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This competition has already occurred against the background of "free" music from p2p systems acupuncture protocol erectile dysfunction discount tadapox 80mg free shipping. As the sellers of cable television have known for thirty years erectile dysfunction medications cost cheap tadapox 80 mg, and the sellers of bottled water for much more than that erectile dysfunction 18 years old cheap tadapox american express, there is nothing impossible at all about "competing with free erectile dysfunction protocol program buy tadapox 80mg with mastercard. Thus in Singapore impotence husband buy tadapox pills in toronto, though piracy is rampant erectile dysfunction doctor karachi cheap tadapox 80 mg on line, movie theaters are often luxurious- with "first class" seats, and meals served while you watch a movie-as they struggle and succeed in finding ways to compete with "free. It would inspire an extraordinary range of new innovators-ones who would have a right to the content, and would no longer fear the uncertain and barbarically severe punishments of the law. We should instead be regulating to minimize the harm to interests affected by this technological change, while enabling, and encouraging, the most efficient technology we can create. What if there is a competitive market providing content at a low cost, but a significant number of consumers continue to "take" content for nothing? Is it better (a) to have a technology that is 95 percent secure and produces a market of size /x/, or (b) to have a technology that is 50 percent secure but produces a market of five times /x/? Less secure might produce more unauthorized sharing, but it is likely to also produce a much bigger market in authorized sharing. Indeed, I have devoted my life to working in law, not because there are big bucks at the end but because there are ideals at the end that I would love to live. Yet much of this book has been a criticism of lawyers, or the role lawyers have played in this debate. The law speaks to ideals, but it is my view that our profession has become too attuned to the client. And in a world where the rich clients have one strong view, the unwillingness of the profession to question or counter that one strong view queers the law. Many, for example, thought crazy the challenge that we file:///C|/Users/hamblebe/Desktop/Free%20Culture%20simplified%208000%20version. Yet just thirty years ago, the dominant scholar and practitioner in the field of copyright, Melville Nimmer, thought it obvious. But more often than not, economists, with no clue about how the legal system actually functions, simply assume that the transaction costs of the legal system are slight. I mean simply because the costs of our legal system are so astonishingly high that justice can practically never be done. How much time should such a lawyer spend reading cases carefully, or researching obscure strands of authority? The law depended upon the careful articulation and development of doctrine, but the careful articulation and development of legal doctrine depends upon careful work. Yet that careful work costs too much, except in the most high-profile and costly cases. And lawyers, as well as academics, should consider it their duty to change the way the law works-or better, to change the law so that it works. It could be made radically more efficient, and inexpensive, and hence radically more just. But until that reform is complete, we as a society should keep the law away from areas that we know it will only harm. And that is precisely what the law will too often do if too much of our culture is left to its review. Think about the amazing things your kid could do or make with digital technology-the film, the music, the Web page, the blog. Or think about the amazing things your community could facilitate with digital technology-collaboration, a barn raising, activism to change something. Think about all those creative things, and then imagine cold thick liquid poured onto the machines. The law should regulate in certain areas of culture-but it should regulate culture only where that regulation does good. Yet lawyers rarely test their power, or the power they promote, against this simple pragmatic question: "Will it do good? I have tried to remedy the instability by redirecting readers to the original source through the Web site associated with this book. If the original link has disappeared, you will be redirected to an appropriate reference for the material. Lawrence Lessing, /Man of High Fidelity: Edwin Howard Armstrong/ (Philadelphia: J. See "Saints: the Heroes and Geniuses of the Electronic Era," First Electronic Church of America, at Amanda Lenhart, "The Ever-Shifting Internet Population: A New Look at Internet Access and the Digital Divide," Pew Internet and American Life Project, 15 April 2003: 6, available at link #2. This is not the only purpose of copyright, though it is the overwhelmingly primary purpose of the copyright established in the federal constitution. State copyright law historically protected not just the commercial interest in publication, but also a privacy interest. By granting authors the exclusive right to first publication, state copyright law gave authors the power to control the spread of facts about them. Amy Harmon, "Black Hawk Download: Moving Beyond Music, Pirates Use New Tools to Turn the Net into an Illicit Video Club," /New York Times,/ 17 January 2002. Netanel, "Copyright and a Democratic Civil Society," /Yale Law Journal/ 106 (1996): 283. See Rochelle Dreyfuss, "Expressive Genericity: Trademarks as Language in the Pepsi Generation," /Notre Dame Law Review/ 65 (1990): 397. In /The Rise of the Creative Class/ (New York: Basic Books, 2002), Richard Florida documents a shift in the nature of labor toward a labor of creativity. I certainly agree with him about the importance and significance of this change, but I also believe the conditions under which it will be enabled are much more tenuous. Leonard Maltin, /Of Mice and Magic: A History of American Animated Cartoons/ (New York: Penguin Books, 1987), 34-35. According to Dave Smith of the Disney Archives, Disney paid royalties to use the music for five songs in /Steamboat Willie:/ "Steamboat Bill," "The Simpleton" (Delille), "Mischief Makers" (Carbonara), "Joyful Hurry No. See Chris Sprigman, "The Mouse that Ate the Public Domain," Findlaw, 5 March 2002, at link #5. Until 1976, copyright law granted an author the possibility of two terms: an initial term and a renewal term. I have calculated the "average" term by determining the weighted average of total registrations for any particular year, and the proportion renewing. Thus, if 100 copyrights are registered in year 1, and only 15 are renewed, and the renewal term is 28 years, then the average term is 32. For the renewal data and other relevant data, see the Web site associated with this book, available at link #6. For an excellent history, see Scott McCloud, /Reinventing Comics/ (New York: Perennial, 2000). Mehra, "Copyright and Comics in Japan: Does Law Explain Why All the Comics My Kid Watches Are Japanese Imports? One hypothesis is that all manga artists may be better off collectively if they set aside their individual self-interest and decide not to press their legal rights. See Siva Vaidhyanathan, /Copyrights and Copywrongs,/ 11 (New York: New York University Press, 2001). See also Lawrence Lessig, /The Future of Ideas/ (New York: Random House, 2001), 293 n. The term accurately describes a set of "property" rights-copyright, patents, trademark, and trade-secret-but the nature of those rights is very different. Jenkins, /Images and //Enterprise/ (Baltimore: Johns Hopkins University Press, 1975), 112. Nimmer, "The Right of Publicity," /Law and Contemporary Problems/ 19 (1954): 203; William L. Edward Goldberg, "Essential Presentation Tools: Hardware and Software You Need to Create Digital Multimedia Presentations," cadalyst, 1 February 2002, available at link #7. Bruce Ackerman and James Fishkin, "Deliberation Day," /Journal of Political Philosophy/ 10 (2) (2002): 129. Noah Shachtman, "With Incessant Postings, a Pundit Stirs the Pot," /New York Times,/ 16 January 2003, G5. John Schwartz, "Loss of the Shuttle: the Internet; A Wealth of Information Online," /New York Times,/ 2 February 2003, A28; Staci D. Kramer, "Shuttle Disaster Coverage Mixed, but Strong Overall," Online Journalism Review, 2 February 2003, available at link #10. Last year Steve Olafson, a /Houston Chronicle/ reporter, was fired for keeping a personal Web log, published under a pseudonym, that dealt with some of the issues and people he was covering. See, for example, Edward Felten and Andrew Appel, "Technological Access Control Interferes with Noninfringing Scholarship," /Communications of the Association for Computer Machinery/ 43 (2000): 9. Tim Goral, "Recording Industry Goes After Campus P-2-P Networks: Suit Alleges $97. Douglas Lichtman makes a related point in "KaZaA and Punishment," /Wall Street Journal,/ 10 September 2003, A24. Aberdeen, /Hollywood Renegades: the Society of Independent Motion Picture Producers/ (Cobblestone Entertainment, 2000) and expanded texts posted at "The Edison Movie Monopoly: the Motion Picture Patents Company vs. For a discussion of the economic motive behind both these limits and the limits imposed by Victor on phonographs, see Randal C. Picker, "From Edison to the Broadcast Flag: Mechanisms of Consent and Refusal and the Propertization of Copyright" (September 2002), University of Chicago Law School, James M. Marc Wanamaker, "The First Studios," /The Silents Majority,/ archived at link #12. Kittredge, of South Dakota, chairman), reprinted in /Legislative History of the 1909 Copyright Act,/ E. To Amend and Consolidate the Acts Respecting Copyright, 223 (statement of Nathan Burkan, attorney for the Music Publishers Association). To Amend and Consolidate the Acts Respecting Copyright, 226 (statement of Nathan Burkan, attorney for the Music Publishers Association). To Amend and Consolidate the Acts Respecting Copyright, 23 (statement of John Philip Sousa, composer). To Amend and Consolidate the Acts Respecting Copyright, 283-84 (statement of Albert Walker, representative of the Auto-Music Perforating Company of New York). To Amend and Consolidate the Acts Respecting Copyright, 376 (prepared memorandum of Philip Mauro, general patent counsel of the American Graphophone Company Association). At the beginning, record companies printed "Not Licensed for Radio Broadcast" and other messages purporting to restrict the ability to play a record on a radio station. Judge Learned Hand rejected the argument that a warning attached to a record might restrict the rights of the radio station. Picker, "From Edison to the Broadcast Flag: Mechanisms of Consent and Refusal and the Propertization of Copyright," /University of Chicago Law Review/ 70 (2003): 281. See also Ben Hunt, "Companies Warned on Music Piracy Risk," /Financial Times,/ 14 February 2003, 11. Additionally, patent rights may lead to higher prices for staple industries such as agriculture. Developing nations may be able to use this to gain the benefits of foreign patents at lower prices. For an analysis of the economic impact of copying technology, see Stan Liebowitz, /Rethinking the Network Economy/ (New York: Amacom, 2002), 144-90. One obvious instance is the case where the individual engaging in pirating would not have purchased an original even if pirating were not an option. Professor Christensen examines why companies that give rise to and dominate a product area are frequently unable to come up with the most creative, paradigm-shifting uses for their own products. This job usually falls to outside innovators, who reassemble existing technology in inventive ways. Amy Harmon, "Industry Offers a Carrot in Online Music Fight," /New York Times,/ 6 June 2003, A1. In 1988, 40 percent of consumers older than ten had taped music to a cassette format. See Recording Industry Association of America, /2002 Yearend Statistics,/ available at link #15. See Recording Industry Association of America, /Some Facts About Music Piracy,/ 25 June 2003, available at link #16: "In the past four years, unit shipments of recorded music have fallen by 26 percent from 1. The music industry worldwide has gone from a $39 billion industry in 2000 down to a $32 billion industry in 2002 (based on U. By one estimate, 75 percent of the music released by the major labels is no longer in print. See Online Entertainment and Copyright Law-Coming Soon to a Digital Device Near You: Hearing Before the Senate Committee on the Judiciary, 107th Cong. While there are not good estimates of the number of used record stores in existence, in 2002, there were 7,198 used book dealers in the United States, an increase of 20 percent since 1993. See Book Hunter Press, /The Quiet Revolution: the Expansion of the Used Book Market/ (2002), available at link #19. See National Association of Recording Merchandisers, "2002 Annual Survey Results," available at link #20. Copyright Infringements (Audio and Video Recorders), 485 (testimony of Jack Valenti). These are the most important instances in our history, but there are other cases as well. See also Picker, "From Edison to the Broadcast Flag," /University of Chicago Law Review/ 70 (2003): 293-96.

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Longer-term ef forts to improve access to health for most vulnerable and hard-to-reach women and children have to be at the centre of disaster preparedness and serve as a platform to build on when a disaster hits. Volunteers need to be trained and equipped with resources necessary to support the delivery of services on a rou tine basis as well as in all phases of an emergency. Scaling-up the community-based health workforce for emergencies and Inter-agency Field Manual on Reproductive Health in Emergencies. Measuring success In order to be able to monitor the progress and demonstrate the impact of pro grammes, it is essential to apply a results-based management approach at all phases of a programme cycle from analysis to design, implementation and evaluation (refer to Project/Programme Planning Guidance Manual). For ex ample, a measure of contraception is used as a tracer for reproductive health. The approach helps to increase awareness of maternal death and create account ability between communities, providers and local authorities. Improving newborn survival and changing house hold essential newborn care practices in rural Bangladesh: the Projahnmo ex perience. An intervention involving traditional birth at tendants and perinatal and maternal mortality in Pakistan. Alma-Ata: Rebirth and Revision 6, Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strate gies make? The use of personal digital as sistants for data entry at the point of collection in a large household survey in southern Tanzania. What can a meta-analysis tell us about traditional birth at tendant training and pregnancy outcomes? Essential Interventions, commodities and guidelines for Reproductive, Maternal, Newborn and Child Health. Monitoring maternal, newborn and child health: understanding key progress indi cators. Implementing community-based perinatal care: Results from a pilot study in rural Pakistan. Improving newborn survival and changing household essential newborn care practices in rural Bangladesh: the Projahnmo experience. Potential role of traditional birth attendants in neonatal healthcare in rural southern Nepal. Its pur be able at all times to act in accordance with the pose is to protect life and health and to ensure principles of the Movement. Impartiality It makes no discrimination as to na Unity There can be only one Red Cross or Red tionality, race, religious beliefs, class or political Crescent Society in any one country. Universality the International Red Cross and Neutrality In order to enjoy the confdence of all, Red Crescent Movement, in which all societies the Movement may not take sides in hostilities or have equal status and share equal responsibili engage at any time in controversies of a political, ties and duties in helping each other, is world racial, religious or ideological nature. This is an open-access artcle distributed under the terms of the Creatve Commons Atributon License, which permits unrestricted use, distributon and reproducton in any medium, provided the original author and source are credited. Abstract Numerous eforts have been put forth to combat childhood overweight and obesity, including standards, goals and Overweight and obesity is a global epidemic among children of all ages. Educaton, interventons, and Actvity Among Youth [4] that school setngs should serve as an evaluatons of the efectveness and outcomes of new initatves aiming to reduce childhood overweight and essental component of a natonal strategy to increase physical obesity are needed to recommend future programs with the actvity, along with preschool and childcare center setngs greatest likelihood of success. Aside from the aforementoned standards, goals and objectves, and recommendatons, additonal natonal standards related to Keywords: Childhood overweight; Obesity; Children; preventng childhood obesity in early care and educaton Nutriton; Physical actvity programs have also been promoted. In additon, these Overweight and obesity is a global epidemic among children later standards support key natonal campaigns for early of all ages. All of the prevalence of combined overweight and obesity in children these interventon eforts have had mixed results thus far. In 2014, an estmated 41 this qualitatve review summarizes the current scientfc million children under the age of fve years were afected by literature on childhood overweight and obesity including trends overweight and obesity [1]. The prevalence of obesity was estmated at 17% in 2011-2014; review will include: factors afectng childhood overweight and extreme obesity was 5. Also, it will examine a number of current Under License of Creative Commons Attribution 3. The stgma associated with childhood Childhood Overweight and Obesity Trends overweight and obesity also carries a risk for psychological and in the United States social problems related to negatve self-image and low self esteem [11]. Interventon eforts need to address both the the prevalence of obesity and overweightness, defned as a th physical and emotonal consequences of obesity. Aside from a slight decrease from 2003-2004 pose more challenges in terms of understanding, measurement, (17. Populatons experiencing rapid and environmental factors including community resources and socioeconomic and/or nutritonal transitons appear to be at even media in society are sending confictng messages partcular risk [1]. However, individuals from all socioeconomic Among these components, the following will be examined more groups, educatonal levels, regions, and cultures have a vested closely in the upcoming discussion: (1) nutriton, (2) physical interest in developing educatonal and behavioral interventons actvity, (3) mental health and mood, (4) sleep hygiene, and (5) to control childhood overweight and obesity in eforts to media usage. Nutriton Nutriton is paramount to healthy growth and development, Efects of Overweight and Obesity on as well as disease preventon during childhood. However, Child and Adolescent Health Healthy People 2020 data indicated that the natonal goals for nutriton in childhood have not been met thus far. Such conditons 2009-2012, there was no change in mean daily fruit or vegetable related to obesity include asthma, diabetes, cardiovascular consumpton of individuals aged two years and older. The health-related quality of vegetable consumpton of individuals aged two years and of life in obese children is so poor that it is similar to that of older. In terms of healthier food adulthood, it is imperatve that parents, caregivers, educators, access for children and adolescents, 24 states had nutriton and all those who tend to children play an actve, instrumental standards for foods and beverages provided to preschool-aged role in preventng overweight and obesity in children. The children in child care compared to Healthy People 2020 target of 2 this article is available from: childhood-obesity. Aside from immediately afer lunch fuctuated, but resulted in a decline minimizing the risks for chronic disease and premature death, with 42. According to the 2008 Physical Actvity Guidelines for Americans, children and adolescents aged 6-17 the mental health status of children is closely associated with years should be physically actve 60 minutes or longer every day. Another study reported actvites that are age and developmentally-appropriate, that the risk for major depressive or anxiety disorder increased enjoyable, and fun [19]. This partcular surveys have suggested that as the number of hours of media study highlights the importance of weight stgmatzaton in usage increases, body fat percentage and the risk of overweight society and the efect that self-percepton of obesity has on also increases in a dose-response manner [42-45]. The types of stress implicated in obesity among young children (ages 5-11) included lack of cognitve stmulaton and emotonal support. For older children Childhood Overweight and Obesity: (ages 12-17), stress related to obesity included mental health Additonal Barriers to Behavior Change problems, physical health problems, and fnancial strain in the home [31]. This research indicated the importance of reducing There are various barriers that impede the progress of stress as a potental factor in combatng childhood obesity. In additon to the challenges embedded in the fve factors discussed in the Sleep hygiene previous secton, there are also a number of environmental barriers. In some circumstances, Inadequate sleep is associated with obesity and is considered healthcare may create barriers to the preventon of childhood to be a modifable risk factor [32]. Additonally, study of children and adolescents, short duratons of nightme most surveyed clinicians believed that they should be actvely sleep in children up to four years of age was related to an involved in preventng obesity in children, but reported that approximate two-fold increased risk for overweight and obesity counseling produced poor results and/or they did not have the [34]. This study indicated that adequate sleep in infancy and the tme to provide that informaton and support [46]. Though state legislaton in this category generally viewing tme for preschool-aged children was associated with a requires private insurers, public insurance programs such as 40% lower prevalence of obesity [35]. State Adequate sleep is also very important for adolescents, and legislaton in this category does not always specifcally refer to may be related to obesity. One study of more than 8,000 childhood obesity, and private insurance companies may or may students in 40 schools reported lifestyle factors associated with not include children. Maryland seems to associated with a four-fold increased risk for obesity in girls and be the only state with a law requiring insurance coverage for a 1. Another study found that obesity evaluaton and management as a child wellness service; obstructve sleep apnea in children 12 years of age or older was it was enacted in 2010 [47]. Disadvantaged youth are more likely to be overweight and obese in adolescence and Media usage during the transiton to adulthood. A study of the Natonal Longitudinal Study of Adolescent Health found that poverty in Media use was frst identfed as a strong correlate of childhood afected obesity in adolescent girls. Additonally, childhood overweight and obesity in the 1980s, and has been neighborhood poverty and low parental educaton were related supported by numerous studies since that tme [39]. Early research focused on television viewing, and Childhood Overweight and Obesity: that is stll the medium with which the most American children Educaton and Interventon spend the greatest number of hours. Recent surveys have indicated that school-age children spend an average of three Due to the fact that all share in the consequences of hours per day watching television, and their tme with screen overweight and obesity on the health outcomes of children and media increases to more than fve hours per day when adolescents, educatonal and policy and practce-based computers and video games are included [40]. While there have interventons required must reach across all regions, cultures, been mixed results in the examinaton of television, gaming, healthcare coverage systems, and socio-economical levels to computer, and smartphone usage [41], multple cross sectonal reach those individuals with the greatest needs. Additonal setngs in which these interventons should be implemented could also the Healthy People 2020 goals and objectves include many include home, child care, school, healthcare, and community. Int J and outcomes of new initatves aiming to reduce childhood Pediatr Obes 5: 282-304. McKeta S, Rich M (2011) the fault, dear viewer, lies not in the Pediatr 146: 732-737. Boreham C, Riddoch C (2001) the physical actvity, ftness and and childhood overweight/obesity. Vale S, Santos R, Soares-Miranda L, Silva P, Mota J (2011) the importance of physical educaton classes in pre-school children. Changes in total energy expenditure in a representatve sample of young children: Cross-sectonal and longitudinal analysis. J (2010) Adopton of body mass index guidelines for screening and Phys Act Health 6: 510-519. Nishtar S, Gluckman P, Armstrong T (2016) Ending childhood systematc review with meta-analysis of randomized clinical trials. To grant consent for the child(ren) to participate in any activity which the attorney-in fact feels appropriate c. Tese models are emerging in response to a series of problems in current services for children and young people. The briefng draws on presentations, discussions and materials submitted by delegates at the workshop, and other published literature. Doing so will require a move away from single institutions towards a systems-based approach organised around networks of care. Suggested citation Kossarova L, Devakumar D and Edwards N (2016) The future of child health services: new models of care. What the 12 models of care are trying to address 23 5 The future of child health services: new models of care Key Points. But the way health care services are provided is still heavily hospital focused and reactive. Tere are serious concerns about child health outcomes and the quality of care children and young people receive. Tese models ofer diferent ways of managing the needs of children and young people with acute and chronic conditions. Over the last 45 years, mortality data show an epidemiological transition away from acute infectious illness towards chronic long-term conditions; however, the way services are provided is still heavily hospital focused and reactive. The Marmot Review in 2010 highlighted the importance of giving children the best start in life to improve health and wellbeing, and reduce inequalities (Marmot, 2010). A system-wide response was put together which focused on early intervention and integration, safety and sustainability, and workforce training. The 11 standards cover supporting primary care, safely reducing hospital stays and connecting the whole system (Royal College of Paediatrics and Child Health and others, 2015). Children difer from adults in at least four important ways: 1) developmental change; 2) dependency on parents and other carers; 3) diferential epidemiology. The briefng is largely based on a workshop run by the Nufeld Trust (see Box 2), as well as on presentations, discussions, materials submitted by representatives of the new models of care who attended the workshop, and published literature. Participants were asked to think about why new models of child services have emerged, what they are doing and why they may be better than the current service provision, as well as to consider the future direction of child health services. The divide between hospital and general practice in health care provision was identifed as the main problem. A lack of training in preventive care by all and an absence of hospital paediatricians in primary care were also identifed. Service organisation should be adapting to this epidemiological change (Wolfe and others, 2013). The increased long-term survival of children with complex disabilities also means that appropriate care needs to be in place to support them. However, in 2014/15 nearly 22 per cent of children in reception class (aged 4?5 years) and one in three children in year 6 (aged 10?11 years) were overweight or obese. Between 2006/07 and 2014/15 the proportion of children in reception who were obese declined from 9. Tere has been an increase in A&E attendances for children under the age of fve over time, which seems to have levelled of in the last year. Unplanned hospitalisations for long-term conditions (diabetes, asthma, epilepsy and convulsions) in people under 20 declined between 2003/04 and 2013/14, suggesting better management of these children in the community, as highlighted by epilepsy and diabetes audits (Royal College of Paediatrics and Child Health, 2014; 2015). Tese trends suggest a need to better understand how acute conditions are managed in primary and secondary care. Capacity in primary care General practice is perceived to be where most paediatric services should be located, but there is a recognition that it often does not have the time, human and physical resources to adequately deal with the need. Overall, the current model of general practice is largely considered to be in need of reform and there have been diferent initiatives trying to transform the sector through scaled-up ways of working (for example federations or networks) or upskilling the workforce to learn about population health management, new ways of consulting with patients, new technologies and collaborative ways of working (Rosen, 2015). Access to high-quality paediatric/child health expertise in the community Participants at the Nufeld Trust workshop felt that a key challenge is that child health is not uniformly recognised as a problem and priority in primary care. However, there are concerns about the gap in paediatric expertise, knowledge and skills available in the community, specifcally about the appropriate paediatric training of providers in primary care (Kennedy, 2010; Royal College of General Practitioners, 2010). Similarly, the expertise of hospital paediatricians is not sufciently available in the community and hospital-based paediatricians are less well trained in minor illness management or health promotion.

But Daley and Barish ran a program that gave kids an opportunity to use film to express meaning about something the students know something about-gun violence erectile dysfunction doctor dallas buy 80 mg tadapox otc. The class was held on Friday afternoons erectile dysfunction doctors in maine buy discount tadapox online, and it created a relatively new problem for the school impotence doctor order tadapox cheap. While the challenge in most classes was getting the kids to come erectile dysfunction doctors in tallahassee cheap 80mg tadapox, the challenge in this class was keeping them away impotence jokes discount tadapox generic. They were working harder than in any other class to do what education should be about-learning how to express themselves jack3d causes erectile dysfunction buy tadapox 80 mg mastercard. Using whatever "free web stuff they could find," and relatively simple tools to enable the kids to mix "image, sound, and text," Barish said this class produced a series of projects that showed something about gun violence that few would otherwise understand. The project "gave them a tool and empowered them to be able to both understand it and talk about it," Barish explained. That tool succeeded in creating expression-far more successfully and powerfully than could have been created using only text. The power of this message depended upon its connection to this form of expression. Education, Daley explained, is about giving students a way of "constructing meaning. Text is one part-and increasingly, not the most powerful part-of constructing meaning. As Daley explained in the most moving part of our interview, "What you want is to give these students ways of constructing meaning. Play for me music that you think reflects that, or show me images that you think reflect that, or draw for me something that reflects that. And then what happens, of course, is eventually, as it has happened in all these classes, they bump up against the fact, "I need to explain this and I really need to write something. But they had come to understand that file:///C|/Users/hamblebe/Desktop/Free%20Culture%20simplified%208000%20version. Every moment of just about every day for that week, and for weeks after, television in particular, and media generally, retold the story of the events we had just witnessed. The genius of this awful act of terrorism was that the delayed second attack was perfectly timed to assure that the whole world would be watching. There was music scored for the breaks, and fancy graphics that flashed across the screen. This was news choreographed in the way we have increasingly come to expect it, "news as entertainment," even if the entertainment is tragedy. But in addition to this produced news about the "tragedy of September 11," those of us tied to the Internet came to see a very different production as well. Some people constructed photo pages that captured images from around the world and presented them as slide shows with text. There was, in short, an extraordinary worldwide barn raising, in the sense Mike Godwin uses the term in his book /Cyber Rights/, around a news event that had captured the attention of the world. But unlike any technology for simply capturing images, the Internet allows these creations to be shared with an extraordinary number of people, practically instantaneously. This is something new in our tradition-not just that culture can be captured mechanically, and obviously not just that events are commented upon critically, but that this mix of captured images, sound, and commentary can be widely spread practically instantaneously. Around the same time, a form of communication that has grown dramatically was just beginning to come into public consciousness: the Web-log, or blog. The blog is a kind of public diary, and within some cultures, such as in Japan, it functions very much like a diary. The best of the blog entries are relatively short; they point directly to words used by others, criticizing with or adding to them. This is the part of America that is most difficult for those of us who love America to accept: Our democracy has atrophied. Of course we have elections, and most of the time the courts allow those elections to count. Democracy means rule by the people, but rule means something more than mere elections. This was the idea that captured the imagination of Alexis de Tocqueville, the nineteenth-century French lawyer who wrote the most important account of early "Democracy in America. Members argued about the "right" result; they tried to persuade each other of the "right" result, and in criminal cases at least, they had to agree upon a unanimous result for the process to come to an end. But for most of us for most of the time, there is no time or place for "democratic deliberation" to occur. We, the most powerful democracy in the world, have developed a strong norm against talking about politics. Political discourse becomes isolated, and isolated discourse file:///C|/Users/hamblebe/Desktop/Free%20Culture%20simplified%208000%20version. Technologies that enable communication at different times, such as e-mail, increase the opportunity for communication. Blogs allow for public discourse without the public ever needing to gather in a single public place. Indeed, the space is filled with political speech, on both the right and the left. Some of the most popular sites are conservative or libertarian, but there are many of all political stripes. And even blogs that are not political cover political issues when the occasion merits. The name Howard Dean may well have faded from the 2004 presidential race but for blogs. One direct effect is on stories that had a different life cycle in the mainstream media. If a particular blogger writes a particularly interesting story, more and more people link to that story. And as the number of links to a particular story increases, it rises in the ranks of stories. People read what is popular; what is popular has been selected by a very democratic process of peer-generated rankings. As Dave Winer, one of the fathers of this movement and a software author for many decades, told me, another difference is the absence of a financial "conflict of interest. The New York headquarters was telling the reporter over and over that her account of the war was too bleak: She needed to offer a more optimistic story. It allows for a much broader range of input into a story, as reporting on the Columbia disaster revealed, when hundreds from across the southwest United States turned to the Internet to retell what they had seen. Blogs, Winer says, are "communicating directly with our constituency, and the middle man is out of it"-with all the benefits, and costs, that might entail. And as the inclusion of content in this space is the least infringing use of the Internet (meaning infringing on copyright), Winer said, "we will be the last thing that gets shut down. As more and more citizens express what they think, and defend it in writing, that will change the way people understand public issues. Of course, it is a rare human who admits that he has been persuaded that he is wrong. When "a lot of us grew up," he explains, that tinkering was done "on motorcycle engines, lawn-mower engines, automobiles, radios, and so on. Digital technologies launch a kind of freedom, or "free collage," as Brown calls it. This opportunity creates a "completely new kind of learning platform," as Brown describes. And it happens in the same collaborative way when that content is part of the Web. As Brown puts it, "the Web [is] the first medium that truly honors multiple forms of intelligence. The law and, increasingly, technology interfere with a freedom that technology, and curiosity, would otherwise ensure. It offers degrees in fields ranging from architecture and engineering to information sciences. More than 65 percent of its five thousand undergraduates finished in the top 10 percent of their high school class. The school is thus a perfect mix of talent and experience to imagine and then build, a generation for the network age. Google brought the Internet much closer to all of us by fantastically improving the quality of search on the network. The idea of search engines that search within the network of a particular institution is to provide users of that institution with better access to material from that institution. Microsoft, for example, has a network file system that makes it very easy for search engines tuned to that network to query the system for information about the publicly (within that network) available content. With the engines that existed before, if you tried to access a file through a Windows browser that was on a computer that was off-line, your computer could crash. Jesse modified the system a bit to fix that problem, by adding a button that a user could click to see if the machine holding the file was still on-line. Over the following six months, he continued to tweak it to improve its functionality. But that means, of course, that three quarters were not, and-so that this point is absolutely clear-Jesse did nothing to induce people to put music files in their public folders. He was a kid tinkering with a Google-like technology at a university where he was studying information science, and hence, tinkering was the aim. Unlike Google, or Microsoft, for that matter, he made no money from this tinkering; he was not connected to any business that would make any money from this experiment. He was a kid tinkering with technology in an environment where tinkering with technology was precisely what he was supposed to do. As he read these papers and watched the news reports about them, he was increasingly astonished. They claimed he operated a network and had therefore "willfully" violated copyright laws. For cases of "willful infringement," the Copyright Act specifies something lawyers call "statutory damages. If you added up the claims, these four lawsuits were asking courts in the United States to award the plaintiffs close to $100 /billion/- six times the /total/ profit of the film industry in 2001. They wanted him to agree to an injunction that would essentially make it impossible for him to work in many fields of technology for the rest of his life. They made him understand that this process of being sued was not going to be pleasant. If he won, he would have a piece of paper saying he had won, and a piece of paper saying he and his family were bankrupt. So Jesse faced a mafia-like choice: $250,000 and a chance at winning, or $12,000 and a settlement. So where is the morality in taking money from a student for running a search engine? And with this, this kid who had tinkered a computer into a $15 million lawsuit became an activist: "I was definitely not an activist [before]. As one commentator tells one part of the story, "A January 1909 deadline was set for all companies to comply with the license. By February, unlicensed outlaws, who referred to themselves as independents protested the trust and carried on business without submitting to the Edison monopoly. In the summer of 1909 the independent movement was in full-swing, with producers and theater owners using illegal equipment and imported film stock to create their own underground market. With coercive tactics that have become legendary, General Film confiscated unlicensed equipment, discontinued product supply to theaters which showed unlicensed films, and effectively monopolized distribution with the acquisition of all U. Of course, California grew quickly, and the effective enforcement of federal law eventually spread west. But because patents grant the patent holder a truly "limited" monopoly (just seventeen years at that time), by the time enough federal marshals appeared, the patents had expired. Recorded Music the record industry was born of another kind of piracy, though to see how requires a bit of detail about the way the law regulates music. At the time that Edison and Henri Fourneaux invented machines for reproducing music (Edison the record player, Fourneaux the player piano), the law gave composers the exclusive right to control copies of their file:///C|/Users/hamblebe/Desktop/Free%20Culture%20simplified%208000%20version. It was clear enough that I would have to buy any copy of the musical score that I performed in making this recording. And it was clear enough that I would have to pay for any public performance of the work I was recording. As South Dakota senator Alfred Kittredge put it, "Imagine the injustice of the thing. Along come the recording companies and companies who cut music rolls and deliberately steal the work of the brain of the composer and publisher without any regard for [their] rights. The innovators who developed the player piano argued that "it is perfectly clear that the introduction of automatic music players has not deprived any composer of anything he had before their introduction. Congress amended the law to make sure that composers would be paid for the "mechanical reproductions" of their music. But rather than simply granting the composer complete control over the right to make mechanical reproductions, Congress gave recording artists a right to record the music, at a price set by Congress, once the composer allowed it to be recorded once. Once a composer authorizes a recording of his song, others are free to record the same song, so long as they pay the original composer a fee set by the law. American law ordinarily calls this a "compulsory license," but I will refer to it as a "statutory license. When John Grisham writes a novel, a publisher is free to publish that novel only if Grisham gives the publisher permission. And thus, in effect, the law /subsidizes/ the recording industry through a kind of piracy-by giving recording artists a weaker right than it otherwise gives creative authors. And the beneficiaries of this less control are the recording industry and the public. The recording industry gets something of value for less than it otherwise would pay; the public gets access to a much wider range of musical creativity.

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In addition impotence from priapism surgery generic 80mg tadapox with visa, by looking at the descriptions for the next stage of dementia impotence after 40 purchase tadapox discount, the professional can begin to help the person and their supporters to think about what needs to be put in place to maintain the person’s quality outcome erectile dysfunction medicine for heart patients generic tadapox 80mg otc. The clinical psychologist and occupational therapist met with the staff team and care manager erectile dysfunction pills wiki tadapox 80mg. The results were used to create a dementia care plan based on the interventions described in this guidance erectile dysfunction caused by obesity order tadapox toronto. This provided a clear overview of who was doing what in relation to Brian’s support needs impotence natural remedies tadapox 80mg cheap. The home manager reported the reviews as helpful as they often did not notice deterioration until they had space to reflect, as they were with the person daily. It also meant better quality care for Brian as all those involved in his care were accountable for certain outcomes. The home manager felt that they were better supported by the community intellectual disabilities team whereas previously they felt that they had been left to struggle until a crisis occurred. Key points I Each area should use the Self-Assessment Checklist to measure the Outcome of their services for people with intellectual disabilities and dementia, and to assist in the development of a local strategy document. Guidance on their Assessment, Diagnosis, Interventions and Support 93 Section 19 – Future directions and research 19. Within this context, the development of new treatments for dementia, and trials to assess such treatments, have a high priority. Clinical trials are not just about pharmaceutical developments but also about psychological treatments and other approaches, the aim of which might be to maintain function and the dignity of those affected by dementia. This section has therefore been added to the revised guidance largely because we recognise that new treatments for dementia are being, and will be, developed and it is imperative that people with intellectual disabilities, in general, and people with Down’s syndrome, specifically, have the opportunity to partake in trials and subsequently benefit from the treatments that are found to be safe and effective. Similarly, people with intellectual disabilities (not due to Down’s syndrome) have a slightly earlier age-related prevalence profile of dementia than the typically developing population. Particularly in people with Down’s syndrome, the longer term objective of research is the development of a preventative treatment. These proposed new treatments will need to be 94 Dementia and People with Intellectual Disabilities tested in formal double blind placebo controlled trials. At present treatment developments aimed at preventing dementia in people with Down’s syndrome are focused on the modification of beta amyloid production in the brain. For people with intellectual disabilities not due to Down’s syndrome advances in treatment are likely to emerge from research in the typically developing population, however, these may need more formal testing (particularly with respect to side effect profiles) in the intellectual disabilities population. Research, whether of a pharmaceutical agent or of some support strategy requires the identification and involvement of people with intellectual disabilities and those who support them. This is particularly the case for people with Down’s syndrome where the risk of developing Alzheimer’s disease relatively early in life is high and treatment aimed at prevention is therefore a priority. Such research requires collaboration between people with dementia and their families, clinicians, social care providers and clinical academics and basic scientists. Research of this type has particular challenges if the right balance is to be achieved between enabling research that will lead to new treatments, on the one hand, and, on the other, ensuring the people with intellectual disabilities and dementia are not exposed to excessively intrusive research or to exploitation. It will be clinicians and support workers who are at the forefront when it comes to recruitment to such trials. Clinicians and those who support people with intellectual disabilities are the gateway to recruitment and the attitude taken to research by these two groups of people has a powerful impact on whether the potential participant is willing to meet those doing the research. Ultimately it must be for the person with intellectual disabilities to decide or, where he/she lacks the capacity to consent, the protocols and safeguards in the appropriate European and national legislations then apply. European Clinical Trials Regulation 536 (2014), Mental Capacity Act (2005), Adults with Incapacity [Scotland] Act (2000). Guidance on their Assessment, Diagnosis, Interventions and Support 95 With the advent of electronic health records searches are now possible according to particular diagnostic categories. The identification of potential participants for research has therefore become more feasible. Specialist services for adults with intellectual disabilities should ensure that all people with intellectual disabilities seen and who have received a diagnosis of dementia are identifiable by the service and at the time of diagnosis those concerned and those supporting them are informed about the importance of research, including any trials that are taking place. Specialist services have a responsibility for the identification of people with intellectual disabilities and dementia and to be willing to approach those meeting the necessary criteria for inclusion in a study on behalf of the research group undertaking the study. In clinical practice different clinicians and services may have their own approaches but for research it is usually necessary to have more formal and time-consuming assessments so that findings can be compared across studies – see section 6 for examples of diagnostic instruments and cognitive and functional assessments. Whilst it is through additional research funding that these more extensive assessments can be undertaken than is possible in clinical practice the use of agreed diagnostic assessments and of standard cognitive assessments would enhance recruitment on a larger scale for studies of, for example, risk and protective factors or for treatment trials. Clinicians working in local specialist services should establish diagnostic and assessment protocols that are agreed and in general use. There are no specific funding streams for dementia research in intellectual disabilities, and it may be seen as a ‘niche” area for mainstream funders. Funders may therefore benefit from being made aware of the importance of research in this area. Staff in services seeing adults with intellectual disabilities and, specifically adults with Down’s syndrome, where the diagnosis of dementia is being considered, should ensure that when a diagnosis of dementia is made the person concerned and those who support them are made aware of research projects being undertaken and permission requested to pass on their details to any approved and relevant research project. Services have the means to retrospectively identify any person with intellectual disabilities diagnosed as having dementia and specifically people with Down’s syndrome either in the age at risk for dementia or with a diagnosis of dementia and be willing to be a point of contact with them if approved and appropriate research is being undertaken that is looking for potential participants. In specialist memory clinics and in services for adults with intellectual disabilities the use of standardised diagnostic and neuropsychological assessments for the diagnosis and monitoring of dementia, as it affects people with intellectual disabilities, is encouraged. This will ensure that comparison can be made across services and over time thereby providing consistent and reliable data on prevalence and incidence of dementia in this population and also enabling recruitment into future trials of any new intervention or treatment. Guidance on their Assessment, Diagnosis, Interventions and Support 97 References Abbey, J. The Abbey pain scale: a 1-minute numerical indicator for people with end stage dementia. The relationship between acquired impairments of executive function and behavior change in adults with Down syndrome. The Test for Severe Impairment: an instrument for the assessment of people with severe cognitive dysfunction. Personality and behaviour changes mark the early stages of Alzheimer’s disease in adults with Down’s syndrome: findings from a prospective population-based study. Executive dysfunction and its association with personality and behaviour changes in the development of Alzheimer’s disease in adults with Down syndrome and mild to moderate learning disabilities. Theoretical exploration of the neural bases of behavioural disinhibition, apathy and executive dysfunction in preclinical Alzheimer’s disease in people with Down’s syndrome: potential involvement of multiple frontal-subcortical neuronal circuits. Aging and developmental disabilities: demographic and policy issues affecting American families. Challenging behaviours: Psychological interventions for severely challenging behaviours shown by people with learning disabilities. Dementia and people with learning disabilities: Guidance on the assessment, diagnosis, treatment and support of people with learning disabilities who develop dementia. Risk factors for dementia in people with Down syndrome: Issues in assessment and diagnosis. Reflections upon the development of a dementia screening service for individuals with Down’s syndrome across the Hyndburn and Ribble Valley area. Intellectual and daily living skills of 30-year-olds with Down’s syndrome: continuation of a longitudinal study. Environmental design to maximize autonomy for older adults with cognitive impairments. See me, Not the dementia: understanding people’s experiences of living in a care home. Epidemiology of psychiatric disorders in elderly compared with younger adults with learning disabilities. The outpatient clinic for adults with Down syndrome; a model to diagnose dementia. The neuropsychological assessment of age-related cognitive deficits in adults with Down’s syndrome. Development and psychometric properties of the Glasgow Depression Scale for people with a learning disability. Using medication to manage behaviour problems among adults with a learning disability: Quick reference guide. The dementia screening questionnaire for individuals with intellectual disabilities. Winterbourne View – Transforming care: A national response to Winterbourne View Hospital. Everybody’s business: Integrated mental health services for older adults: a service development guide. A comparative study of stress and unmet needs in carers of South Asian and white adults with intellectual disability. Happy eating: Making eating and drinking safe an enjoyable for people with dementia. Evaluation of a screening instrument for dementia in ageing mentally retarded persons. Cognitive functioning in relation to brain amyloid-b in healthy adults with Down syndrome. Supporting South Asian families with a child with severe disabilities: A report to the Department of Health. Informal carers of adolescents and adults with learning difficulties from the South Asian communities: Family circumstances, service support and carer stress. Establishing a database for proactive screening of adults with Down’s syndrome: when services work together. The prevalence of dementia in Europe: a collaborative study of 1980–1990 findings. Population-based study of the prevalence and presentation of dementia in adults with Down’s syndrome. The debate on ethnicity and dementia: from category fallacy to person-centred care. How we developed a multidisciplinary screening project for people with Down’s syndrome given the increased prevalence of early onset dementia. Difficulties of dealing with dementia in individuals with intellectual disabilities: the healthcare perspective. Understanding learning disability and dementia: Developing effective interventions. Donepezil for treatment of cognitive dysfunction in children with Down syndrome aged 10–17. Milton Keynes: Open University Press Guidance on their Assessment, Diagnosis, Interventions and Support 103 Lai, F. Using positron emission tomography and Carbon 11–Labeled Pittsburgh compound B to image brain fibrillar b-Amyloid in adults with Down syndrome: Safety, acceptability, and feasibility. One chance to get it right: Improving people’s experience of care in the last few days and hours of life. Down syndrome and dementia: a randomized, controlled trial of antioxidant supplementation. Assessment and diagnosis of depression in adults with intellectual disabilities: a review. A prospective 14-year longitudinal follow-up of dementia in persons with Down syndrome. The national task group on intellectual disabilities and dementia practices consensus recommendations for the evaluation and management of dementia in adults with intellectual disabilities. The physical environment of special care units: Needs of residents with dementia from the perspective of staff and family. Psychiatric symptoms associated with dementia in older people with learning disability. Dementia: Supporting people with dementia and their carers in health and social care. Medicines adherence: Involving patients in decisions about prescribed medicines and supporting adherence. Guidance on their Assessment, Diagnosis, Interventions and Support 105 National Institute for Health and Clinical Excellence (2010). The route to success in end of life care – Achieving quality for people with intellectual disabilities. Evaluation of the effect of orientation cues on wayfinding in persons with dementia. The clinical efficacy of citalopram in treatment of emotional disturbances in dementia disorders in Nordic multicentric study. Behavioural excesses and deficits associated with dementia in adults who have Down syndrome. A 24-week, double-blind, placebo controlled trial of donepezil in patients with Down syndrome and Alzheimer’s disease – Pilot study. Long-term safety and efficacy of donepezil in the treatment of dementia in Alzheimer’s disease in adults with Down syndrome: open-label study. Rivastigmine in the treatment of dementia in Alzheimer’s disease in adults with Down syndrome. Rivastigmine transdermal patches in the treatment of dementia in Alzheimer’s disease in adults with Down syndrome – pilot study. Royal College of Psychiatrists, British Psychological Society & Royal College of Speech and Language Therapists (2007). Guidance on their Assessment, Diagnosis, Interventions and Support 107 Strydom, A. Prevalence of dementia in intellectual ability using different diagnostic criteria. Report on the state of science on dementia in people with intellectual disabilities. Dementia in older adults with intellectual disabilities– epidemiology, presentation, and diagnosis. Does behavioral improvement with Haloperidol or Trazodone treatment depend on psychosis or mood symptoms in patients with dementia? Misplaced and forgotten: People with learning disabilities in residential services for older people.

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Quality: burning erectile dysfunction drugs patents generic tadapox 80mg on line, tender erectile dysfunction generics cheap tadapox 80 mg with amex, annoying erectile dysfunction caused by obesity purchase generic tadapox line, tir depressive or monosymptomatic hypochondriacal psy ing erectile dysfunction pills for sale best order tadapox, nagging pain; discomforting (McGill Pain Ques chosis erectile dysfunction age young order tadapox 80mg online. Time Pattern: usually constant once it begins erectile dysfunction causes high blood pressure generic tadapox 80mg with amex, but may be variable; increases in intensity from mid Signs and Laboratory Findings morning to late evening. Temporary relief by food or drink is al Brief, sharp pain in a tooth, often not understood until a most pathognomonic. Signs and Laboratory Findings Site Usually normal but there has been experimental evi Mouth. Sometimes low iron, B12i folate or other vitamin B or Age of Onset: third decade onward. Start: brief pain on zinc levels, but correction of nutritional factors infre biting or chewing. Usual Course Fifty percent spontaneous remission within 6-7 years of Signs onset; sometimes intractable. Percussion of this cusp pro tricyclic antidepressant drugs in low doses (30-60 mg). The cusp might move away from the Treatment frequently more difficult in patients who have tooth when manipulated. Usual Course Complications the pain recurs with biting and chewing until the cusp Secondary emotional changes. Pathology Relief Unknown, but frequently occurs around the time of It is relieved when the cracked portion of the tooth fi menopause. Summary of Essential Features and Diagnostic Criteria Complications Burning tongue or other parts of oral mucosa, usually None. Atypical facial pain; atypical odontalgia; atypical trigeminal neuralgia; oral candidiasis; erosive lichen Pathology planus; geographic tongue; vitamin, iron, or zinc defi A crack in the tooth allows chemicals and microorgan ciency. Sub ated with additional tenderness due to submandibular mandibular lymphadenitis. X2 Pain Quality: constant, dull ache, may throb, associated with severe halitosis. Dry socket occurs when this fails to happen either because there is no bleeding due to too much adrenaline in the local anesthetic solution, or be cause the blood is diluted by washing the mouth out, or Diseases of the Jaw, Inflammatory because the clot is broken down by infection. Usually the pain suc (V-1) ceeds the aura with or without a symptom-free interval. In occasional attacks in the classic migraineur, the pain Definition starts without a preceding aura. The pain is throbbing, Throbbing head pain in attacks, often with a prodromal ranges from mild to severe in intensity, reaches a pla state and usually preceded by an aura which frequently teau, and usually lasts from 4 to 72 hours if unmodified contains visual phenomena. Nausea, vomiting, photopho lateral and alternates sides during an attack or between bia, and phonophobia often accompany the pain. Characteristically, the pulsating quality Typically unilateral, but may be bilateral. Other Characteristics: Unknown: vascular disturbances have been emphasized; anorexia, nausea and vomiting, photophobia, and pho central nervous system changes may be fundamental. Precipitating Factors Main Features Numerous, may include stress, mood changes, relaxa Frequent positive family history of migraine-like type of tion, dietary factors. In most cases, at Anorexia, nausea, vomiting, photophobia, and phono tacks have started by late puberty. With ?complicated migraine, various defi tacks may be associated with emotional stress, ciency symptoms and signs. In approximate order of frequency, the with serotonin activity, in particular serotonin 1D recep following phenomena occur during the aura phase: blur tor agonists like sumatriptan. Ergotamine dependence or other monymous distribution), paresthesias, mostly in the re dependence on medication, even analgesic medication. In extremely rare cases, there may be alloesthesia, micropsia, and macrop Complications sia, or distortions of perspective. Duration Page 78 Social and Physical Disability Other Features Interruption of work in severe cases. Reduced efficiency Common migraine attacks usually last 1-2 days but may for many. Essential Features Complications Presence of an aura phase, at least during the occasional Drug abuse of analgesics and/or ergotamine. Repetitive, unilateral, and occasionally bilateral throb bing headache attacks, moderate to severe in intensity, often with a premonitory stage but without a distinct, Migraine Variants (V-3) clinically discernible aura, usually accompanied by nau sea, vomiting, photophobia, and phonophobia. The pain Hemiplegic migraine, migraine accompagnee, basilar alternates sides between attacks or even during an attack. The neuro Main Features logical symptoms and signs are more pronounced than in Prevalence: the prevalence is probably high. The question of the nature of the range from 1% to 31% depending on the criteria for underlying neurological disturbance may be more im definition of headache. Common migraine occurs much portant than that of the differential diagnosis from other more often than classic migraine (the ratio of common to headache syndromes. If the patient has had several attacks with aura, the majority being without an aura, the patient ?Migraine cervicale is not grouped as a migraine vari should still be classified under classic migraine. It complaints are clearly accentuated by minimal physical may rather be a headache associated with neck disorders activity. Classic and common migraine, Chiari malformations, arteriovenous malformations and other structural abnor Relief malities, pseudotumor cerebri, etc. X7c phasized that in this variant the pain episode is self Note: See note on Cluster Headache (V-6). Success in treatment Carotidynia (V-4) may, therefore, be confounded with the natural course of the disease. Definition Continuous dull aching pain, sometimes throbbing, near Pathology Unknown. The nosologic status of these headaches re the upper portion of the carotid arteries and adjoining mains obscure. Main Features Prevalence: occurrence unknown, depends somewhat upon the criteria used, probably rather rare. Pain Quality: the pain is constant and dull, should accordingly be categorized, whenever possible, aching or throbbing. There is, however, a tendency for the pain episodes to recur after a symptom-free interval. Inten sity: moderate, not very severe; apparently less severe Cluster Headache (V-6) than migraine headache. Definition Precipitating Factors Unilateral, excruciatingly severe attacks of pain, princi Moving the head, swallowing, coughing, etc. The carotid artery may on palpation ap Site pear enlarged, pulsating, and tender, and externally ap Ocular, frontal, temporal areas: considerably less fre plied pressure against the common carotid artery may quent in infraorbital area, ipsilateral upper teeth, back of the head, entire hemicranium, neck, or shoulder. Regional mus maximum pain is usually in ocular, retro-ocular, or pe Page 80 riocular areas. The side may, however, change (in approximately 15% of the patients), even within a Usual Course given cluster period. Age of Onset: most frequently, Social and Physical Disability headaches start between the ages of 18 and 40. Many patients, nevertheless, Quality: the pain is constant, stabbing, burning, or even manage to do their work between attacks. Patients characteristically pace the floor, bang their heads against the walls, etc. Perhaps cavernous sinus changes or ?central Time Pattern: attacks grouped in bouts (?cluster peri changes. Attacks may skip a day or two Differential Diagnosis or more during the cluster period. Nocturnal attacks are Sinusitis, chronic paroxysmal hemicrania, chronic clus typical. The patients tend to smoke and drink rather ter headache, cluster-tic syndrome, and migraine. In cogenic headache and tic douloureux ought not to tensity: at maximum, excruciatingly severe. Note: Although cluster headache is grouped with mi graine and similar disturbances, it is doubtful if vascular Associated Symptoms and Signs disturbances are the primary source of these events, and Usually there is no nausea, but some may occur, proba the second code digit refers to alternative possibilities bly with the more severe attacks or at the peak of at for the origin of the pain. Ipsilateral miosis or ptosis associated with some attacks; occasion References ally they persist after attacks and sometimes perma Kudrow, L. Ipsilateral conjunctival injection, lacrimation, Oxford University Press, London, 1980. Relief From ergot preparations, oxygen, corticosteroids, lith ium, verapamil, methysergide, etc. Slight ipsilateral ptosis or miosis may occur during attacks, and Definition rarely also edema of the upper lid. Photophobia and Multiple daily attacks of severe to excruciating unilateral more rarely phonophobia are occasionally present during head pain, more frequently occurring in females than in attacks. Tinnitus, hypersensitivity in the area of the oph males, and principally in ocular, frontal, and temporal thalmic division of the Vth cranial nerve, bradycardia, areas by day and night, usually accompanied by ipsilat and extrasystoles occur in some patients during severe eral lacrimation, conjunctival injection, and nasal stuffi attacks. Chronicity denotes an unremitting stage Laboratory Findings Increased nasal secretion and lacrimation (and partly that has lasted more than a year. Ocular, frontal, and temporal areas; occasionally the infraorbital, aural, mastoid, occipital, and nuchal areas. Relief Pain may also be felt in the ipsilateral part of the neck, Immediate, absolute, and permanent from continuous arm, and upper part of the chest. Usual Course System the chronic course may be primary chronic or it may Uncertain. Once chronic, the head and autonomic nervous systems are implicated during ache usually remains chronic. Age of Onset: average around 35 (more than 90% completely during the greater part of pregnancy, to reap are aged 11-60). Characteristically, there is marked fluctuation in the severity of attacks and their frequency. A period of Social and Physical Disability 1-2 moderate attacks per day (occasionally even barely Considerable during the nontreated stage, including sui noticeable) is followed by a period with frequent, severe cidal thoughts. In the worst cases, the patient does not attacks, thus providing a ?modified cluster pattern. Not infrequently, the patients are Essential Features awakened by the nocturnal attacks. Some patients walk Unremitting presence for at least one year of relatively around during attacks, others sit quietly, still others curl shortlasting repetitive unilateral attacks, associated with up in bed. Intensity: at maximum, the pain attacks are ipsilateral autonomic symptoms and signs. Absolute excruciatingly severe, but there is marked fluctuation in response to indomethacin. Sinusitis, chronic cluster head Attacks may be precipitated in the occasional patient ache, cluster headache, cluster-tic syndrome, hemicrania (around 10%) by bending or rotating the head, particu continua. The features of the remitting form are the same as for the the differences mainly concern the temporal pattern. Accordingly, for Definition other details, the section on the unremitting variety (V Bouts of excruciatingly severe unilateral pain, usually in 7. Absolute relief from indo males, principally in the ocular, frontal, and temporal methacin. Definition Attacks of unilateral severe or excruciating headache, Main Features occurring more frequently in females than in males, in the chronic form may be primary chronic. The chronic form of cluster headache is more rare period exceeds 12 months, the chronic, unremitting stage than the episodic form (approximately 1:8); the diagno has been reached). The remitting stage may seemingly sis requires at least two or more attacks per week over a go on indefinitely. Main Features the remitting form seems to be more rare than the un Relief remitting. This is partly due to the not infrequent con the same measures are effective as for cluster headache, version of the remitting form to the chronic one. Relief Immediate, absolute, and permanent effect of indo Essential Features methacin. The unremitting presence of unilateral, relatively short lasting, and excruciatingly severe attacks for at least one year. Autonomic symptoms and signs on the sympto Essential Features Frequently occurring, relatively shortlasting attacks of matic side. Absolute re Sinusitis, chronic paroxysmal hemicrania, cluster head sponse to indomethacin. Definition Relief the coexistence of the features of cluster headache and the most successful treatment appears to be the use of tic douloureux (trigeminal neuralgia), whether the two carbamazepine or baclofen, or both, rather than the con entities occur concurrently or separated in time. Site Usual Course Pain limited to the head and face; the two parts of the the attacks of cluster headache and tic douloureux may syndrome generally appear on the same side. The cluster start concurrently, or the attacks of tic douloureux may headache element is located in the ocular area as is usual precede those of cluster headache. Quality: a combination of the following: cluster headache Essential Features pain which includes agonizingly severe, longlasting, Coexistence of features of cluster headache and tic dou burning or throbbing pain, and, concurrently or sepa loureux. These two components of the syndrome may rated in time, sharp, agonizing, electric shock-like stabs appear simultaneously or separated in time. The attack is often pre scans may be necessary to rule out tumors in the cere cipitated by speaking, swallowing, washing the face, or bello-pontine region. This happens concurrently with, or temporally separated from, the features of cluster headache. X8h 10-120 minutes, frequently occurring at night, and char acteristically occurring in cluster periods lasting 4-8 References weeks, once or twice a year, but at times entering a more Green, M. Page 84 Post-traumatic Headache (V-10) well, and soft-tissue lesions from cervical sprain syn drome.

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