-tolerant, insect-resistant, and disease-resistant soybean varieties although only herbicide-tolerant soybean is the only commercialized biotechnologyderived soybean with an improved pest control trait. Efforts to screen soybean germplasm for commercial levels of tolerance to glyphosate have not been successful (Kishore, Padgette, and Fraley 1992). The process involved soaking 450,000 soybean seeds in the chemical mutagen (ethyl methanesulfonate) and then screening and selecting the plants for sulfonylurea tolerance. The result was one plant that exhibited elevated tolerance to sulfonylurea herbicides such as chlorimuron and thifensulfuron. Multistate field trials were conducted in Illinois, Indiana, and Iowa in 1988 and the first generation of seed for the commercially approved event was field-tested in 1991 (Padgette et al. These amino acids are essential for crucial plant processes such as protein synthesis, cell wall formation, defense against pathogens and insects, production of hormones, and production of compounds required in energy transduction such as plastoquinone (Duke 1988). Glufosinate inhibits the biosynthetic enzyme gluta20 mine synthetase, which is involved in general nitrogen metabolism in plants, including the assimilation of ammonia accumulated as a result of photorespiration and nitrate reduction. The herbicidal activity of glufosinate is based on the resulting accumulation of ammonia in cells, the cessation of photorespiration and photosynthesis, and the disruption of chloroplast (Vasil 1996). Insect-Resistant Insect resistance in soybean has been achieved through the use of conventional breeding and genetic engineering. Marker assisted breeding also has facilitated identification and selection of natural insect resistance. Natural insect resistance in soybean has been identified in several exotic Japanese soybean lines towards Mexican bean beetles, bean leaf beetles, striped blister beetles, and stink bugs (Clark et al. The development of elite, insect-resistant, high-yielding soybean varieties by means of conventional plant breeding techniques has proven difficult due to the genetic complexity of insect resistance and the lack of cost effective methods for evaluating insect resistance in breeding programs (All, Boerma, and Todd 1989; Rowan et al. Four cultivars developed through conventional breeding methods possessing moderate insect tolerance have been released commercially. But these cultivars had agronomically unacceptable characteristics such as inferior yields, late maturity, and lodging susceptibility (Walker et al. Using genes from the soil bacterium Bacillus thuringiensis (Bt), genetic engineering has been used to introduce insect resistance to soybean. University of Georgia researchers made the first report of the successful expression of an insect-resistant gene from Bt in soybean, by means of the Cry1Ab gene (Walker et al. Subsequently, soybean lines were developed to express another Bt protein, Cry1Ac, by two separate groups, at the University of Georgia (Walker et al. Field tests showed that Cry1Ac Bt soybean had significant resistance to velvetbean caterpillar and lesser cornstalk borer (Elasmopalpus lignosellus), and less pronounced resistance to corn earworm (Heliothis zea) and soybean looper. The availability of resistance from various sources allows the "stacking" of insect resistance traits for more broad-spectrum insect control. Stacking may be used to combine different types of native insect resistance and/or resistance developed using genetic engineering through the use of conventional breeding or any combination. Indeed, to develop insecticidal soybean with a broad spectrum of control, Bt soybean is being stacked with the natural insecticidal resistance from exotic Japanese soybean lines mentioned earlier (Walker et al. Insect-resistant Bt soybean is still in development and has not been commercialized. CystX was found to possess resistance to more than 150 populations of soybean cyst nematode. CystX resistance was made available in a limited release for the 2001 and 2002 growing seasons. More extensive marketing will be facilitated by the stacking of CystX with glyphosate tolerance [C. Soybean resistance to cyst nematode also is being developed through biotechnology approaches using marker-assisted selection (Bell-Johnson et al. Research is in progress at the Universities of Illinois, Georgia, and North Carolina to identify and to characterize genes for the enhanced or over expression of proteinase inhibitors that are toxic to nematodes, through the use of marker-assisted selection. Proteinase inhibitors interfere with protein digestion in nematodes, eventually leading to mortality. Other Soybean Pest Control Traits Traditional crop improvement techniques have been used in the development of soybean varieties that can tolerate diseases such as Phytophthora root rot, downey mildew, bacterial pustule, target spot, and wild fire (Hartwig 1974; Hartwig, Musen, and Maxwell 1978; Hartwig and Epps 1977). The transgene used in this study, however, was not stable and resulted in the loss of resistance in subsequent plant generations. As early as 1957, the lack of effective and economical chemical options for nematode control in soybean increased the pressure to screen and to identify nematode-tolerant soybean genotypes (Caviness and Riggs 1976; Hartwig 1987). The stability of gene expression over multiple generations of this newly developed soybean line is still being tested. Insect-resistant soybean could be available in the next few years, while other pest control traits are expected further down the road. Argentina has the highest adoption rate of glyphosate-tolerant soybean, planting 98% of its 27. This is the highest adoption rate for any biotechnology-derived crop in the world. The popularity of glyphosate-tolerant soybean is due to advantages of the technology over conventional weed control practices. It is necessary to understand the limitations of conventional weed control options to appreciate why farmers have embraced glyphosatetolerant soybean. The major reasons farmers have adopted the herbicide-tolerant soybean so widely are lowered production costs, reduced crop injury, and simplicity and flexibility in weed management. Weed Control in Non-biotechnology-derived Soybean Weed control is one of the biggest challenges for soybean farmers because poorly controlled weeds drastically decrease crop yield and quality. Common cocklebur, jimsonweed, and velvetleaf are among the worst broadleaf weeds that infest soybean fields. Full season infestation of these weeds can result in soybean yield losses ranging from 12 to 80%, depending on the competing weed species and their density (Barrentine 1989; Stoller and Woolley 1985). United States soybean farmers began switching from the use of tillage to control weeds to herbicides in the late 1950s. Glyphosate-tolerant soybean has received regulatory approval for planting in Argentina, Canada, Japan, Mexico, the United States, and Uruguay (Nickson and Head 1999). First available in the United States and Argentina in 1996, adoption in those two countries account for 99% of total herbicide-tolerant soybean acreage in the world. The United States has the largest area planted to glyphosate-tolerant soybean, planted on 68% of the total 75. Herbicides are applied at various points of the growing season, during field preparation, planting, or crop growth. The efficacy of soilapplied herbicides depends greatly on rainfall, with poor weed control resulting from extremely low or high rainfall conditions after herbicide applications. Moreover, the decision to make a soil-applied herbicide treatment, and the selection of herbicide, involves guesswork because these decisions are made anticipating the weed species that may emerge. Commonly used soil applied soybean herbicides are chlorimuron, metolachlor, metribuzin, pendimethalin, and trifluralin. Postemergence herbicides are applied after the crop emerges from the soil, which provides farmers the opportunity to determine which weed species are emerging with their crop and enables them to better focus their weed management strategies on particular weed problems. Achieving weed control within 4 to 8 weeks after soybean emergence is crucial to avoid significant yield losses (Barrentine 1974; Eaton, Russ, and Feltner 1976). Currently, there are at least 70 registrations for herbicides for weed management in soybean, plus numerous mixtures (Crop Protection Reference 2002). Even with all these choices, several deficiencies persist in soybean weed control. These deficiencies include potential for crop injury, development of herbicide-resistant weeds, carryover of herbicides, narrow spectrum of control, and antagonism between broadleaf and grass herbicide tank mixes. Herbicides are effective if they have selective toxicity to weeds without also being toxic to the crop. Many commonly used soybean herbicides, however, can cause injury to the soybean crop (Kapusta, Jackson, and Mason 1986; Wax, Bernard, and Hayes 1973). Crop injury symptoms resulting from some commonly used herbicides include stunted growth, yellowing of leaves, reddening of leaf veins, and speckling, bronzing, or burning of leaves. Although these symptoms do not always decrease yield, they sometimes delay canopy closure, which increases weed competition with the crop (Padgette et al. But short season soybean crops, such as those planted in rotation with another crop during the same season. Application rates for some herbicides are intentionally kept low to decrease the possibility of crop injury. To achieve adequate weed control at low rates, weeds must be relatively small at the time of treatment. In some instances, low herbicide rates may result in incomplete weed control in heavily infested sites (Rawlinson and Martin 1998). Another limitation to conventional programs is the development of herbicide-resistant weeds. Some conventional herbicides used in soybean have residual deleterious effects on rotation crops due to persistence of the herbicide in soil. Carryover of an herbicide with residual activity from one planting to the next may cause economically significant levels of damage in subsequent plantings of sensitive crops other than soybean. Residues of some herbicides can remain in the soil for a year or more, and so farmers must pay close attention to the herbicide history of a field when making planting decisions. For example, guidelines specify a waiting period of 26 months (mo) after imazethapyr application before planting potato or flax and 18 mo before planting sweet corn, cotton, sunflower, oats, safflower, or sorghum (Crop Protection Reference 2002). Finally, many soybean herbicides control only certain weeds at specific growth stages. Farmers usually have several species of weeds in any particular field and would normally need to control both grass and broadleaf weeds. But tank mixing herbicides to minimize the number of trips over the field can result in antagonism between the compounds, whereby efficacy of the grass herbicide is diminished. In this case, two passes over the field or increased rates of the grass herbicide may be necessary to avoid this antagonism. Weed Control in Biotechnology-derived Herbicide-tolerant Soybean the primary reason that farmers have switched from conventional weed management programs to glyphosate-tolerant soybean is the simplicity of the program: instead of using multiple herbicides to achieve adequate weed control, farmers can rely on one herbicide to control a broad spectrum of weeds without crop injury. In addition, glyphosate has no crop rotation restrictions and may be used to control weeds that have developed resistance to other herbicides. It is effective against a wide spectrum of annual and perennial grasses and broadleaf weeds. By planting glyphosate-tolerant soybean, farmers are able to apply glyphosate directly over the crop and take advantage of this wide spectrum of weed control. Glyphosate-tolerant soybean facilitates the use of a single herbicide rather than a combination of several narrow spectrum herbicides. Glyphosate also is more effective than other herbicides against generally larger weeds, thus giving farmers more flexibility in timing herbicide treatments. This flexibility in timing allows farmers to wait for sub-optimal spraying weather, such as several days of high winds, to pass before applying the herbicide treatment. Owen (2000) suggested that control of perennial weed problems such as hemp dogbane was improved in the Midwest with the adoption of glyphosate-tolerant soybean. This simplicity in weed control is the reason most often cited by farmers for the adoption of glyphosate-tolerant soybean (Owen 1997a). Glyphosate can be applied at any stage of growth in soybean, with little or no crop injury (Tharp, Schabenberger, and Kells 1999). Further, glyphosate has no carryover restrictions, because it is degraded rapidly in the soil, which allows farmers the added flexibility of planting any crop in rotation with soybean. Finally, improved weed control decreases the level of weed seed contamination of the harvested crop. Weed seed contamination is problematic because farmers receive decreased prices proportional to the level of weed seed contamination. Insect Resistant Insect-resistant Bt soybean is still under development and could be available in the next few years. Once Bt soybean is commercialized, adoption will depend on the level of pest pressure in different areas and on its efficacy and price compared to conventional insect control. Chemical control remains the only consistently effective tactic for control of mid- or late- season outbreaks of insect pests on soybean (Higley and Boethel 1994). Chemical control of soybean looper is difficult, however, because it has developed resistance to a variety of conventional insecticides, including organophosphates, carbamates, and pyrethroids that have been used to manage it on the several crops it infests. Insecticide use is low in most soybean producing regions of the United States, with less than 1% of soybean acreage nationwide treated with insecticides. But approximately one-third of the soybean acreage in several Southeastern and Delta states is treated regularly. Adoption of Bt soybean will occur where farmers find advantages over conventional insect control practices. For instance, Bt soybean may provide better control of pests such as the lesser cornstalk borer, that are difficult to control using foliar insecticides because of their burrowing nature. Soybean with innate insect protection properties will be useful in climatic regions where insect pressures justify insecticide applications. Virus Resistance Bean pod mottle virus is transmitted efficiently in nature, within and between soybean fields, by several species of chrysomelid beetles. Like nematode-resistant soybean varieties, biotechnologyderived virus-resistant varieties will be adopted depending on the efficacy, cost, and spectrum of control compared with those of current management practices. Measuring shifts in pesticide use attributable solely to the introduction of biotechnology-derived crops is a challenge as many factors also influence farmer decisions, not the least of which are changes in weather patterns and natural variability in pest pressure. While the benefits of reductions in pesticide use may be clearer, assessing the benefits of the substitution of one pesticide for another is more complicated, raising complex issues surrounding relative toxicity. Here the evidence on changes in herbicide use since the introduction of glyphosate-tolerant soybean is reviewed, and potential changes in pesticide use for those traits not yet commercialized are considered. Glyphosate-tolerant Soybean Since the commercial introduction of glyphosatetolerant soybean in the United States in 1996, dramatic changes have been observed in the mix of herbicides being used for weed control in soybean crops. Growing a nonhost for two years is generally adequate to allow a susceptible soybean cultivar to be grown. Several soybean cultivars are tolerant to root knot nematode species (Sinclair and Backman 1989). No information on herbicide use trends was available for countries other than the United States; therefore, the following discussion is limited to observed trends in herbicide use in the United States. Glyphosate was used on 20% of soybean acreage in 1995, as a burndown before planting, or as a spot treatment during the growing season, applied directly to weeds in the field. Imazethapyr was the most commonly used herbicide in soybean, applied to 44% of acreage in 1995. Since the commercialization of glyphosate-tolerant soybean in 1996, however, imazethapyr usage steadily decreased to just 12% of soybean acreage by 2000. Similar trends were noted with the other soybean herbicides such as chlorimuron, pendimethalin, and trifluralin. Because of differences in average application rates between different herbicide active ingredients, the net effect of substituting glyphosate for other herbicides may be either an increase or decrease in the total pounds of active ingredient (ai) used. Average soybean herbicide application rates, in terms of active ingredient per acre, have increased slightly since the introduction of glyphosate-tolerant soybean.
Some retarded adults make sounds somewhat similar to those made by infants; (2) stage of speech development that precedes understandable words acne research purchase permethrin 30 gm with visa. Glossary 163 bone conduction hearing test administration of tones to forehead with a vibrator; results are compared to air conduction test results to determine type of hearing loss acne 5th grade order permethrin 30 gm visa. Bourneville disease (See tuberous sclerosis) Brachmann-de Lange syndrome (See de Lange syndrome) burnout a term used to describe loss of motivation or desire to continue working in a particular setting skincare for over 60 purchase 30 gm permethrin overnight delivery, as in group homes or other residential facilities skin care 5-8 years purchase permethrin 30 gm line. The cells of the gray matter are involved in cerebromacular degenerations acne 8 dpo permethrin 30 gm cheap, and those in the white matter skin care vietnam purchase permethrin 30 gm, with demyelinization in the leukodystrophies acne laser treatment cost permethrin 30gm mastercard. Clinical manifestations appear after 6 months of age skin79 skin care buy 30gm permethrin visa, when growth failure, weakness, dehydration, and fever may occur; few children live beyond 8 years of age. It may be an inapparent infection for the mother, but can, if transmitted to the fetus, cause a devastating generalized infection, including encephalitis with subsequent damage to the developing nervous system; a m<~jor complication is the damage to the central nervous system, often with severe mental retardation. In dyslexia term used in inconsistent ways; generally indicates serious reading difficulty; condition characterized by an inability to read more than a few words with understanding. Glossary 171 educational retardation academic achievement, as measured by standardized tests, on one or more of the basic skill subjects that is markedly below that expected for chronological age level. In mood, often accompanied by encephalitis inflammation of the brain resulting from the response of the cerebral tissues to a wide variety of infections and, occasionally, toxins; the diagnosis of encephalitis is usually restricted to those diseases in which there is a diffuse, non purulent cerebral inflammation that principally affects the gray matter; other clinical and pathological syndromes are better termed encephalopathies. Glossary 173 exogenous mental retardation a term sometimes used to refer to retardation assumed to originate from causes external to the body. Friedreich ataxia (hereditary spinocerebellar ataxia) a hereditary disorder transmitted as an autosomal recessive gene affecting males and females equally; usual age of onset is between 7 and 10 years, with manifestations of stumbling, ataxia, loss of position sense, kyphoscoliosis, pes cavus, extensor plantar responses, and occasional electrocardiographic changes; the disorder is progressive, and death usually occurs by 30 years of age. Two different enzymatic defects produce galactosemia, but the clinical manifestations of each one are distinct. The more common form has an almost complete deficiency of galactose-I-phosphate uridyl transferase activity. The disorder is serious, leading to death in infancy or mental retardation in those who survive. The other, an uncommon disorder, results from a deficiency of galactokinase, is relatively benign, and characterized clinically only by the presence of catal"acts. Residents may work in the community and care for themselves and their quarters but are assured assistance in budgeting money, personalized supervision, and counseling as the need anses. Glossary 177 high risk infants those who have a high probability of disability as indicated by specified environmental or physical factors identified during the prenatal, perinatal, or early childhood period. Some of the affected persons have had impaired speech, a few are retarded in growth, and some are mentally retarded. Hoover cane a long flexible cane that is swept in an arc in front of blind persons to aid in detection of obstacles and terrain changes; used by some blind retarded persons. Hurler syndrome (gargoylism, mucopolysaccharidosis) a disorder of mucopolysaccharide metabolism associated with characteristic facial appearance, including broad bridge of the 178 Classification in Mental Retardation nose, open mouth with protruding large tongue, thickened lips, corneal clouding, coarse facial features. Glossary 179 idiot an obsolete term used centuries ago to describe all retarded persons and during the 19th and early 20th century to describe persons who would today be called profoundly or severely retarded. This listing is available and quickly accessible to professionals, parents, retarded persons, and the community. The agency makes referrals to the needed, appropriate, and most readily available resources. Theoretically, one-fourth of the offspring inherit the abnormal genetic factor from each parent and are affected; one-half are heterozygotes like parents, and one-fourth are normal. Krabbe diffuse sclerosis (globoid cell leucodystrophy, acute infantile diffuse sclerosis) a rapidly progressive degenerative disorder of the cerebral white matter occurring in infancy with autosomal inheritance. Affected infants appear normal at birth; clinical manifestations begin during the first months of life and consist of stiffness of the lower extremities, feeding difficulties, spells of incessant screaming. Edema, diarrhea, dermatitis, depigmentation, and hepatomegaly are common manifestations. Laurence- Moon- Biedl-Bardet syndrome a clinical syndrome characterized by mental retardation, obesity, hypogenitalism, polydactyly, and retinitis pigmentosa; mode of transmission appears to be autosomal recessive. Glossary Lignac syndrome (See cystinosis) 183 lipidosis (cerebral) inborn or acquired disorders of lipid metabolism affecting the brain. If the mass contains meninges and also neural elements of spinal cord or nerve roots, it is classified as a meningomyelocele. Glossary mild mental retardation (See mental retardation) 185 minimal brain dysfunction a term previously used to describe a condition in which a child may show behavioral or educational but not necessarily neurological signs indicative of neurological dysfunction; because the term is used in a variety of ways by different professionals, it has proven to be of limited utility. Glossary 187 norm-referenced test a standardized test with specified procedures for administration and scoring of test items and summarized statistics describing the performance on the test of a reference group of specified ages 01grade levels; the performance of an examinee can be compared with that of others; scores are reported as standard scores, percentiles, grade equivalents, age equivalents, stanines, or T-scores. Glossary 189 phocomelia a deformity in which one or more limbs are very short or missing; sometimes found in certain rare disorders associated with mental retardation. Originating in play therapy with children, these materials have subsequently been adapted for psychodiagnostic testing and evaluation. Often used synonymously with the term postmature for infants whose gestation exceeds the normal 280 days by 7 days or more. Prader-Willi syndrome a syndrome characterized by hypotonia, hypogonadism, and extreme obesity. Although there is usually some degree of cognitive deficit, not all affected individuals are mentally retarded. Infants who weigh 2,500 g or less at birth are considered to have had either a shortened gestational period, a less than expected rate of intrauterine growth, or both, and are termed infants of low birth weight. Prematurity and low birth weight are usually concomitant, particularly among infants weighing 1,500 g or less at birth; both are associated with increased neonatal morbidity and mortality. Glossary 193 psychopharmacological agent drugs and other active substances used in the treatment of behavioral disorders and to influence affective, behavioral, and emotional states. Drugs used to modify behavior are generally classified into stimulants (dextroamphetamine, methylphenidate), tranquilizers (thioridazine, chlorpromazine), and antidepressents (tricyclic amines). This may result in destruction of the Rh positive red blood cells and lead to pathology in the offspring, such as abortions, still births, kernicterus, or mental retardation. Rh sensitization (See Rh incompatibility) Rochester method (See total communication) rubella German measles; when occurring in a pregnant woman during the first trimester, the infection may affect the fetus by causing Glossary 195 congenital anomalies, including deafness, cataracts, cardiac malformations, and/or mental retardation. There are several systems of sign language with some overlapping gestures among them. Glossary 197 social worker a specialist with graduate school traInIng in social work and trained to provide a variety of social services; many social workers are also psychothe,-apists. Use of the standard error of measurement can improve clinical decisions in making diagnoses. Stanford-Binet Intelligence Scale (See measured intelligence) stereotyped behavior complex, repetitive movements that appear to be nonfunctional, especially repetitive hand movements, rocking, object twirling, or head banging; "blindisms. Glossary 199 syphilis a venereal disease that can cause mental retardation in a child whose mother contracted the disease during pregnancy and transmitted it to the fetus in the prenatal period. Tay-Sachs disease a form of cerebral gangliosidosis, largely confined to children of Jewish ancestry derived from northeastern Europe; caused by a single autosomal recessive gene. Between 3 and 10 months of age, there is some deterioration in development, blindness, and seizures. An antenatal diagnosis can be made by enzymatic determination of fluid obtained by amniocentesis. The congenital form (communicated to fetus from mother) is frequently manifested by a syndrome consisting of chorioretinitis, cerebral calcification, mental retardation, convulsions, and hydrocephalus or microcephaly. Training services are differentiated from educational services by their emphasis on those skills universally needed to function at a minimum level as part of society. Glossary trisomy 21 (See Down syndrome) 201 tuberous sclerosis a syndrome characterized by adenoma sebaceum, seizures, and often mental retardation of varying degree; may be an autosomal dominant or a recessive type of inheritance. Specifically, a student who does not accomplish much in school as would be expected from his or her measured intelligence. Physical: Sits unsupported or pulls self upright momentarily; reaches for objects; has good thumb-finger grasp; manipulates objects. Note: some persons who are profoundly retarded in other areas have moderate to good motor skills, including ambulation. Cormnunication: Jmitates sounds, laughs, or smiles back (repeats "Ma-ma," "buh-buh" responsively); no effective speech; may communicate in sounds and/or simple gestures; responds to gestures and/or signs. Physical: Stands alone or may walk unsteadily or with help; coordinates eye-hand movements. Social: Responds to others in predictable fashion; communicates needs by gestures, noises, or pointing; plays "patty-cake" or plays imitatively with simple interaction; occupies self alone with "toys" for a few minutes. Physical: Walks alone steadily; can pass ball or objects to others; may run and climb steps with help. Social: Plays with others for short periods, often as parallel play or under direction; recognizes others and may show preference for some persons over others. Physical: Climbs up and down stairs but not alternating feet; runs and jumps; balances briefly on one foot; can pass ball to others; Appendix 205 transfers objects; does 4- to 6-piece form-board puzzles without aid. Communication: Speaks in 2- or 3-word sentences (Daddy go work); names simple common objects (boy, car, ice cream, hat); understands simple directions (put the shoe on your foot, sit here, get your coat); knows people by name. Physical: Hops or skips; climbs steps with alternating feet; rides tricycle (or bicycle over 8 years); climbs trees or jungle gym; plays dance games; throws ball and may hit target. Communication: Has speaking vocabulary of over 300 to 400 words and uses grammatically correct sentences. Understands simple verbal communications, including directions and questions ("Put it on the shelf. Social: Participates in group activities and simple group games; interacts with others in simple play ("Store," "House") and expressive activities (art, dance). Physical: Can run, skip, hop, dance; uses skates or sled or jump rope; can go up and down stairs alternating feet; can throw ball and hit target. Communication: May communicate in complex sentences; speech is generally clear and distinct; understands complex verbal communication, including words such as "because" and "but. Social: Participates in group activities spontaneously; engages in simple competitive exercise games (dodge ball, tag, races); has friendship choices that are maintained over weeks or months. Economic activity: May be sent on simple errands and make simple purchases with a note; knows money has value but does not know values; may use coin machines. Occupation: May prepare simple foods (sandwiches); can help with simple household tasks (bed making, sweeping, vacuuming); can set and clear table. Self-direction: May ask if there is "work" to do; may pay attention to task for 10 minutes or more; makes efforts to be dependable and carry out responsibility. Appendix 207 Physical: Good body control; good gross- and fine-motor coordination. Recognizes words, reads sentences, ads, signs, and simple prose material with comprehension. Economic activity: Can be sent on shopping errand for several items without notes; makes minor purchases; adds coins to dollar with fair accuracy. Occupation: May do simple routine household chores (dusting, garbage, dishwashing); prepare simple foods that require mixing. Self-direction: May initiate everyday activities; attends to task 15 to 20 minutes (or more); is conscientious in assuming responsibility for simple household tasks. Since by definition individuals are not retarded unless they show significant deficit in both measured intelligence and adaptive behavior, those individuals who function at higher levels than illustrated here cannot be considered to be retarded. Physical: Goes about hometown (local neighborhood in city, campus at residential center) with ease, but cannot go to other towns alone without aid; can use bicycle, skis, ice skates, trampoline, or other equipment requiring good coordination. Communication: Communicates complex verbal concepts and understands them; carries on everyday conversation, but cannot discuss abstract or philosophical concepts; uses telephone and communicates in writing for simple letter writing or orders but does not write about abstractions or important current events. Economic activity: Can be sent or go to several shops (without a note to shopkeepers) to purchase several items; can make change correctly, but may not use banking facilities; may earn living but has difficulty handling money without guidance. Occupation: Prepares simple meals; performs everyday household tasks (cleaning, dusting, dishes, laundry); as adult can engage in semiskilled or simple skilled job not requiring complex thinking or judgment. Self-direction: Initiates most of own activities; is conscientious about work and assumes much responsibility but needs guidance on jobs requiring responsibility for important decisions (health care, care of others, complicated occupational activity). The decision to classify any individual as retarded is crucial in the life of that individual and requires sound clinical skills in those making such decisions. All standardized tests should be administered with strict adherence to directions, scoring of test items should be done with extreme carefulness. Consideration should be given to the characteristics of the measures used, including Appendix 209 validity, standard error of measurement, and type of content. In such cases, there is a good probability that the individual is in need of some type of special service and will need to be provided services or referred to another service agency. Mother reported that Bill feeds self and dresses self except for shoe tying, that he tries to help around the house and with younger children. He conversed with the psychologist freely, asked many questions about objects in room. Home language is Spanish and Maria plays with Spanish-speaking children around home, with English-speaking ones at school. Cannot read in English except for signs and some functional words, names, and some basic sight words she has learned in the two months she has been in school. Is well coordinated physically, plays competitive exercise games at school and home. Two errors on Bender-Gestalt with 210 Classification in Mental Retardation Koppitz scoring. Although difficult to test because of language barrier, she understood enough English to follow simple directions of tests. There is strong probability that she will function at higher level when she has mastered English, but she should be monitored by teachers and given re-evaluation if indicated. Parents have been concerned about her development since Camilla was 4 years old, primarily because of slow language development and slowness in development of self-help skills. Mother works parttime, but has spent a lot of time with Camilla from infancy, reading to child, playing with her, and attempting to stimulate language. Camilla has good articulation, uses short sentences with correct grammar, but vocabulary is limited for age. Repeated kindergarten and standardized achievement tests at school have consistently been 1 Y2 to 2 grades below expected for age. In class and in everyday life, she appears to per- Appendix 211 form at a lower level than indicated by latest standardized test scores. Currently she is functioning at l~e tarded level in both adaptive behavior and measured intelligence. Speech is very difficult to understand but she comprehends and responds to compound and complex sentences. She will need special services and probably will be classified as eligible for special education on basis of "Orthopedic Handicap" or "Physical Handicap. Self-help skills 212 Classification in Mental Retardation limited to attempts to feed self with spoon and attempting to remove some clothing. Psychologist reported that he seemed not to understand object permanence (Piaget scheme). In educational programs he has mastered simple communication board with 3 objects, has learned 4 signs for communication (drink, eat, thank you, please). Large number of trials with guidance and modeling required for acquisition of any new skill. Now reads some functional words and about 150 basic sight words and has simple word attack skills. Stanford Achievement Test in Fall of this year indicated: Reading Comprehension-2. Is very quiet and does not talk much to strangers; was difficult to test, but did cooperate during testing. Vineland Social Maturity Scale has gone from 46 to 58 since moving to foster home. He is at lower limits of Mild level and could have been classified as either Mild or Moderate under current system. The history, current behavior in foster home, ability to make rapid progress, and standard error of measurement of Binet were alI considered in making this decision on level of retardation. Mother reported that he uses a spoon for self feeding (with much spilling), and can remove his socks and underpants; he is partially toilet trained but still has some daytime accidents; he speaks single words and occasional two word sentences or holophrastic phrases. Language level estimated to be at about 23 months level by speech/language therapist. On basis of overall current functioning, language, standard error of measurement of Binet. Feeds and dresses himself, but needs help in selection of clothing to wear and must be "checked" to ensure everything is appropriate before going out. Can go to store 2 blocks away on errand, but takes note for storekeeper and does not know if he has been given correct change. Is reliable in helping with simple household 214 Classification in Mental Retardation chores such as bed making, table setting, running vacuu m cleaner, helping at simple chores in kitchen. His speech is barely understandable, with many articulation problems, but he responds to directions and requests. He functions adequately in a sheltered workshop on simple tasks requiring stuffing bags, simple assembly, and attaching stickers in correct places. He understands that he is paid for work and talks about using the money he makes, but must be supervised in making purchases with his money. Has been in educational programs since age 6 in separate school consortium supported by several school districts. Feeds self with spoon and dresses self, but mother buys clothing "easy for her to get on" because she has difficulty with some clothing. Attempts to help at home and does set table, but must do so by setting "a place for Mom, one for Dad, one for me. She likes to talk, using simple, repetitive statements or questions such as "Can you get me ajob? Has attempted training in two different sheltered workshops, but "made no progress.
If the aponeurosis is lacerated transversely acne quitting smoking generic permethrin 30gm with visa, traction from the muscle bellies will cause considerable gaping of the wound acne leather jacket buy 30 gm permethrin. Secondary to trauma or infection acne treatment home remedies discount permethrin 30 gm amex, blood or pus may accumulate 438 Anatomy skin care 3-step buy permethrin 30 gm without a prescription, Histology acne hormonal imbalance buy 30 gm permethrin visa, and Cell Biology subjacent to the epicranial aponeurosis skin care olive oil 30 gm permethrin visa. The inferior sagittal sinus (answer b) and the great cerebral vein join to form the straight sinus acne treatment home remedies buy permethrin 30gm lowest price. The superior (answer e) and inferior petrosal sinuses (answer d) both drain the cavernous sinuses skin care tips for men cheap permethrin 30 gm with amex, the former connecting with the ipsilateral transverse sinus. The sigmoid sinus (answer a) is in between the transverse sinus and the origin of the internal jugular vein. Many nosebleeds occur in this area since it is exposed to most of the incoming air. There are four blood vessels that supply blood to this area: 1) anterior ethmoid artery (a branch off the ophthalmic artery); 2) sphenopalatine artery (a branch off the maxillary artery that came through the sphenopalatine foramen; 3) greater palatine artery (a branch also off the maxillary artery, but has run through both the greater foramen and the incisive foramen to get to the nose); and 4) septal branch artery (a branch off the superior labial artery which comes off the facial artery). While the lay press often suggests holding the bridge of the nose (answers a and e), this would only block blood within the infratrochlear artery, which mainly serves the exterior dorsal surface of the nose. Holding (answer c) both sides of the nose at the junction of the nasal bones with the lateral nasal cartilages would tend to block blood flow within the external branch of the anterior ethmoid. Thus (answer b) holding both sides of the upper lip between his fingers will cut off blood to the septal branch of the superior labial artery and apply pressure from the oral cavity over the incisive foramen (answer d) would cut off blood coming from the greater palatine arteries. Note, it is difficult to stop blood within either the sphenoid palatine artery or anterior ethmoid arteries by applying any external pressure. The pterygoid venous plexus (answer a) communicates with the cavernous sinus via the ophthalmic veins. The frontal emissary vein (answer c) communicates with the superior sagittal sinus via the foramen cecum. The basilar venous plexus (answer d) communicates with the inferior petrosal sinus. The parietal emissary vein (answer e) also communicates with the superior sagittal sinus. Also, somites never develop past the initial stage (somitomere), but do give rise to some mesodermal derivatives of the head including the bones at the base of the skull (visceral chondrocranium). It is not divided into somatic (answer d) and splanchnic (answer e) portions separated by a coelom. The buccal branch of the facial nerve innervates muscles of facial expression (including the buccinator muscle) between the eye and the mouth, whereas the buccal branch of the trigeminal nerve (answer b) is sensory. The levator palpebrae superioris muscle (answer c), which elevates the upper eyelid, is innervated by the oculomotor nerve, whereas the involuntary superior tarsal muscle (answer d) is supplied by sympathetic nerves. Falls in older adults (while 62 many not be old for those young at heart) that do not produce skull fracture may still provide enough force to cause the brain to move in relationship to the meningeal layers causing 440 Anatomy, Histology, and Cell Biology bleeding inside the skull. As the vein tears it often bleeds into to a potential space inside the dura mater, but outside the fluid impervious outer layer of the arachnoid mater. These are veins that bleed into this potential space, so bleeding is often slow to develop. Subdural hematomas are usually treated by drilling a small hole in the skull bones over the center of the hematoma and the blood clot is removed. A pituitary tumor (answer c) might affect vision, but normally does not cause papilledema. Pain and temperature sensation above and below the level of the cord lesion would be preserved. The cell bodies of first-order afferent (sensory) neurons are located in the dorsal root ganglia. Their central processes enter the spinal cord and ascend one segment before synapsing with a second-order neuron in the dorsal horn. The central processes of second-order neurons cross in the ventral white commissure to the opposite side of the cord and ascend in the lateral spinothalamic tract to the ventral posterior lateral nucleus of the thalamus where they synapse with third-order neurons, which relay the message to cortical neurons of the postcentral gyrus of the parietal lobe. Lesions occurring unilaterally in a peripheral nerve would result in an ipsilateral deficit, whereas lesions in a crossed ascending pathway, in the thalamus, or in the cortex would result in contralateral deficits. Normally the maxillary process moves medially and fuses with the medial nasal process at the philtrum on both sides of the upper lip. The fact that the cleft involves both the lip and bony primary palate suggests failure of the maxillary process Head and Neck Answers 441 to fuse with the medial nasal process. The mandibular process (answers a and b) does not normally fuse with either the lateral or medial nasal processes (answer c). The lateral and medial nasal processes (answer e) fuse to form a nostril separate from the oral cavity. It is generally due to vascular compression by cerebral arteries on a portion of the trigeminal nerve that causes pain, especially during situations that cause increases in blood pressure. Wry neck (answer d) may be due to tearing of the sternocleidomastoid muscle during the birthing process. Craniosynostosis (answer e) is an abnormal head shape often due to the premature replacement of a fibrous cranial suture with bone. The ability to taste in the anterior two-thirds of the tongue (answer a) is not at risk because that information is carried by the lingual nerve, below the tongue. The ability to protrude your tongue (answer b) is provided by innervation from the hypoglossal nerve, which innervates all the intrinsic tongue muscles and lies below the tongue and is not a risk. It aids in the opening of the mouth (answer c) and movement of the mandible from side-to-side (answer e). They enter the cranium through the foramen magnum after which they join to form the basilar artery. The basilar artery terminates by bifurcating into the posterior cerebral arteries. The vertebral arteries form the basilar artery which in turn feeds the posterior cerebral arteries (answer e). The extracranial hematoma is the growing "goose egg" that was developing on the outside of her head. The physical findings of papilledema, frontal bone skull fracture and accumulating blood inside the cranial bones anterior to the cranial suture are all consistent with epidural hematoma. Most likely the frontal bone fractured, lacerating the frontal branch of the middle meningeal artery and veins which run in grooves near the pterion. The temporal region of the skull is particularly thin in this region and more prone to compression fractures. Subdural hematomas (answer c) rarely present in a limited area, rather they occupy one complete cerebral hemisphere as the arachnoid mater separates from the dura mater. It is unlikely that a spinal tap, if performed would contain blood [indication of subarachnid hemorrhage (answers d and e)]. In addition it would likely shear off the olfactory nerves that pass through the cribriform plate of the ethmoid bone, resulting in anosmia (inability to smell) on left side. The lacrimal bone (answer b) surrounds the nasal lacrimal duct and if fractured might lead to a runny nose, but this would not explain the lack of ability to smell. The nasal bone (answer c) froms the root of the nose is often broken in boxers, but would not necessary lead to a runny nose or continued headaches. Damage to this nucleus results in loss of the gag reflex, difficulty in swallowing, and hoarseness. The lateral spinothalamic tract (answer b) passes through the medulla and carries sensory information (pain and temperature) from the contralateral extremities and trunk. Descending sympathetic pathways (answer d) course through the medulla to reach the intermediolateral cell column of the spinal gray matter. Damage to those fibers would result in loss of ability to dilate the pupil (meiosis), drooping eyelid (ptosis), and loss of sweating ipsilaterally (hemianhydrosis). Damage to nerve fibers passing to and from the cerebellum via the inferior cerebellar peduncle (answer e) would result in intention tremor and lack of coordination. The lateral pterygoid muscles, acting bilaterally, protract the jaw and, acting unilaterally, rotate the jaw during chewing. Because the fibers of the superior head of the lateral pterygoid muscle insert onto the anterior aspect of the articular disk of the temporomandibular joint as well as onto the head of the mandible, spasm of this muscle, such as in a yawn, can result in dislocation of the mandible by pulling the disk anterior to the articular tubercle. Reduction is accomplished by pushing the mandible downward and back, so that the head of the mandible reenters the mandibular fossa. The temporalis (answer e), medial pterygoid (answer c), and masseter (answer d) muscles primarily elevate the jaw in molar occlusion. When the pharyngeal pouches persist, they may form connections to the exterior of the neck immediately anterior to the boundary of the sternocleidomastoid muscle. Since this weeps fluid it is most likely a fistula or external cyst (which was not one of the options). An internal branchial sinus (answer b) would only be a blind pouch off 444 Anatomy, Histology, and Cell Biology the pharynx and have no external connections. The internal opening for this fistula would most likely be within the bed of the palatine fossa (2nd pharyngeal pouch) or further inferiorly within the pharynx if is from the third or lower pharyngeal embryonic pouches. Persistent glossopharyngeal fistula (answer a) (opening of the embryonic glossopharyngeal duct) more rarely makes a connection to the surface ectoderm and like a thyroglossal duct cyst (answer f) would be a midline structure. Spina bifida occulta (answer e) is associated with a tuft of hairy skin over a defect in the posterior arch of the spinal cord. The spastic paralysis, hyperreflexia, and positive Babinski reflect an upper motor neuron lesion. The corticobulbar and corticospinal tracts pass through the cerebral peduncles (basis pedunculi). Those originating in the right cortex will pass through the right peduncle and then cross to the contralateral side in the pyramidal decussation, resulting in left-side hemiplegia. It is of interest that the lower motor neurons innervating muscles of facial expression located below the eye receive upper motor neurons (corticobulbar tract) only from the contralateral cortex, whereas lower motor neurons innervating facial muscles above the eye. Because there were no sensory deficits, neither the thalamus (answers d and e) nor sensory cortex (answers a and b) were involved. The sensory tracts are arranged dorsolaterally in the midbrain and do not pass through the affected area. Decreased blood flow in these regions explains the observed motor and sensory deficits. The anterior choroidal artery (answer a) is a branch of the internal carotid Head and Neck Answers 445 artery and is primarily distributed to the basal ganglia, hippocampus, and choroid plexus of the lateral ventricle. The posterior communicating artery (answer c) connects the internal carotid and vertebral arterial systems. The ophthalmic artery (answer d) is a direct branch of the internal carotid artery that enters the orbit along with the optic nerve. Although the anterior cerebral artery (answer e) has a wide distribution and anastomoses with branches of both the middle and posterior cerebral arteries, it primarily supplies medial and superior portions of the cortex. A problem in the internal auditory meatus (answer b) usually affects hearing and balance. That the superior salivatory nucleus (answer a) is normal is indicated by normal lacrimation. Hence, the lesion must be distal to the origin of the greater superficial nerve at the genu of the facial nerve (answer c). However, absence of hyperacusis indicates that the branch to the stapedius muscle is functioning normally, and this fact suggests that the lesion is close to the stylomastoid foramen. Loss of taste and diminished salivation locate the lesion proximal to the origin of the chorda tympani nerve. If the lesion were distal to the stylomastoid foramen (answer e), taste and salivation would have been normal, with facial paralysis as the only sign. The cerebrospinal fluid produced in the lateral and third ventricles must reach the fourth ventricle to escape into the subarachnoid space through the foramina of Luschka and Magendie. Venous blood (answer a) would be dark regions along the superior sagiatal sinus for instance. They are innervated, respectively, by the trigeminal nerve and the pharyngeal branch of the vagus nerve. The anterior palatoglossal arch, or anterior faucial pillar, is formed by the mucosa overlying the palatoglossal muscle. The posterior faucial pillar, or 446 Anatomy, Histology, and Cell Biology palatopharyngeal arch, likewise is formed by the palatopharyngeus muscle. The salpingopharyngeus muscle (answer c), also innervated by the pharyngeal branch of the vagus nerve, arises from the torus tubarius at the opening of the auditory tube and inserts into the pharyngeal musculature. The superior and middle pharyngeal constrictors (answer e) are innervated by the pharyngeal branch of the vagus nerve. The stylopharyngeus and styloglossus muscles (answer d) originate from the styloid process and insert onto the lesser horn of the hyoid and into the tongue, respectively. Levator veli palatini and tensor veli palatini muscles (answer a) are above the soft palate. Closure of the neural tube begins near the midpoint of its length and proceeds in both directions simultaneously (thus not answers a and c). The neurectoderm of the neural tube will give rise to neurons and some glial cells (astrocytes, oligodendroglia, and ependymal cells), but the precursors of microglia (the monocyte-macrophage lineage) migrate into the nervous system from the blood (thus not answer b). The sensory ganglia are formed by neural crest cells that migrated before the development of mature neurons (answer e). While most strokes present with sudden onset of neurological symptoms, the majority of stokes are ischemic (answer b) in nature due to blood clots blocking blood to the brain. In this man, however, he probably had a hemorrhagic stroke as a consequence of increased blood pressure due to straining, because of constipation. Subdural hematoma (answer c), while common in the elderly, would not result in a bloody spinal tap. Deviation of the tongue to the right on protrusion results from the unopposed action of the left genioglossus muscle, which is innervated by the left hypoglossal nerve. The hypoglossal nerve also innervates numerous other tongue muscles involved in deglutition. The question only asks about the cause of the tongue deviation so the other answers (answers a, b, d, e) are irrelevant. Loss of innervation to the lateral rectus results in unopposed tension by the medial rectus, which produces internal strabismus. Paralysis of this nerve (answer b) would result in lateral deviation of the eye (external strabismus) accompanied by ptosis (drooping eyelid). In addition, mydriasis (dilated pupil) results from loss of function of the parasympathetic component of the oculomotor nerve. The optic nerve (answer a) is responsible for receiving the special sense of sight. The distal tendon of the stylohyoid muscle is split by the digastric muscle (not answer d) passing through its trochlea attached to the lesser horn. The sphenomandibular ligament inserts onto the lingula of the mandibular foramen (answer c); the stylohyoid ligament inserts onto the lesser horn of the hyoid bone. Inflammation of the mucous membrane that lines the sinuses may sometimes lead to a build up of pus that can block the normal drainage pathways. In this instance, the anterior wall of the frontal sinus was compromised and pus escaped into the forehead and into the upper eyelid, since the frontalis muscle, a normal barrier, attaches only into skin of the forehead. In order to allow movement, the skin of the eyelid is only attached to underlying structures by loose areolar connective tissue, through which infections easily spread. The swelling spontaneously reduced after the first week of treatment and no visible defects were noted 1 month later. Trigeminal neuralgia or tic douloureux (answers a and b) is characterized by sudden sharp pains over the distribution of one or more branches of the trigeminal nerve. Although pain is perceived within the ophthalmic division, the teenager would not suffer from sudden sharp twinges of pain, rather a dull constant pain from swollen tissue. A sty (answer e) is an inflammation of the sebaceous gland, associated with each eyelash or cilia. A chalazion is an inflammation of a Meibomian or tarsal gland, which lies on the inner surface of the eyelid. This could cause a bulge in the upper eyelid but does not fit with the other clinical findings. If there is no projection of the spinal cord or its covering through the bony defect, the condition is generally hidden (spina bifida occulta). However, it is termed spina bifida cystica when spinal material traverses the defect. In a meningocele (answer c), this is a saclike projection formed only by the meninges. If the projection contains neural material, it is a meningomyelocele, which is the case for this newborn. Rachischisis (answer a) is an extreme example of spina bifida cystica in which the neural folds underlying the vertebral defect fail to fuse, leaving an exposed neural plate. Anencephaly (answer b) occurs when the cranial neural tube fails to fuse, thus resulting in lack of formation of forebrain structures and a portion of the enclosing cranium. Hydrocephaly (answer e) results from blockage of the narrow passageways between the ventricles or between the ventricles and the subarachnoid space. Resultant swelling of the ventricles compresses the brain against the cranial vault and may cause serious mental deficits. In addition to the internal jugular vein, the jugular foramen contains the glossopharyngeal nerve (innervating the stylopharyngeus muscle) (answer d), the vagus nerve (innervating palatal (answer a), pharyngeal, and laryngeal musculature), and the spinal accessory nerve [innervating the sternocleidomastoid (answer b) and trapezius muscles (answer e)]. An inconsistent thyroid ima artery, when present, may arise from the aortic arch, the innominate artery, or the common carotid artery. There are no branches of the internal carotid artery (answer a) and infrequent branches of the common carotid artery in the neck. The transverse cervical artery (answer d) supplies the posterior triangle of the neck. The vertebral arteries (answer e) give off spinal and muscular branches in the neck.
Permethrin 30 gm visa. THESE FACE PRODUCTS ARE CAUSING YOUR ACNE!.
